Ramipril

What is ramipril?

Ramipril is a type of medicine known as an angiotensin-converting enzyme (ACE) inhibitor. It is used to treat high blood pressure (hypertension) and heart failure. Treating high blood pressure helps to prevent heart attacks, strokes and kidney problems.

How does ramipril work?

Ramipril is an angiotensin-converting enzyme inhibitor (ACE inhibitor). Angiotensin-converting enzyme is involved in the production of a hormone called angiotensin II, which causes constriction of the vessels and elevation of blood pressure. Therefore, by inhibiting the production of this hormone, vessels relax and blood pressure is reduced. This reduces the effort required by the heart to pump blood around the body.

How long does ramipril take to work?

Ramipril will begin to lower blood pressure within just a few hours, but it will take a few weeks to have full effect.

Active ingredients

The active ingredient in ramipril tablets is ramipril.

Inactive ingredients

The inactive ingredients in ramipril are hypromellose, pregelatinised maize starch, microcrystalline cellulose, and sodium stearyl fumarate. The 2.5mg tablets also contain yellow ferric oxide (E172), and the 5 mg tablets also contain red ferric oxide (E172).

Please note: Different manufacturers of generic ramipril may use different inactive ingredients in their drugs than those listed here.

How to start taking ramipril?

Never start taking ramipril without the instruction of a doctor. To begin with, a doctor will start you on a low dose to reduce the risk of side effects. You can then build-up to the dose recommended for your condition. Take ramipril once a day at the same time each day. Tablets should be swallowed whole with water and should not be crushed or split.

Ramipril dosage

Always take ramipril as instructed by a doctor. The usual starting dose of ramipril is 1.25–2.5mg taken once daily and can be increased gradually over time until your blood pressure is controlled. For the treatment of high blood pressure, heart failure, for reducing the risk of heart attack or stroke or for treatment following a heart attack, the maximum daily dosage is 10mg.

Why do I take ramipril in the evening?

It is sometimes advised to take ramipril before bed, particularly the first dose, as it can make you feel dizzy.

Ramipril side effects

Like all medications, ramipril can cause side effects in some people. Stop taking ramipril and see a doctor immediately if you experience any of the following serious side effects:

• A severe allergic reaction to ramipril, including swelling of the face, lips or throat, difficulty breathing, itching or rashes.
• A severe skin reaction, including rash, ulcers in your mouth, worsening of pre-existing skin disease, reddening, blistering or detachment of skin.
• Yellow skin or eyes – this can be a sign of liver problems
• Unexpected bleeding or bruising, catching infections more easily, or feeling tired – this can indicate a blood disorder
• Faster, uneven or forceful heart rate, chest pain or tightness – this can be signs of a heart problem
• Shortness of breath, wheezing or a persistent cough – this can be a lung problem
• Severe stomach pain that may reach through to your back – this can indicate a problem with the pancreas
• Not passing as much urine as normal – this can be a sign of kidney problems
• Weakness in the arms or legs, or problems speaking – these may indicate a stroke

Common side effects (affecting up to 1 in 10 people) include:

• Dry, tickly cough
• Feeling dizzy
• Fainting, hypotension (abnormally low blood pressure)
• Headache
• Nausea or vomiting
• Diarrhoea, or constipation
• Mild skin rash
• Blurred vision
• Hair loss
• Sinusitis or bronchitis
• Dry mouth
• Breathlessness
• Stomach upset or gut pain
• Chest pain or angina
• Muscle pain or cramps
• Blood tests showing more potassium than usual in the blood
• Angioedema (rapid swelling of the skin)
• Palpitations or an irregular heartbeat
• Fatigue
• Drowsiness
• Sensory changes e.g. pins and needles or numbness
• Changes in kidney function
• Runny nose
• Sleep disorders
• Altered taste
• Tinnitus (ringing in the ears)
• Increased risk of infection
• Muscle spasms

Uncommon side effects can affect up to 1 in 100 people and include:

• Joint pain
• Confusion
• Erectile dysfunction
• Fever
• Anaemia
• Hyperhidrosis (increased sweating)
• Heart attack 
• Pancreatitis
• Peripheral oedema (swelling in the hands or feet)
• Sensitivity to sunlight
• Respiratory (lung) disorders
• Stroke
• Anxiety
• Decreased appetite
• Worsening of asthma
• Mood changes including depression
• Reduced libido
• Visual disorders

The following rare side effects can affect up to 1 in 1,000 people:

• Blood tests showing a decrease in red blood cells, white blood cells, platelets or haemoglobin
• Hepatitis (liver inflammation)
• Stevens-Johnson syndrome (a red rash typically causing blisters)
• Conjunctivitis (eye inflammation
• Hearing impairment
• Movement disorders
• Onycholysis (a disorder of the nails)
• Tremor
• Vasculitis (inflammation of the vessels, causing rash)

Other side effects (frequency not known):

• Altered sense of smell
• Bone marrow failure
• Impaired concentration
• Gynaecomastia (breast development or enlargement)
• Reynaud’s phenomenon (a condition of the vessels in the fingertips)
• Syndrome of inappropriate ADH (a problem with the kidney and regulation of urine)
• Toxic epidermal necrolysis (a severe blistering skin condition)

Contraindications

Do NOT take ramipril if you:

• Are allergic to any of the ingredients in this medication
• Have a history of angioedema, a severe allergic reaction that includes itching, hives, red marks on the hands, feet and throat, swelling around the eyes or lips, difficulty breathing and swallowing
• Are pregnant or breastfeeding

Before taking ramipril, tell your doctor if any of the following apply to you:

• You have heart problems including cardiomyopathy and valvular heart disease
• You have liver problems
• You have kidney problems, including if you are having dialysis
• You have diabetes 
• You are of black African or Caribbean origin
• You have any problem with the salts in your blood (e.g. potassium, sodium)
• You have lost a lot of salts or fluids through vomiting, diarrhoea, sweating more than usual, being on a low-salt diet, taking diuretics or having dialysis
• You have primary aldosteronism
• You are going to receive an anaesthetic
• You might become pregnant
• Your blood pressure is abnormally low or unstable
• You have severe or symptomatic aortic stenosis
• You are having desensitization treatment for wasp stings
• You have a collagen vascular disease such as scleroderma or systemic lupus erythematosus
• You have peripheral vascular disease or generalised atherosclerosis

Drug interactions

Before taking ramipril, tell your doctor if you are taking any other medicines, including those purchased over the counter without a prescription. 

In particular, tell your doctor if you are taking any of the following:

• Angiotensin receptor blockers (ARB) e.g. Candesartan, Lorsaran
• Calcium channel blockers e.g. Amlodipine
• Aliskiren
• Anti-inflammatory medicines such as Ibuprofen 
• Diuretics e.g. Indapamide, Bendroflumethiazide, Furosemide
• Allopurinol 
• Bee/wasp venom extracts
• Antacids
• Amiloride
• Eplerenone
• Heparins
• Potassium salts
• Trimethoprim
• Medicines for heart rhythm such as Digoxin or Procainamide
• Alpha-blockers e.g. Doxasocin 
• Medicines for diabetes e.g. Insulin, Metformin, and Sulfonylureas
• Lithium
• Steroid medicines for inflammation such as prednisolone
• Sacubitril/valsartan for treatment of long-term chronic heart failure
• Medicines used for the treatment of low blood pressure, shock, cardiac failure, asthma or allergies such as ephedrine, noradrenaline or adrenaline
• Chemotherapy medicines
• Medicines to stop the rejection of organs after surgery such as Ciclosporin, Temsirolimus, Sirolimus, Everolimus
• Spironolactone
• Racecadotril

How to cope with ramipril side effects?

The most common side effect of ramipril is dizziness, and your doctor will start by prescribing a low dose so that your body can adjust to the treatment. If you feel dizzy, or experience blurred vision, stop what you are doing and find somewhere to lie down until it has passed. Do not try to drive, ride a bike, or operate heavy machinery. Some people may experience headaches while taking ramipril, which can be managed by drinking plenty of fluids and taking painkillers if necessary. However, if headaches persist for longer than a week, speak to your doctor for advice.

Ramipril and pregnancy

Tell your doctor if you are pregnant or are planning to become pregnant. The use of ACE inhibitors is contraindicated in pregnancy, as it can be harmful to your baby. If you become pregnant while taking ramipril, consult your doctor immediately. Ramipril should not be taken while breastfeeding.

Ramipril and alcohol

Alcohol can increase the blood pressure-lowering effect of ramipril and cause you to feel dizzy or lightheaded. You should avoid alcohol altogether when you first start taking ramipril, or if you continue to experience dizziness during treatment.

Ramipril and driving

If you experience dizziness or blurred vision while taking ramipril, do not drive or ride a bike.

Alternatives to ramipril

There are a few different options available for treating high blood pressure. Patients who are over the age of 55 or of Afro-Caribbean descent may be better suited to an alternative treatment, as ACE inhibitors are thought to be less effective for these groups. Alternative medications for treating high blood pressure include ACE inhibitors, diuretics, angiotensin receptor blockers (ARB) and beta-blockers. Speak to a doctor to find out which type of blood pressure medication is best for you.

Lifestyle changes to make when taking ramipril

Alongside treatment, it is important to make a few lifestyle changes to boost the health of your heart. Eating too much salt is one of the main causes of high blood pressure, so try not to eat more than 6g of salt per day. Try also to cut back on fatty foods, and include plenty of fruit and vegetables, whole grains and lean protein. Exercising regularly helps to keep your heart and blood vessels in good condition and also help you deal with stress. Stress can cause your blood pressure to rise so try to find ways to avoid it, such as spending time with friends and family, going for walks and giving yourself time to relax where possible. If you haven’t already done so, quit smoking, and try and reduce the amount of alcohol you drink.

Ramipril vs lisinopril

Ramipril and lisinopril are both ACE inhibitors that work in the same way with a similar risk of side effects. The active ingredient in ramipril is ramipril, and the active ingredient in lisinopril is lisinopril dihydrate. Ramipril has been shown to be more effective than lisinopril at reducing blood pressure and reducing mortality. 

What will happen if I stop taking ramipril?

Never stop taking ramipril without first consulting a doctor, as this can cause a dangerous rise in blood pressure and increase your risk of experiencing a heart attack or stroke.

Can I stop taking ramipril when my blood pressure is reduced?

Even if your blood pressure is reduced, it is recommended that you continue to take ramipril. This medication is usually taken for life, as coming off it can cause your blood pressure to rise and lead to a heart attack or stroke.

Can I take ramipril before surgery?

If you are scheduled to undergo surgery that requires a general anaesthetic, let your doctor know if you are taking ramipril. They may advise you to stop taking it 24 hours before you undergo surgery.

Will I need to take ramipril forever?

Ramipril is intended for long-term use and is usually taken for the rest of your life.

Is ramipril a statin?

Ramipril is not a statin. Statins are used in the treatment of high cholesterol. You may be prescribed both ramipril and a statin to reduce your overall risk of cardiovascular events.

Is ramipril a beta blocker?

Ramipril is not a beta-blocker, it is an ACE inhibitor. Both beta-blockers and ACE inhibitors are used to reduce blood pressure.

What should I do if ramipril isn’t working for me?

It can take several weeks before you get the full benefits of taking ramipril. If your condition does not improve or worsens, speak to your doctor for advice.