Ramipril - EM Doctors

1. About ramipril

Ramipril is a medicine widely used to treat high blood pressure and heart failure. It's also prescribed after a heart attack.

Ramipril helps prevent future strokes, heart attacks and kidney problems. It also improves your survival if you're taking it for heart failure or after a heart attack.

This medicine is available on prescription. It comes as tablets, capsules and as a liquid that you swallow.

NHS coronavirus advice

If you have coronavirus, or think you might have it, keep taking your blood pressure medicines as usual.

There is no clear evidence that taking angiotensin-converting enzyme (ACE) inhibitors like ramipril will cause complications.

Updated: 17 March 2020

2. Key facts

Ramipril lowers your blood pressure and makes it easier for your heart to pump blood around your body.
Your very first dose of ramipril may make you feel dizzy, so it's best to take it at bedtime. After that you can take ramipril at any time of day.
Some people get a dry, irritating cough with ramipril.
If you get severe diarrhoea or vomiting from a stomach bug or illness, tell your doctor. You may need to stop taking ramipril for a while until you feel better.
Drinking alcohol can increase the blood pressure-lowering effect of ramipril, which can make you feel dizzy or lightheaded.
Ramipril is also called by the brand name Tritace.

3. Who can and can't take ramipril

Ramipril can be taken by adults aged 18 and over.

If you have diabetes, check your blood sugar (glucose) more often, particularly in the first few weeks.

This is because ramipril can lower the sugar level in your blood.

Ramipril is not suitable for everyone.

To make sure ramipril is safe for you, tell your doctor if you:

have had an allergic reaction to ramipril or any other medicine in the past
are trying to get pregnant, are already pregnant or you're breastfeeding
are having dialysis or any other type of blood filtration
have heart, liver or kidney problems
have unstable or low blood pressure
have diabetes
are going to have a major operation (surgery) or general anaesthetic to put you to sleep
have recently had any diarrhoea or vomiting
are on a low-salt diet
are going to have desensitisation treatment to reduce your allergy to insect stings
have a blood problem such as low white blood cell count (neutropenia or agranulocytosis)

4. How and when to take it

It's usual to take ramipril once or twice a day.

You may be advised to take your first dose before bedtime, because it can make you dizzy.

After the very first dose, you can take ramipril at any time during the day.

Try to take it at the same time every day.

You can take ramipril with or without food. Swallow ramipril tablets or capsules whole with a drink.

If you're taking ramipril as a liquid, it'll come with a plastic syringe or spoon to help you measure out the right dose.

If you don't have one, ask your pharmacist for one. Do not use a kitchen teaspoon as it won't give the right amount.

How much will I take?

The dose of ramipril you take depends on why you need the medicine. Take it as instructed by your doctor.

To decide the correct dose for you, your doctor will check your blood pressure and ask you if you're getting any side effects.

You may also have blood tests to check how well your kidneys are working and the amount of potassium in your blood.

Depending on why you're taking ramipril, the usual starting dose is between 1.25mg once a day and 2.5mg twice a day.

This will be increased gradually over a few weeks to a usual dose of:

2.5mg to 5mg once a day for high blood pressure
5mg twice a day or 10mg once a day for heart failure or after a heart attack

If you're bothered by side effects with ramipril, you may stay on a lower dose.

The maximum dose is 5mg twice a day or 10mg once a day.

Will my dose go up or down?

You will probably be prescribed a low dose of ramipril at first so it doesn't make you feel dizzy.

This will usually be increased gradually until you reach the right dose for you.

The first time you may be prescribed a pack that contains tablets of 3 different strengths of ramipril (2.5mg, 5mg and 10mg).

Your doctor will tell you which strength to take, how often to take it, and when or if you need to increase your dose.

Important

Take ramipril even if you feel well, as you will still be getting the benefits of the medicine.

What if I get ill while I'm taking it?

If you get severe diarrhoea or vomiting for any reason, stop taking ramipril.

When you're able to eat and drink normally, wait for 24 to 48 hours, then start to take it again.

If you have questions about this, contact your doctor or pharmacist.

What if I forget to take it?

If you miss a dose of ramipril, leave out that dose and take your next dose at the usual time.

Do not take a double dose to make up for the forgotten dose.

If you forget doses often, it may help to set an alarm to remind you.

You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What if I take too much?

If you take too many ramipril tablets by accident, contact your doctor or go to your your nearest A&E straight away.

An overdose of ramipril can cause dizziness, sleepiness and a pounding heartbeat.

The amount of ramipril that can lead to an overdose varies from person to person.

Urgent advice: Call your doctor or go to A&E straight away if you take too much ramipril

If you need to go to hospital, do not drive yourself - get someone else to drive you or call for an ambulance.

Take the ramipril packet or leaflet inside it, plus any remaining medicine, with you.

5. Side effects

Like all medicines, ramipril can cause side effects in some people, but many people have no side effects or only minor ones.

Side effects often improve as your body gets used to the medicine.

Common side effects

These common side effects happen in more than 1 in 100 people.

Talk to your doctor or pharmacist if these side effects bother you or don't go away:

a dry, tickly cough that does not go away
feeling dizzy or lightheaded, especially when you stand up or sit up quickly (this is more likely to happen when you start taking ramipril or move on to a higher dose)
headaches
diarrhoea and being sick (vomiting)
a mild skin rash
blurred vision

Serious side effects

It happens rarely, but some people have serious side effects after taking ramipril.

Call a doctor straight away if you get:

yellow skin or the whites of your eyes turn yellow - this can be a sign of liver problems
paleness, feeling tired, faint or dizzy, any sign of bleeding (like bleeding from the gums and bruising more easily), sore throat and fever and getting infections more easily - these can be signs of a blood or bone marrow disorder
a faster heart rate, chest pain and tightness in your chest - these can be signs of heart problems
shortness of breath, wheezing and tightening of the chest - these can be signs of lung problems
severe stomach pain - this can be a sign of an inflamed pancreas
swollen ankles, blood in your pee or not peeing at all - these can be signs of kidney problems
weak arms and legs or problems speaking - these can be signs of a stroke

If you suspect that you or someone else is having a stroke, phone 999 immediately and ask for an ambulance.

Serious allergic reaction

In rare cases, ramipril may cause a serious allergic reaction (anaphylaxis).

Immediate action required: Call 999 or go to A&E if:

you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you're wheezing
you get tightness in the chest or throat
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling

You could be having a serious allergic reaction and may need immediate treatment in hospital.

These aren't all the side effects of ramipril.

For a full list, see the leaflet inside your medicine packet.

You can report any suspected side effect to the UK safety scheme.

6. How to cope with side effects

What to do about:

a dry irritating cough - cough medicines don't usually help for coughs caused by ramipril. Sometimes the cough gets better on its own. Talk to your doctor if it carries on, bothers you or stops you sleeping, as another medicine may be better. Even if you stop taking ramipril, the cough may take a few days to a month to go away.
feeling dizzy - if ramipril makes you feel dizzy when you stand up, try getting up very slowly or stay sitting down until you feel better. If you begin to feel dizzy, lie down so that you don't faint, then sit until you feel better.
headaches - make sure you rest and drink plenty of fluids. Do not drink too much alcohol. Ask your pharmacist to recommend a painkiller. Talk to your doctor if they last longer than a week or are severe.
diarrhoea and being sick (vomiting) - drink plenty of fluids, such as water or squash, to prevent dehydration. If you're being sick, take small, frequent sips of fluid. Speak to a pharmacist if you have signs of dehydration, such as peeing less than usual or having dark, strong-smelling pee. Do not take any other medicines to treat diarrhoea or vomiting without speaking to a pharmacist or doctor. If you get diarrhoea or vomiting from a stomach bug or illness, tell your doctor. You may need to temporarily stop taking ramipril until you feel better.
itching or a mild rash - it may help to take an antihistamine, which you can buy from a pharmacy. Check with the pharmacist to see what type is suitable for you.
blurred vision - avoid driving or using tools or machines while this is happening. If it lasts for more than a day or two, speak to your doctor as they may need to change your treatment.

7. Pregnancy and breastfeeding

Ramipril is not normally recommended in pregnancy or when breastfeeding.

But it may be prescribed if your doctor thinks the benefits of the medicine outweigh the risks.

If you're planning a pregnancy or already pregnant, talk to your doctor about the benefits and possible harms of taking ramipril.

These will depend on how many weeks pregnant you are and the reason you need to take it. There may be other treatments that are safer for you.

For more information about how ramipril can affect you and your baby during pregnancy, read this leaflet on the Best Use of Medicines in Pregnancy (BUMPS) website.

Ramipril and breastfeeding

Small amounts of ramipril may get into breast milk. This can cause low blood pressure in the baby.

Talk to your doctor, as other medicines might be better while you're breastfeeding.

Non-urgent advice: Tell your doctor if you're:

trying to get pregnant
pregnant
breastfeeding

8. Cautions with other medicines

There are some medicines that may interfere with the way ramipril works.

Tell your doctor if you're taking:

anti-inflammatory medicines, such as ibuprofen, indomethacin or aspirin for pain relief (low-dose aspirin - 75mg a day - is safe to take with ramipril)
medicines to treat low blood pressure, heart failure, asthma or allergies, such as ephedrine, noradrenaline or adrenaline
medicines for high blood pressure, such as aliskeren
medicines that can lower your blood pressure, such as some antidepressants, nitrates (for chest pain), baclofen (a muscle relaxant), anaesthetics or medicines for an enlarged prostate gland
medicines to damp down your immune system, such as ciclosporin or tacrolimus
medicines that make you pee more, such as furosemide
medicines that can increase the amount of potassium in your blood, such as spironolactone, triamterene, amiloride, potassium supplements, trimethoprim (for infections) and heparin (for thinning blood)
steroid medicines, such as prednisolone
allopurinol (for gout)
procainamide (for heart rhythm problems)
medicines for diabetes
racecadotril (for diarrhoea)
lithium (for mental health problems)

Mixing ramipril with herbal remedies or supplements

There's very little information about taking herbal remedies and supplements with ramipril.

Important

For safety, tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements.

9. Common questions

How does ramipril work?

How long does ramipril take to work?

Ramipril starts to work within a few hours to reduce high blood pressure, but it may take a few weeks for full effect.

If you're taking ramipril for heart failure, it may take weeks, even months, before you feel better.

If you're taking ramipril for high blood pressure or after a heart attack, you may not have any symptoms.

In these cases, you may not feel any different when you take ramipril.

This doesn't mean that the medicine isn't working - and it's important to keep taking it.

How long will I take it for?

Is ramipril safe to take for a long time?

What will happen if I stop taking it?

Can I come off ramipril now my blood pressure is lower?

Even if your blood pressure is successfully lowered by ramipril, it's best to carry on taking it.

If you stop taking ramipril, your blood pressure could rise back up again.

If you need blood pressure-lowering medicines, you'll probably need to take them for the rest of your life.

Remember, by keeping your blood pressure low, you're protecting yourself against having a heart attack or stroke in the future.

Can I drink alcohol with it?

Are there similar medicines to ramipril?

There are several other ACE inhibitor medicines that work in the same way as ramipril.

They include enalapril, lisinopril and perindopril.

There are also lots of other types of blood pressure-lowering medicines:

calcium channel blockers - for example, amlodipine
angiotensin receptor blockers - for example, candesartan
beta blockers - for example, bisoprolol
diuretics - for example, bendroflumethiazide

If you can't take ramipril or other ACE inhibitor medicines because of side effects such as a dry cough, you may be able to switch to another type of blood pressure-lowering medicine.

This will usually be an angiotensin receptor blocker, such as candesartan, irbesartan, losartan or valsartan.

What are the differences between ramipril and other ACE inhibitors?

Ramipril works as well as other ACE inhibitors when you take it to lower blood pressure and for heart failure.

The side effects are also similar to those of other ACE inhibitors.

There are a few differences between ramipril and other ACE inhibitors.

Ramipril is officially approved to be used for reducing the risk of having a heart attack or stroke, but other ACE inhibitors may not be.

It's also approved for reducing or delaying kidney problems, but other ACE inhibitors may not be.

Can I take ramipril before surgery?

Is ramipril addictive?

Will it affect my contraception?

Will it affect my fertility?

Is there any food or drink I need to avoid?

Can I drive or ride a bike?

Can lifestyle changes help?

You can boost the health of your heart by making some key lifestyle changes.

These will also help if you have high blood pressure or heart failure:

quit smoking - smoking increases your heart rate and blood pressure. Quitting smoking brings down your blood pressure and relieves heart failure symptoms. Try to avoid secondhand smoke.
cut down on alcohol - drinking too much alcohol raises blood pressure over time. It makes heart failure worse, too. Try to keep to the recommended guidelines of no more than 14 units of alcohol a week. A standard glass of wine (175ml) is 2 units. A pint of lager or beer is usually 2 to 3 units of alcohol.
exercise - regular exercise lowers blood pressure by keeping your heart and blood vessels in good condition. It doesn't need to be too energetic - walking every day will help.
eat well - aim to eat a diet that includes plenty of fruit and veg, wholegrains, fat-free or low-fat dairy products and lean proteins. It's a good idea to cut down on salt, too. Eating too much salt is the biggest cause of high blood pressure - the more salt you eat, the higher your blood pressure will be. Aim for no more than 6g of salt a day.
deal with stress - when you're anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. This can make heart failure worse, too. Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible. Spend time with friends and family to be social and help avoid stress.
vaccinations - if you have heart failure, it's recommended that you have a flu jab every year and a pneumonia vaccination (also known as the pneumococcal vaccine) every 5 years. Ask your doctor about these vaccinations. You can have them free on the NHS.