Ramipril: NHS prescribing information and patient guide

Ramipril belongs to a class of medicines called angiotensin-converting enzyme (ACE) inhibitors.

It works by relaxing and widening blood vessels, which lowers blood pressure and reduces the workload on your heart.

The NHS prescribes ramipril for several conditions:

• High blood pressure (hypertension): to reduce the risk of stroke, heart attack, and kidney problems
• Heart failure: to improve survival and reduce symptoms such as breathlessness and fluid retention
• After a heart attack: to protect the heart muscle and prevent further cardiac events
• Diabetic kidney disease: to slow the progression of kidney damage in patients with diabetes
• Prevention of cardiovascular events: in high-risk patients, even if blood pressure is already well controlled

According to NICE guidelines (NG136), ACE inhibitors such as ramipril are recommended as first-line treatment for hypertension in adults under 55, and for patients with type 2 diabetes at any age.

Ramipril is available in tablet and capsule form in strengths of 1.25 mg, 2.5 mg, 5 mg, and 10 mg.

The BNF provides clear dosing recommendations for ramipril, which NHS prescribers follow. The dose is always tailored to your individual needs and the condition being treated.

For high blood pressure:

• Starting dose: 1.25 mg to 2.5 mg once daily
• Maintenance dose: 2.5 mg to 10 mg once daily
• The dose is usually increased at intervals of two to four weeks

For heart failure:

• Starting dose: 1.25 mg once daily
• Target dose: 10 mg once daily (or maximum tolerated dose)
• Dose increases are made gradually under medical supervision

After a heart attack:

• Starting dose: 2.5 mg twice daily, changing to 5 mg twice daily after two days
• Maintenance dose: adjusted based on tolerance

Important points:

• Take ramipril at the same time each day, with or without food
• If you miss a dose, take it as soon as you remember unless it is nearly time for your next dose
• Do not take a double dose to make up for a missed one
• Your doctor should check your blood pressure, kidney function, and potassium levels regularly, particularly during the first few months

For detailed dosing information, see our ramipril dosage guide.

Ramipril can interact with a number of other medicines and supplements. The BNF lists several important interactions that your prescriber and pharmacist should be aware of.

Key interactions include:

• NSAIDs (ibuprofen, naproxen): can reduce the blood-pressure-lowering effect and increase the risk of kidney damage
• Potassium supplements or potassium-sparing diuretics (spironolactone, amiloride): increase the risk of dangerously high potassium levels
• Lithium: ramipril can raise lithium levels, requiring closer monitoring
• Other blood pressure medicines: combining multiple antihypertensives increases the risk of low blood pressure
• Aliskiren: concurrent use is contraindicated in patients with diabetes or moderate to severe kidney impairment

Ramipril should not be taken if you:

• Are pregnant or planning to become pregnant (it can harm the developing baby)
• Have a history of angioedema
• Have bilateral renal artery stenosis
• Are breastfeeding

Use with caution in patients with:

• Kidney impairment (dose adjustment may be needed)
• Aortic stenosis or hypertrophic cardiomyopathy
• Connective tissue diseases such as systemic lupus erythematosus

Always tell your doctor about all medicines, supplements, and herbal remedies you are taking before starting ramipril.

When you start ramipril, your GP practice will arrange regular monitoring to ensure the medication is working safely. This is a standard part of NHS prescribing for ACE inhibitors.

Before starting treatment:

• Baseline blood test for kidney function (eGFR and creatinine) and electrolytes (potassium and sodium)
• Blood pressure measurement

After starting or changing the dose:

• Blood test within one to two weeks to check kidney function and potassium
• Blood pressure check to ensure adequate control without excessive lowering

Ongoing monitoring:

• Annual blood test as part of your regular medication review
• More frequent monitoring if you have kidney disease, diabetes, or are taking other medicines that affect potassium

NICE recommends that GPs use these checks as an opportunity to review your cardiovascular risk more broadly, including cholesterol levels, smoking status, and lifestyle factors.

If your blood tests show a significant rise in creatinine (more than 30 per cent from baseline) or potassium above 5.5 mmol/L, your doctor may need to reduce the dose or consider an alternative.

Ramipril is available as an NHS prescription and is one of the most cost-effective blood pressure medicines. Here is what you need to know about accessing it.

Prescriptions:

• Ramipril requires a prescription from a doctor, nurse prescriber, or pharmacist prescriber
• It is available as tablets (1.25 mg, 2.5 mg, 5 mg, 10 mg) and capsules
• Generic ramipril is widely available and is the standard choice on the NHS
• Most patients pay the standard NHS prescription charge, though many with long-term conditions may be exempt

Repeat prescriptions:

• Once your dose is stable, your GP can set up a repeat prescription
• Many practices offer electronic repeat dispensing, allowing your pharmacist to dispense monthly supplies without needing a new prescription each time
• You will still need an annual medication review

NHS pharmacy services:

• Community pharmacists can answer questions about ramipril side effects and interactions
• The NHS Blood Pressure Check service is available at many pharmacies for adults over 40
• Some pharmacies offer medication use reviews (MURs) to help you get the most from your treatment

If you are concerned about the cost of prescriptions, ask your pharmacist about prepayment certificates, which can save money if you need multiple items each month.