Ramipril side effects: what you need to know

The most frequently reported side effects of ramipril are generally mild and tend to improve as your body adjusts to the medication.

According to the BNF, these affect up to 1 in 10 people taking the medicine.

Common side effects include:

• Dry cough: the most characteristic ACE inhibitor side effect, affecting around 5 to 10 per cent of patients. It is a persistent, tickly cough that does not produce phlegm
• Dizziness or light-headedness: particularly when standing up quickly, most noticeable during the first few days of treatment
• Headaches: usually mild and tend to resolve within the first week
• Fatigue: feeling more tired than usual, especially during dose adjustments
• Nausea: mild stomach upset that often settles with food

These side effects are a result of how ramipril works by inhibiting the angiotensin-converting enzyme.

The dry cough, for instance, occurs because ACE inhibitors increase levels of bradykinin in the lungs.

If any of these symptoms persist beyond a few weeks or significantly affect your daily life, speak to your GP about adjusting your dosage or considering an alternative medication.

Although serious side effects of ramipril are uncommon, it is essential to recognise them promptly. The MHRA and NICE advise seeking immediate medical help if you experience any of the following.

Angioedema:

This is a rare but potentially life-threatening allergic reaction causing swelling of the face, lips, tongue, or throat. It can make breathing and swallowing difficult.

If you notice any swelling, stop taking ramipril and call 999 immediately. Angioedema can occur at any point during treatment, even after months of use.

Hyperkalaemia (high potassium levels):

Ramipril can raise potassium levels in the blood, particularly if you have kidney problems or take potassium-sparing diuretics.

Symptoms may include muscle weakness, an irregular heartbeat, or numbness and tingling. Your doctor should arrange regular blood tests to monitor this.

Kidney impairment:

ACE inhibitors can affect kidney function, particularly in patients with pre-existing renal disease or renal artery stenosis.

A rise in creatinine levels during the first few weeks of treatment may require dose adjustment.

Severe hypotension:

A marked drop in blood pressure can cause fainting, particularly after the first dose or following dose increases. This risk is higher in patients who are volume-depleted or taking diuretics.

Some side effects of ramipril occur less frequently but are still worth knowing about. These affect between 1 in 100 and 1 in 1,000 people.

• Skin rashes: including itching, redness, and photosensitivity reactions
• Taste disturbances: a metallic or altered taste that usually resolves over time
• Gastrointestinal symptoms: diarrhoea, constipation, or abdominal discomfort
• Muscle cramps: occasionally reported, particularly in the legs
• Mood changes: mild anxiety or sleep disturbances have been documented
• Dry mouth: related to the same mechanism that causes the dry cough

The BNF notes that most of these effects are dose-dependent, meaning they may improve if your prescriber reduces the dosage.

If you are experiencing bothersome symptoms, do not stop your medication without medical advice, as sudden discontinuation of ramipril can cause a rebound increase in blood pressure.

The dry cough associated with ramipril is one of the most common reasons patients request a change of medication. Understanding why it occurs can help you make an informed decision with your doctor.

Why does it happen?

Ramipril inhibits ACE, which normally breaks down bradykinin. The resulting accumulation of bradykinin in the lungs triggers a persistent, non-productive cough.

This is a class effect of all ACE inhibitors and is not related to the dose.

Key features of the ACE inhibitor cough:

• It is dry and tickly, without phlegm
• It may worsen at night or when lying down
• It can develop weeks or even months after starting treatment
• It is more common in women and in non-smokers

What can you do?

• Speak to your GP. They may suggest switching to an angiotensin receptor blocker (ARB) such as losartan or candesartan, which rarely causes cough
• Do not stop ramipril without medical advice
• The cough typically resolves within one to four weeks of stopping the medication

NICE guidelines recommend ARBs as an appropriate alternative for patients who develop an ACE inhibitor cough.

Certain groups of patients are more susceptible to ramipril side effects. Your prescriber should take these factors into account when starting or adjusting your treatment.

Higher-risk groups include:

• Patients with kidney disease: reduced renal function increases the risk of hyperkalaemia and further kidney impairment
• Older adults: more prone to dizziness and falls due to blood pressure changes
• People taking multiple medications: interactions with NSAIDs, potassium supplements, or diuretics can increase the risk of side effects
• Patients with heart failure: the first dose can cause significant hypotension, which is why treatment is often started under medical supervision
• People of African-Caribbean descent: ACE inhibitors may be less effective and cause more side effects in this group, as noted in NICE hypertension guidelines

If you fall into any of these categories, your doctor should monitor you more closely, particularly during the first few weeks of treatment.

Regular blood tests to check your kidney function and potassium levels are essential.

Most ramipril side effects are manageable, but there are situations where you should seek medical advice promptly.

Contact your GP or pharmacist if you experience:

• A persistent dry cough that affects your sleep or daily activities
• Dizziness that does not improve after the first few days
• Skin rashes or itching
• Swollen ankles or unexplained weight gain
• Muscle weakness or cramps

Seek urgent medical attention (call 999 or go to A&E) if you notice:

• Swelling of the face, lips, tongue, or throat (angioedema)
• Difficulty breathing or swallowing
• Chest pain or a very irregular heartbeat
• Signs of a severe allergic reaction such as widespread rash with blistering

The NHS advises that you should never stop taking ramipril suddenly without speaking to your doctor first.

If side effects are troublesome, your GP can discuss reducing your dose, changing the time you take the tablet, or switching to a different blood pressure medication.