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Ramipril: 7 things you should know

Medically reviewed by Carmen Pope, BPharm. Last updated on April 4, 2023.

1. How it works

  • Ramipril may be used for the treatment of high blood pressure or heart failure that occurs following a heart attack.
  • Ramipril works by inhibiting an enzyme called angiotensin-converting enzyme (ACE). This enzyme is involved in the production of angiotensin II, a powerful vasoconstrictor (narrows arteries), which also stimulates the release of the hormone aldosterone from the adrenal glands (aldosterone can increase blood pressure). By inhibiting this enzyme, ramipril opens up the arteries (vasodilates) and lowers blood pressure. This also reduces how hard the heart has to work to pump blood around the body, helping to relieve the symptoms of heart failure.
  • Ramipril belongs to a group of medicines known as angiotensin-converting enzyme (ACE) inhibitors. It may also be called a nonsulfhydryl ACE inhibitor.

2. Upsides

  • May be used for the treatment of high blood pressure.
  • Ramipril may also be used to treat heart failure (usually in conjunction with other agents) or heart failure that occurs in stable patients within the first few days of a heart attack.
  • Ramipril is also approved for the prevention of major cardiovascular events (such as cardiovascular death, a heart attack, or stroke) in people aged 55 and over who are at high risk for a cardiovascular event. This includes people with a history of coronary artery disease, stroke, or diabetes who have at least one other cardiovascular risk factor, such as high blood pressure, high total cholesterol or decreased HDL-cholesterol, smoking, or microalbuminuria) but without LVEF or heart failure.
  • Ramipril slows the rate of progression of kidney disease in people with diabetes with albuminuria greater than 30 mg/24 hours.
  • In high blood pressure, ramipril reduces both lying down and standing blood pressure without a significant orthostatic effect (this is the drop in blood pressure that may occur when you go from a sitting to a standing position). However, people who become dehydrated while taking ramipril are at higher risk of an orthostatic effect.
  • In people with heart failure, ramipril decreases the size of the heart and increases how much blood the heart can pump out. It also increases exercise tolerance, without having much of an effect on heart rate. Ramipril use can decrease the severity of heart failure, rates of hospitalization, and symptoms such as shortness of breath and tiredness. Beneficial effects remain apparent with continued dosing.
  • Effective alone or in combination with other treatments for high blood pressure.
  • May be administered once or twice a day.
  • Generic ramipril is available.

3. Downsides

If you are between the ages of 18 and 60, take no other medication or have no other medical conditions, side effects you are more likely to experience include:

  • A headache, dizziness, and fatigue.
  • A dry cough that usually resolves on discontinuation of therapy. This side effect is common to all ACE inhibitors.
  • Occasionally, ramipril may cause excessive lowering of blood pressure but the risk is higher in those on diuretic therapy or who are sodium depleted or dehydrated.
  • Rarely may cause angioedema of the face, lips, tongue, throat, and extremities. May occur at any time during treatment. Immediate discontinuation is warranted if angioedema is affecting breathing.
  • Also rare is the development of blood disorders and kidney and liver failure.
  • May increase blood potassium levels, the risk is higher in people with diabetes, poor kidney function, and in people using potassium-sparing diuretics or taking potassium supplements.
  • May have less of a blood pressure-lowering effect in patients of African-American descent compared to those without this ethnicity. Also, the incidence of angioedema (a skin reaction associated with head and neck swelling) is higher in African-American patients.
  • May not be suitable for some people and can interact with several other medications (including NSAIDs and lithium) - consult your prescribing doctor before taking any other medications including those brought over the counter. A dosage reduction may be needed in people with kidney disease.
  • Should not be used by women who are pregnant or at risk of pregnancy because it may cause injury or death to the developing fetus.
  • Ongoing monitoring of blood pressure, kidney function, and electrolyte levels is recommended.

Note: In general, seniors or children, people with certain medical conditions (such as liver or kidney problems, heart disease, diabetes, seizures) or people who take other medications are more at risk of developing a wider range of side effects. View complete list of side effects

4. Bottom Line

Ramipril is used for the treatment of high blood pressure and also for heart failure that occurs immediately following a heart attack. Ramipril, as with other ACE inhibitors, may not be as effective in people of African-American descent.

5. Tips

  • Usually administered once daily; however, your doctor may decide to prescribe it to you twice daily if it appears the effects of ramipril are wearing off quickly. Ensure you are adequately hydrated before starting ramipril. If you are taking ramipril for high blood pressure, continue this medication even if you feel well. High blood pressure does not usually have symptoms.
  • Swallow whole, do not crush or chew. If necessary, open up the contents of the capsule and sprinkle on applesauce or mix with water or apple juice. May be taken with or without food.
  • Treatments that lower blood pressure, such as ramipril, should always be part of a comprehensive cardiovascular risk reduction plan (that also targets, if appropriate, cholesterol-lowering, diabetes risk reduction, exercise, weight loss, and smoking cessation).
  • Report any signs of fever or a sore throat to your doctor who may carry out further tests to ensure it is not neutropenia (a decrease in white blood cells). Also report any signs or symptoms of angioedema (swelling of face or throat, difficulty breathing) immediately to your doctor.
  • Your doctor should monitor your blood pressure, kidney function, and potassium levels regularly.
  • May cause a fall in blood pressure that may be noticed as light-headedness, especially when you rise from a sitting or lying down position. This usually goes away after a few days of therapy. However, if it persists, call your doctor and ask for his/her advice; symptoms usually resolve with continued therapy. Ensure you do not become dehydrated. If you develop excessively low blood pressure, lie down and seek immediate medical attention.
  • Also call your doctor if you develop chest pain, a change in your heartbeat, or weakness.
  • Do not use salt substitutes or supplements containing potassium without first consulting your doctor.
  • Ensure you use adequate contraception or abstain from sex to avoid pregnancy while taking ramipril. If you inadvertently become pregnant while taking ramipril, contact your healthcare provider immediately.
  • If you also have diabetes, you may need to monitor your blood sugar levels more closely during the first few weeks of ramipril therapy.
  • Limit your alcohol intake while taking ramipril because alcohol can further lower your blood pressure and increase the risk of side effects.
  • Talk to your doctor or pharmacist before taking other medications or supplements brought over the counter because some may interact with ramipril.

6. Response and effectiveness

  • Peak concentrations of ramipril are reached within an hour of oral administration.
  • Blood pressure-lowering effects are seen within an hour of oral administration with peak effects achieved within four to six hours. These are maintained for at least 24 hours, although in some patients these effects may diminish towards the end of the 24-hours. It may take several weeks before optimal blood pressure-lowering effects are achieved.
  • Abrupt withdrawal of ramipril has not resulted in an abrupt increase in blood pressure; however, as with most antihypertensive drugs, it is best to discontinue ramipril slowly.
  • Studies have shown that ramipril is as effective and well tolerated as enalapril.

7. Interactions

Medicines that interact with ramipril may either decrease its effect, affect how long it works, increase side effects, or have less of an effect when taken with ramipril. An interaction between two medications does not always mean that you must stop taking one of the medications; however, sometimes it does. Speak to your doctor about how drug interactions should be managed.

Common medications that may interact with ramipril include:

  • aliskiren
  • allopurinol (may enhance the potential for allergic reactions)
  • amifostine
  • amphetamines
  • antipsychotic agents (may enhance the blood pressure-lowering effect)
  • aspirin
  • azathioprine
  • diuretics
  • duloxetine
  • ferric gluconate
  • gold injections for arthritis
  • grass pollen allergen extract
  • heparin
  • levodopa
  • lithium
  • NSAIDs, such as ibuprofen, diclofenac, and naproxen
  • other ACE inhibitors (such as captopril or lisinopril) or ARBs (such as candesartan or irbesartan)
  • phosphodiesterase-5-inhibitors, such as sildenafil
  • potassium supplements or medications that increase potassium levels (such as spironolactone)
  • trimethoprim.

Ramipril may also cause blood sugar levels to drop more than expected when taken with diabetes medication, including insulin. Increased blood sugar monitoring may be required.

Note that this list is not all-inclusive and includes only common medications that may interact with ramipril. You should refer to the prescribing information for ramipril for a complete list of interactions.


Further information

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use ramipril only for the indication prescribed.

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Copyright 1996-2023 Revision date: April 4, 2023.