Scriptonline

Ramipril: uses, dosage and side effects

Ramipril is an ACE inhibitor. It is prescription-only in Ireland and is used for high blood pressure, for heart failure, after a heart attack and to reduce cardiovascular risk. This page explains what it is used for, how it is taken, its side effects, the blood tests that go with it and how an existing prescription is renewed.

What ramipril is used for

Ramipril is used to lower high blood pressure, to treat heart failure, to protect the heart after a heart attack and to reduce the risk of heart attack, stroke and cardiovascular death in people at high risk. It is also used to slow the progression of kidney disease in some people, particularly where protein is leaking into the urine. It is an angiotensin converting enzyme inhibitor: it blocks the production of a substance that narrows blood vessels, so the vessels relax and pressure falls. High blood pressure normally causes no symptoms, so the benefit is measured in readings and in long-term risk rather than in how you feel from day to day. That is why ramipril is taken continuously, often for years, and why it is not something to take only when you feel unwell. Chest pain at rest, or pain with sweating and breathlessness, is an emergency and needs 112 or 999 rather than an extra tablet.

Side effects of ramipril

The best known side effect is a dry, persistent, tickly cough, which can start weeks or months after beginning treatment and does not respond to cough medicine. It is not dangerous, but it is a common reason for a doctor to switch to a different class of medicine, so mention it rather than putting up with it. Dizziness, especially after the first dose or a dose increase, headache, tiredness and nausea are also reported. One reaction needs emergency care: swelling of the face, lips, tongue or throat, or difficulty breathing or swallowing. This is angioedema, it is uncommon but it can be life-threatening, and it can appear after months of uneventful treatment. Stop the medicine and call 112 or 999. Also contact a doctor promptly for fainting, a marked reduction in how much urine you pass, yellowing of the skin or eyes, signs of infection with fever, or symptoms of a high potassium level such as muscle weakness and an irregular heartbeat.

Dosage and how to take ramipril

Ramipril is taken by mouth once a day in most cases, at about the same time each day, and the capsules or tablets are swallowed with water. The prescriber sets the strength, normally starting low and increasing in steps with blood pressure readings and blood tests in between, because the aim is the dose that controls the pressure without dropping it too far. The first dose is often taken at bedtime, since dizziness is most likely then. Blood tests belong to the treatment: kidney function and potassium are checked before or shortly after starting and after dose increases. If you miss a dose, take the next one at the usual time rather than doubling up. If you develop a severe stomach upset with vomiting or diarrhoea, or become dehydrated in hot weather, contact your GP practice, because ACE inhibitors are sometimes paused during dehydration to protect the kidneys. Do not stop the medicine on your own because your readings look normal.

Is ramipril available without a prescription in Ireland?

No. Ramipril is a prescription-only medicine in Ireland and no pharmacy can supply it without a valid prescription. This class of medicine needs blood tests for kidney function and potassium, and the dose is titrated against readings, so supply without a prescription would remove exactly the checks that make it safe. If you want your blood pressure measured, a pharmacy or your GP practice can do it. Ramipril is not a controlled drug, so it is not among the substances excluded from cross-border prescriptions under Article 11(6) of Directive 2011/24/EU. A prescription issued by a prescriber elsewhere in the EU or EEA can be presented in an Irish pharmacy, and the Pharmaceutical Society of Ireland has published guidance for pharmacists on dispensing such prescriptions. The pharmacist still exercises professional judgement and may decline where anything is unclear, so the document has to carry the fields set out in the Annex to Implementing Directive 2012/52/EU and name the active substance.

Renewing an existing ramipril prescription

If a doctor has already assessed you, started you on ramipril and your treatment needs to be continued, you can request a repeat prescription through our medical questionnaire. A doctor reviews what you write and, where continuation is appropriate, issues a cross-border prescription as a PDF document by e-mail; you bring it and photo identification to any pharmacy. There is no PIN code, and there is no video consultation, no telephone appointment and no live chat, because the assessment is asynchronous. Documents are issued by lek. Damian Wojno, a doctor registered in Poland, PWZ no. 3211301. Have recent blood pressure readings and your most recent kidney and potassium results to hand when you fill in the questionnaire, and keep up your reviews with your GP, because those tests are part of the treatment and a renewal service does not replace them. This route is for continuing established treatment, not for starting an ACE inhibitor for the first time. The fee of 19,90 € covers the medical consultation, not the issuing of a document. If the doctor declines on medical grounds, the fee is returned. If you do not send documentation the doctor asks for, the consultation counts as carried out and the fee is not refunded.

Cost and reimbursement in Ireland

The counter price of ramipril depends on the strength, the pack size, the manufacturer and the pharmacy, and it is set by the pharmacy rather than by us. Generic ramipril has been available for many years and is among the less expensive cardiovascular medicines. We do not sell medicines and we do not quote prices for them; the pharmacist will tell you the cost before dispensing. On the state side, the HSE runs the medical card scheme and the Drugs Payment Scheme, which caps what a household pays for approved prescribed medicines in a calendar month. Since this treatment is usually long-term and often combined with other medicines, it is worth asking the pharmacy how your prescriptions sit within those schemes. How a prescription written by a prescriber in another EU country is treated under them is decided by the HSE and applied at the counter. Our charge is the consultation fee described above and is separate.

Interactions and alcohol

The interactions that matter most with ramipril involve potassium and the kidneys. Potassium supplements, salt substitutes containing potassium chloride and potassium-sparing diuretics can push potassium to dangerous levels when combined with an ACE inhibitor. Anti-inflammatory painkillers such as ibuprofen and naproxen, taken regularly, reduce the blood-pressure effect and add strain to the kidneys, particularly alongside a diuretic. Lithium levels can rise. Ramipril must not be combined with sacubitril and valsartan, and a gap between them is required. Combining it with aliskiren or with an angiotensin receptor blocker is avoided in some patients, including people with diabetes. Alcohol adds to the blood-pressure lowering effect and can make dizziness and fainting more likely, especially soon after a dose increase, while regular heavy drinking raises blood pressure over time. Give the prescriber a complete list of your medicines, including anything bought over the counter.

Who should not take ramipril

Ramipril must not be taken in pregnancy, and it is not suitable for anyone who has had angioedema, whether on a previous ACE inhibitor or otherwise, nor for anyone who has had an allergic reaction to this class. It is contraindicated with sacubitril and valsartan and in people with narrowing of the arteries to both kidneys. It is also avoided in severe kidney impairment without specialist supervision. Care and extra monitoring are needed if you have kidney disease, a high potassium level, aortic or mitral valve narrowing, liver disease, diabetes, or if you take a diuretic, because the first doses can drop blood pressure sharply. Tell any surgeon or anaesthetist before an operation that you take it. This is not a complete list. The contraindications and warnings for your product are set out in its leaflet and in the summary of product characteristics published by the HPRA, and only a doctor who knows your history can apply them to you.

Generic and brand names

Ramipril is the international non-proprietary name of the active substance and is dispensed in Ireland mostly as generic ramipril carrying the manufacturer's name; the original brand name is Tritace. It also appears in fixed-dose combination products with a diuretic or a calcium channel blocker, which are convenient but count as a different prescription with two substances on the box. If you take a combination product, know both of its substances, because otherwise it is easy to take the same medicine twice under two different names. Ramipril belongs to the same family as lisinopril, perindopril and enalapril; they work in the same way but are not interchangeable dose for dose, so switching is a prescriber's decision. At the counter, check the active substance and the strength rather than the brand. A cross-border prescription names the active substance, which is what allows a pharmacist in another country to dispense the equivalent product authorised there.

Ramipril in pregnancy and breastfeeding

Ramipril must not be used in pregnancy. ACE inhibitors can seriously harm the developing baby, particularly after the first three months, so treatment is changed before conception where possible and stopped as soon as pregnancy is confirmed. If you are taking ramipril and discover you are pregnant, contact your doctor without delay rather than simply continuing, and do not leave high blood pressure untreated either: your doctor will change you to a medicine that is used in pregnancy. Women who could become pregnant should discuss contraception and pre-pregnancy planning with the prescriber. While breastfeeding, the choice depends on the alternatives and on your baby, and it belongs to your doctor or maternity service. Because this needs an individual assessment and usually shared care, our questionnaire is not the right route in pregnancy. Contact your GP or maternity service.

Where to find the patient information leaflet

Every medicine authorised in Ireland has a patient information leaflet, and the leaflet inside your own pack is the version that applies to you. The Health Products Regulatory Authority (HPRA) keeps a public database of medicines authorised here, where you can look up the leaflet and the summary of product characteristics for the exact strength and manufacturer you have been given. For centrally authorised medicines the European Medicines Agency publishes the same documents. Read the leaflet before the first dose and again if the pack you collect looks different from the last one, because generic versions can differ in their inactive ingredients even when the active substance and the strength are identical. If anything in the leaflet does not match what you were told, ask your pharmacist before taking the medicine. A leaflet is written for the whole patient population, so it lists effects that are uncommon; it is not a prediction of what will happen to you.

Is ramipril prescription-only in Ireland?

Yes. Ramipril requires a valid prescription in Ireland, because the dose is titrated against blood pressure readings and it needs blood tests for kidney function and potassium. It is not a controlled drug, so it is not excluded from cross-border prescriptions under Article 11(6) of Directive 2011/24/EU.

How long does ramipril take to work?

Blood pressure begins to fall from the first doses, but the full effect of a given dose builds over weeks, and the dose is usually increased in steps with readings and blood tests in between. Do not judge treatment on a single reading the day after starting.

What are the common side effects of ramipril?

A dry persistent cough is the best known, along with dizziness after the first dose or a dose increase, headache, tiredness and nausea. Swelling of the face, lips, tongue or throat, or difficulty breathing, is an emergency: stop the medicine and call 112 or 999.

Can I drink alcohol while taking ramipril?

Alcohol adds to the blood-pressure lowering effect and can make dizziness or fainting more likely, particularly soon after a dose increase, while regular heavy drinking raises blood pressure over time. Keep intake modest and mention it at review.

How do I get a repeat prescription for ramipril?

If a doctor has already started you on it, fill in our medical questionnaire with recent blood pressure readings and your latest kidney and potassium results to hand. A doctor reviews it and, where continuation is appropriate, issues a cross-border prescription as a PDF by e-mail. Keep up your GP monitoring.