Does ramipril cause a cough? Understanding this common side effect

October 14, 2025 •

4 min read

Reported in 5–35% of patients, a persistent, non-productive cough is a well-known side effect of the blood pressure medication, ramipril. This article delves into the pharmacological reasons behind this reaction and outlines the most effective management strategies.

Quick Summary

Ramipril, an ACE inhibitor, can cause a persistent dry cough by increasing bradykinin levels in the airways. The reaction is dose-independent and often resolves by switching to an alternative medication, such as an ARB.

Key Points

Dry and Persistent Cough: A dry, tickling cough is a recognized side effect of ramipril, occurring in up to 35% of users.
Caused by Bradykinin : The cough results from the accumulation of bradykinin in the airways, a substance whose breakdown is inhibited by ramipril.
Alternative Medication is Key: Switching to an angiotensin II receptor blocker (ARB) like losartan is the most effective way to resolve the cough, as ARBs do not affect bradykinin levels.
Dose-Independent Reaction: The likelihood and severity of the cough are not related to the dosage of ramipril, so reducing the dose is generally ineffective.
Resolution Time: The cough typically subsides within 1 to 4 weeks after discontinuing ramipril, though some relief can be felt within 48 hours.
No OTC Fix: Over-the-counter cough suppressants do not address the root cause of an ACE inhibitor-induced cough and are not recommended for effective relief.
Consult a Doctor: It is crucial to consult your healthcare provider before stopping or changing your medication to ensure your blood pressure remains controlled and to rule out other causes.

What is ramipril and why is it prescribed?

Ramipril is a type of medication known as an angiotensin-converting enzyme (ACE) inhibitor. It is widely prescribed to treat a number of cardiovascular conditions, including high blood pressure (hypertension), congestive heart failure, and to reduce the risk of heart attack and stroke. It works by blocking the ACE enzyme, which prevents the production of a hormone that narrows blood vessels. By relaxing blood vessels, ramipril effectively lowers blood pressure and increases blood flow to the heart and kidneys.

The definitive link between ramipril and cough

For a notable percentage of patients, up to 35% in some studies, ramipril is associated with a specific type of side effect: a dry, persistent, and often tickling cough. This cough is a "class effect" of ACE inhibitors, meaning it can be triggered by any medication in this class, not just ramipril. The cough is typically non-productive, meaning it doesn't bring up mucus or phlegm, and is not a symptom of infection. Its onset can vary significantly, appearing anywhere from within hours of the first dose to several months after starting treatment. For many, the cough is particularly bothersome at night, likely due to a change in position that affects fluid pooling in the airways. The severity of the cough is independent of the medication dose, so simply reducing the dose rarely provides relief.

The pharmacological mechanism: Bradykinin and substance P

The cough induced by ramipril is an idiosyncratic reaction, meaning it occurs only in susceptible individuals and isn't a direct result of the medication's intended function. While the exact mechanism is not fully understood, it is primarily attributed to the accumulation of certain compounds in the lungs and airways.

Bradykinin Accumulation: A key function of the ACE enzyme, which ramipril inhibits, is the breakdown of a substance called bradykinin. When this process is blocked, bradykinin levels increase. Elevated bradykinin can irritate nerves in the airways, triggering the persistent, dry cough.
Substance P: Similar to bradykinin, the breakdown of substance P is also affected by ACE inhibitors. This compound, a neuropeptide involved in inflammation and pain, can also accumulate and contribute to heightened cough reflex sensitivity.
Prostaglandin Production: Bradykinin accumulation can also lead to increased production of prostaglandins, which further sensitize the cough reflex.

It is believed that a combination of these factors leads to the characteristic dry cough experienced by some ramipril users.

Management and alternative treatments

The most effective way to address a persistent cough caused by ramipril is to consult with a doctor to discuss changing medication. The cough does not typically go away on its own and over-the-counter cough medicines are generally ineffective because they do not address the underlying cause.

Your doctor will likely consider the following options:

Switching to an ARB: The most common and effective solution is to switch from an ACE inhibitor like ramipril to an Angiotensin II Receptor Blocker (ARB). ARBs work on the same biological pathway but do not interfere with the breakdown of bradykinin. Common ARBs include candesartan, losartan, and valsartan.
Using a different class of blood pressure medication: If an ARB is not suitable, other classes of medications such as calcium channel blockers or diuretics can be considered to maintain blood pressure control.
Other interventions: In some cases, adding a calcium channel blocker to the existing regimen has been shown to reduce the cough. For temporary relief while a medication change is being arranged, some patients find that sipping warm water or tea with honey, or using sugar-free lozenges can soothe the throat.

Comparison: Ramipril (ACE Inhibitor) vs. Losartan (ARB)


Feature	Ramipril (ACE Inhibitor)	Losartan (ARB)	Comparison
Mechanism of Action	Blocks ACE, preventing angiotensin I from becoming angiotensin II.	Blocks the angiotensin II receptor, preventing angiotensin II from binding.	Different action, same therapeutic effect.
Incidence of Cough	Common (5–35%) due to bradykinin accumulation.	Very low, as it does not affect bradykinin levels.	A major reason to switch medications.
Resolution of Cough	Resolves within 1–4 weeks after discontinuation.	Does not cause cough, so no resolution period needed.	ARBs provide immediate relief from this side effect.
First-line Treatment	Often prescribed first, historically cheaper.	Equally effective, now widely available as generics.	No longer a strong medical need to prefer ACE inhibitors first.
Cardiovascular Benefit	Effective for hypertension, heart failure, and risk reduction.	Equally effective for these conditions.	Both offer similar benefits for target conditions.

How long does the cough last after stopping ramipril?

If you and your doctor decide to stop ramipril due to a persistent cough, you can expect the symptom to subside relatively quickly. Most patients report a noticeable improvement within 48 hours and complete resolution within one week. In some instances, it may take up to a month for the cough to fully disappear. It is important to note that you should never stop taking your medication abruptly without consulting your doctor, as this can worsen underlying health conditions.

Conclusion

A dry, persistent cough is a recognized and common side effect of ramipril and other ACE inhibitors, caused by the accumulation of bradykinin and substance P in the airways. It is not harmful but can significantly impact a patient's quality of life. The most effective treatment is to switch to a different class of medication, such as an angiotensin II receptor blocker (ARB), which provides the same cardiovascular benefits without causing the cough. With numerous effective alternatives available, patients who experience this adverse effect can find relief and continue managing their blood pressure effectively. Always consult a healthcare provider for a proper diagnosis and treatment plan before making any changes to your medication.

Drug-induced chronic cough and the possible mechanism of angiotensin-converting enzyme inhibitor-induced cough

Frequently Asked Questions

No, you should never stop taking ramipril without consulting your healthcare provider. Stopping abruptly can cause your blood pressure to rise, increasing your risk of heart attack or stroke. A doctor will help you transition to a suitable alternative medication.

Over-the-counter cough suppressants are generally ineffective for a cough caused by ramipril. This is because the cough is a reaction to a chemical imbalance, not a symptom of an infection. Temporary relief might be found with lozenges or honey.

The cough typically begins to subside within a few days of stopping the medication. Most patients see a complete resolution within 1 to 4 weeks, but in some cases, it may take up to a month for the symptom to fully clear.

The cough is specific to ACE inhibitors like ramipril. It occurs because these drugs increase the levels of a substance called bradykinin in the airways, which triggers the cough reflex. Other classes of blood pressure medication, like ARBs, do not have this effect.

No, a dry cough from ramipril is not harmful to your lungs. It is an irritating and bothersome side effect, but it does not cause damage to your lung tissue. However, any cough that is severe or accompanied by other symptoms should be evaluated by a doctor.

Angiotensin II Receptor Blockers (ARBs), such as losartan or candesartan, are the most common and effective alternative. They provide similar blood pressure control without causing the accumulation of bradykinin that leads to the cough.

While waiting to discuss alternative medication with your doctor, you can try some simple remedies for temporary relief. This includes sipping warm water or tea with honey, using sugar-free lozenges, and elevating your head with pillows while sleeping.