Understanding Drug Interactions: What Cannot Be Taken with Ramipril?

October 11, 2025 •

3 min read

In hypertensive patients taking ramipril, hyperkalemia (high potassium levels) occurs in approximately 1% of individuals. Understanding what cannot be taken with ramipril is vital to prevent serious health complications, including those related to potassium levels and other drug interactions.

Quick Summary

Ramipril can interact with certain drugs, supplements, and health conditions. Key interactions include NSAIDs, potassium supplements, specific heart medications like sacubitril/valsartan, and diuretics, which can increase risks of kidney problems or high potassium.

Key Points

Sacubitril/Valsartan: Do not take ramipril within 36 hours of Entresto (sacubitril/valsartan) due to a high risk of angioedema.
Potassium: Avoid potassium supplements and potassium-containing salt substitutes, as ramipril can cause dangerously high potassium levels (hyperkalemia).
NSAIDs: Pain relievers like ibuprofen and naproxen can reduce ramipril's effectiveness and harm the kidneys, especially in vulnerable patients.
Other Blood Pressure Drugs: Combining ramipril with aliskiren (in diabetics) or other ACE inhibitors/ARBs is generally contraindicated or not recommended.
Alcohol: Alcohol can increase the blood pressure-lowering effect of ramipril, leading to increased dizziness and risk of fainting.
Pregnancy: Ramipril is contraindicated during pregnancy as it can cause serious harm or death to the developing fetus.
Diuretics: Co-administration with diuretics ('water pills'), especially potassium-sparing types, increases the risk of both low blood pressure and high potassium.

Ramipril is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure, heart failure, and improve post-heart attack survival. It lowers blood pressure by relaxing blood vessels. Safe use requires avoiding certain substances and considering specific health conditions. Always inform your healthcare provider of all medications, herbs, and supplements you use.

Contraindicated and Major Drug Interactions

Some medications are strictly contraindicated with ramipril due to severe risks.

Sacubitril/Valsartan (Entresto)

Combining ramipril with neprilysin inhibitors such as sacubitril (in Entresto) is contraindicated due to a significantly increased risk of life-threatening angioedema. A 36-hour washout period is necessary when switching between these medications.

Aliskiren

The combination of ramipril and aliskiren is contraindicated in patients with diabetes and should be avoided in those with moderate to severe kidney impairment. This combination increases the risk of low blood pressure, high potassium, and acute kidney failure.

Other RAS Blockers (ARBs and other ACE Inhibitors)

Using ramipril with another ACE inhibitor or an angiotensin II receptor blocker (ARB) is generally not advised. This dual therapy can heighten the risk of hypotension, hyperkalemia, and worsening kidney function without added benefits.

Moderate Interactions and Substances to Use with Caution

NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

The combination of ramipril and NSAIDs like ibuprofen or naproxen can reduce ramipril's effectiveness and, in vulnerable individuals (elderly, dehydrated, pre-existing kidney disease), lead to kidney damage or acute kidney failure. Consult your doctor about occasional or low-dose use.

Potassium Supplements and Salt Substitutes

Ramipril can increase blood potassium levels. Avoid potassium supplements and salt substitutes with potassium chloride unless directed by a doctor, as this combination can cause hyperkalemia and serious heart rhythm issues.

Diuretics (Water Pills)

Diuretics can increase the risk of a significant blood pressure drop after starting ramipril. Potassium-sparing diuretics pose a particularly high risk of hyperkalemia when combined with ramipril.

Lithium

Concurrent use of ramipril with lithium can increase blood lithium levels, raising the risk of toxicity. Close monitoring of lithium levels is necessary if these medications are used together.

Alcohol

Alcohol can enhance ramipril's blood pressure-lowering effect, potentially causing dizziness and fainting. Limit or avoid alcohol, especially when starting treatment or after dose changes.

Ramipril Interaction Comparison Table


Interacting Substance	Potential Risk	Management Advice
Sacubitril/Valsartan	Significantly increased risk of life-threatening angioedema.	Contraindicated. A 36-hour washout period is mandatory when switching.
NSAIDs (e.g., Ibuprofen)	Reduced antihypertensive effect; increased risk of kidney damage.	Avoid long-term use. Consult a doctor for pain relief alternatives. Renal function should be monitored.
Potassium Supplements	High risk of hyperkalemia (dangerously high potassium levels).	Avoid unless explicitly prescribed and monitored by a healthcare provider.
Potassium-Sparing Diuretics	Additive effect leading to hyperkalemia.	Use with caution and frequent monitoring of serum potassium.
Alcohol	Additive blood pressure-lowering effect, causing dizziness and fainting.	Avoid or limit consumption, especially at the start of treatment.
Lithium	Increased risk of lithium toxicity.	Requires frequent monitoring of serum lithium levels if co-administered.

Health Conditions Requiring Precaution

Certain health conditions require caution or contraindicate ramipril use:

Pregnancy: Ramipril is contraindicated due to the risk of fetal harm or death, particularly in the second and third trimesters.
History of Angioedema: Patients with a history of angioedema should not take ramipril.
Kidney Problems: Use with caution and potentially reduced dosage in patients with renal artery stenosis or severe kidney impairment.
Liver Problems: Caution is advised in patients with severe hepatic impairment.

Conclusion

Knowing what cannot be taken with ramipril is essential for safe and effective treatment. Key interactions involve other RAS medications, substances affecting potassium levels, and those impacting kidney function. Always discuss all medications, supplements, and lifestyle factors with your healthcare provider to prevent dangerous interactions. Do not alter your medication regimen without medical approval.

Authoritative Link: For more information on Ramipril, you can visit the NHS page on the medicine: https://www.nhs.uk/medicines/ramipril/

Frequently Asked Questions

It is generally advised to avoid taking ibuprofen with ramipril. The combination can reduce the blood pressure-lowering effect of ramipril and increase the risk of kidney damage, particularly with long-term use or in elderly patients.

Drinking alcohol can enhance the blood pressure-lowering effects of ramipril, potentially causing dizziness or fainting. It's recommended to limit or avoid alcohol, especially when first starting the medication or changing your dose.

Taking potassium supplements with ramipril can lead to hyperkalemia, a condition of dangerously high potassium levels in the blood. This can cause muscle weakness and serious heart rhythm problems. You should not use potassium supplements unless directed by your doctor.

You should avoid using salt substitutes that contain potassium. While no specific foods are strictly forbidden, it's wise to be cautious with consuming large amounts of high-potassium foods like bananas, oranges, and some leafy greens, especially if you have kidney problems.

Ramipril should not be taken with aliskiren (especially in diabetics) or Entresto (sacubitril/valsartan). Combining it with other ACE inhibitors or ARBs is also not recommended due to increased risks of low blood pressure, high potassium, and kidney issues.

Taking these two medications together, or within 36 hours of each other, is contraindicated because it greatly increases the risk of angioedema, a severe and potentially fatal swelling of the throat and face.

A persistent dry cough is a common side effect of all ACE inhibitors, including ramipril, and is caused by the inhibition of bradykinin degradation. If the cough is bothersome, it is unlikely to go away on its own. Contact your doctor, who may switch you to a different class of medication.

No, ramipril is not safe during pregnancy and is contraindicated. It can cause serious injury and even death to the developing fetus, especially if taken during the second and third trimesters. Inform your doctor immediately if you become pregnant.