Ramipril

Oral health effects

• Angioedema

  Class effect: orofacial/airway swelling.

  Mechanism: Bradykinin accumulation from ACE inhibition.

  Clinical management: Emergency management if airway involved; refer for review.

• Persistent dry cough (ACE inhibitor cough)

  A dry, tickly, non-productive cough is a class effect of ACE inhibitors caused by bradykinin accumulation; it can start weeks to months after starting and resolves within days to weeks of stopping. Label: increased cough in almost 12% of ramipril patients in a 1-year study; 8% vs 4% placebo in the AIRE trial; cough was the most common reason for discontinuation (1.0%).

  Clinical management: Ask about chronic cough at medical history review. Cough can be triggered by water spray, prophy paste or supine positioning: use high-volume suction, a more upright chair position and short breaks. Persistent cough is a reason for the patient to discuss alternatives (e.g. an ARB) with their prescriber; do not advise stopping the medication.

• Taste disturbance (dysgeusia)

  Taste disturbance (and, less often, increased salivation or dry mouth) is listed among less common (<1%) adverse reactions on the ramipril label; altered taste is a recognised ACE-inhibitor class effect.

  Clinical management: Ask about altered or metallic taste; reassure that it is usually reversible. Encourage good oral hygiene and hydration, and suggest the patient mention persistent taste change to their prescriber.