BBC Dr gives ‘increased risk’ update to blood pressure ramipiril users after ‘side effect’ alert

BBC Dr gives ‘increased risk’ update to blood pressure ramipiril users after ‘side effect’ alert In 1 in 140 cases drugs such as ramipril can trigger a reaction called angioedema, resulting in swelling of the lips, face, tongue or throat. A GP and TV doctor has given a warning to millions taking one of the most common drugs used in the UK for high blood pressure. Dr Mark Porter who has been a regular on The One Show, Watchdog Healthcheck and presenter of Radio 4’s flagship medical series Inside Health spoke out after the Medicines and Healthcare Products Regulatory Agency (MHRA) highlighting a ‘rare but potentially serious side-effect’. The ACE inhibitor family of drugs like ramipril are the subject of the alert. Dr Porter said millions of people in the UK take these drugs, and not just for raised blood pressure. He said: “The side-effect is something every person taking an ACE inhibitor, and every doctor prescribing it, should be aware of, hence this latest MHRA safety update. “In rare cases — somewhere between 1 in 1,000 and 1 in 140 cases, depending on which statistics you favour — drugs such as ramipril can trigger a reaction called angioedema, resulting in swelling of the lips, face, tongue or throat. And in more severe reactions this can lead to difficulty swallowing and breathing, and very occasionally even be life-threatening. Those most at risk include women, the over-65s, smokers and people of black or African-Caribbean ethnicity. “The MHRA warning contains two important messages. The first is to remind medics like me that this can be a delayed reaction, occurring weeks or even many months after starting the drugs, and that, while easy to confuse with serious allergic reactions (anaphylaxis) to things like peanuts or wasp stings, it often requires different emergency treatment because conventional approaches, like injecting adrenaline, may not work. “The second — and the one relevant to you, if you or a member of your family are taking an ACE inhibitor (see below) — is to make people aware of the following points when they are prescribed one: - Although uncommon, angioedema can occur at any time while taking an ACE inhibitor, even if you have been taking it for a long period without problems. - Always seek urgent medical attention if you develop swelling of the face, lips, tongue or throat, or experience difficulty breathing or swallowing while taking ACE inhibitors. - Do not take further doses if angioedema is suspected and inform a healthcare professional immediately. - Always tell healthcare professionals if you have ever experienced angioedema, including while taking an ACE inhibitor. - Be aware that angioedema can occur for other reasons, and a healthcare professional may still recommend an ACE inhibitor for you in these instances. - If you develop problems breathing or swallowing, dial 999. Dr Porter said he had seen his own patients have the symptoms. He said: ”I have had patients of mine develop angioedema on these drugs but, despite prescribing it to thousands over the past 40 years, I have never seen a life-threatening reaction, thankfully. So while the warning might appear alarming, this is not a new problem but a rare one that would benefit from better awareness. “In general ACE inhibitors are very well tolerated and are the first choice for many people with high blood pressure and some heart and kidney conditions. However, they do have another side-effect that I would like to highlight. ACE-inhibitor cough is far more common than angioedema and, surprisingly, is often missed or ignored. “About one in ten people taking these drugs will develop the cough, which is typically dry and persistent, and annoying rather than disabling. The exact mechanism behind this side-effect is still the subject of some debate but, put simply, the drugs can give your cough reflex a hair trigger, meaning you cough repeatedly when you don’t need to.” Dr Porter said the side effect can come on days, weeks or months after starting the drug. He said sometimes it only starts after a chest infection and added: “With the patient presenting with a dry cough that just won’t settle over weeks or months after a relatively minor illness. And it’s in cases like this that the link with the drug can be missed as both patient and doctor worry about other causes of persistent cough, ranging from acid reflux and asthma to whooping cough and lung cancer. Finally, there is some suggestion that people who have this reaction may also be prone to angioedema. “Fortunately, once correctly identified, ACE-inhibitor cough is easy enough to fix, by simply switching to a similar family of drugs called the sartans (see below). It can take a few weeks for the cough to settle and for blood pressure control to be regained, but the substitution should cure the problem in the vast majority of people. “One last caution about ACE inhibitors: taking them alongside non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen and naproxen, which are widely used for arthritis and other aches and pains, can lead to serious kidney problems in some people. So if you are on an ACE inhibitor please don’t self-medicate with ibuprofen (paracetamol is safer in this regard) and if prescribed an anti-inflammatory do ask whether you need to have your kidney function monitored (a blood test at the surgery).” Meanwhile drug shortages are some of the worst GPs and pharmacists have ever seen, according to leaders. The National Pharmacy Association (NPA) said the lack of medicines available for some conditions is a serious risk to patient safety. The Royal College of GPs (RCGP) is backing calls for pharmacists to be able to make changes to prescriptions when a medicine is unavailable, and to dispense a safe alternative. Drug shortages in recent months include commonly dispensed medicines such as painkillers, blood pressure medication and drugs to manage epilepsy, according to the NPA. Ramipril high blood pressure drug is one of those affected, together with prescription co-codamol and some strengths of low-dose aspirin. There are also ongoing shortages of Creon, which helps people with conditions including cystic fibrosis and pancreatic cancer digest food. There has been a long-term Europe-wide shortage of this drug, with patients describing how they have rationed Creon pills or chosen to eat less to make packs last longer. According to the European Medicines Agency, the company that produces Creon is experiencing limitations in production capacity, coupled with high demand, which may go on well into 2027.