ACE inhibitors
Workhorse tablets that relax blood vessels. Used for blood pressure, heart failure, after a heart attack and to protect the kidneys. Cheap, effective, occasionally coughy.
At a glance
- For
- High blood pressure, heart failure, after a heart attack, protecting the kidneys in diabetes
- Works
- Lowers blood pressure by about 8/5 points on average. In heart failure, cuts the risk of dying by about a sixth to a quarter
- Cost
- Under the $25 PBS co-payment, about $15–22 a month for generics (brand premiums extra); $7.70 concession
- Kicks in
- Blood pressure falls within days; full effect in 2–4 weeks
- Taken for
- Usually long term, once a day
- Watch for
- Dry cough (up to about 1 in 10), dizziness, headache, high potassium, kidney changes on blood tests
The cough is irritating, not dangerous. A swollen lip or tongue is the opposite: that’s a 000 call.
Brand names
- Perindopril (Coversyl), ramipril (Tritace)
- Enalapril (Renitec), lisinopril (Zestril)
- Captopril, trandolapril, quinapril, many generics and combination tablets
How it works
They block the enzyme that makes angiotensin II, a hormone that tightens blood vessels and holds on to salt and water. Wider vessels mean lower pressure and less strain on the heart and kidneys.
Used for
- High blood pressure and heart failure
- After a heart attack, and lowering heart attack and stroke risk in heart disease
- Protecting the kidneys in diabetes (approved uses vary by medicine)
Side effects
Full side-effect list (from the product information)
How often, from the official product information (e.g. perindopril). Bold = serious.
Common 1 in 10 to 1 in 100
- Dry, tickly cough (a common reason to switch)
- Dizziness, headache, vertigo or pins and needles
- Low blood pressure
- Blurred vision, ringing in the ears
- Shortness of breath
- Nausea, vomiting, tummy upset, altered taste
- Rash, itch, muscle cramps or weakness
Uncommon 1 in 100 to 1 in 1,000
- Angioedema (swelling of the face, lips, tongue or throat)
- High potassium, low sodium or low blood sugar
- Kidney impairment
- Low mood, poor sleep or drowsiness
- Fainting, palpitations
- Wheeze, dry mouth
- Hives, sweating or sun sensitivity
- Joint or muscle pain, erection problems
- Chest pain, ankle swelling or fever
Rare 1 in 1,000 to 1 in 10,000
- Acute kidney failure
- Low sodium (SIADH)
- Flushing, psoriasis flare
- Raised liver tests
Very rare fewer than 1 in 10,000
- Low blood counts (white cells, platelets, red cells)
- Heart attack, angina, irregular heartbeat or stroke
- Pancreatitis, hepatitis or erythema multiforme
- Confusion, runny nose
Frequency not known reported, rate unclear
- Cold, pale fingers (Raynaud’s)
Get help urgently if
- Swelling of the face, lips, tongue or throat, or trouble breathing (angioedema, even after years of use). Call 000
- Fainting, passing very little urine, or fever with mouth ulcers
Good to know
- Sick-day rule: if you are vomiting, have diarrhoea or are dehydrated, pause it and see your doctor. Restart once eating and drinking normally.
- Kidney function and potassium are checked after starting and dose changes. Avoid potassium supplements, salt substitutes and anti-inflammatories (e.g. ibuprofen) unless your doctor agrees.
- If cough is a problem, an ARB (e.g. candesartan, irbesartan) works similarly with much less cough.
- Avoid in pregnancy. Tell your doctor if planning pregnancy.
Common questions
Do ACE inhibitors cause a cough?
A dry, tickly cough affects up to about 1 in 10 people and is a common reason to switch. An ARB, such as candesartan or irbesartan, works similarly with much less cough.
What is the sick-day rule for ACE inhibitors?
If you are vomiting, have diarrhoea or are dehydrated, pause it and see your doctor. Restart once you are eating and drinking normally.
Can ACE inhibitors cause swelling?
Rarely, they cause angioedema: swelling of the face, lips, tongue or throat, even after years of use. Call 000 if this happens or you have trouble breathing.
What are examples of ACE inhibitors?
Common ACE inhibitors in Australia include perindopril, ramipril, enalapril, lisinopril, trandolapril and quinapril. Their names all end in “-pril”.
What is the difference between an ACE inhibitor and a sartan?
Both relax blood vessels by acting on the same hormone system, and they work about equally well. Sartans (such as candesartan, irbesartan and telmisartan) rarely cause the dry cough that ACE inhibitors can. They aren’t normally taken together.
What are the side effects of ACE inhibitors?
A dry cough affects about 1 in 10 people. Others include dizziness (especially when starting), raised potassium and changes in kidney function, so blood tests are needed. Rarely, face or tongue swelling occurs, which is an emergency.
Information only. Not a recommendation or endorsement of any product. Whether a medicine suits you depends on your health and other medicines, so talk to your doctor or pharmacist. In an emergency, call 000 (Australia) or your local emergency number. From a mobile, 112 works in most countries.
More information
- Coversyl Arginine (perindopril) summary of product characteristics (UK)
- Healthdirect: Medicines information
- Cochrane: Blood pressure lowering with ACE inhibitors
- PBS: Perindopril 5 mg
maladywise.com/medicines/ace-inhibitors/