Can ramipril (angiotensin-converting enzyme inhibitor) cause hyperkalemia?

From the Guidelines

Yes, ramipril can cause high potassium levels (hyperkalemia) in the blood, especially in patients with kidney problems, diabetes, or those taking potassium supplements or potassium-sparing diuretics, as stated in the 2018 guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Key Points to Consider

• Ramipril belongs to a class of medications called angiotensin-converting enzyme (ACE) inhibitors, which work by blocking an enzyme that normally helps the body produce angiotensin II, a substance that narrows blood vessels and increases potassium retention.
• When taking ramipril, the kidneys may retain more potassium than usual instead of excreting it through urine.
• Symptoms of high potassium may include muscle weakness, irregular heartbeat, and nausea.
• Regular blood tests to monitor potassium levels are recommended while taking ramipril, especially when starting the medication or adjusting the dose, as suggested in the guideline 1.
• If you experience symptoms of high potassium while taking ramipril, contact your healthcare provider immediately as severe hyperkalemia can be dangerous and may require prompt medical attention.

Important Considerations

• The risk of hyperkalemia is increased in patients with chronic kidney disease (CKD) or those taking potassium supplements or potassium-sparing diuretics, as noted in the guideline 1.
• It is essential to monitor potassium levels regularly and adjust the dose of ramipril or other medications as needed to minimize the risk of hyperkalemia.
• Patients with a history of angioedema with ACE inhibitors should avoid taking ramipril, and alternative medications should be considered.

From the FDA Drug Label

In clinical trials with ramipril, hyperkalemia (serum potassium >5. 7 mEq/L) occurred in approximately 1% of hypertensive patients receiving ramipril. The latter decrease may result in a small increase of serum potassium In hypertensive patients with normal renal function treated with ramipril alone for up to 56 weeks, approximately 4% of patients during the trial had an abnormally high serum potassium and an increase from baseline greater than 0.75 mEq/L

Yes, ramipril can cause high potassium.

• Hyperkalemia occurred in approximately 1% of hypertensive patients receiving ramipril 2.
• Risk factors for the development of hyperkalemia include renal insufficiency, diabetes mellitus, and the concomitant use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes 2.
• Approximately 4% of patients had an abnormally high serum potassium and an increase from baseline greater than 0.75 mEq/L 2.

From the Research

Ramipril and Hyperkalemia

• Ramipril, an angiotensin-converting enzyme (ACE) inhibitor, can increase the risk of hyperkalemia, particularly when used in combination with other agents that block the renin-angiotensin-aldosterone system (RAAS) 3.
• A study published in the European journal of preventive cardiology found that dual therapy with ramipril and telmisartan increased the incidence of hyperkalemia compared to monotherapy with either agent 3.
• However, another study published in Collegium antropologicum found that ramipril did not significantly increase serum potassium levels in chronic hemodialysis patients, but close monitoring of potassium levels is still necessary 4.
• In contrast, a study published in The American journal of medicine found that the use of ACE inhibitors, including ramipril, was associated with a higher risk of hyperkalemia in chronic hemodialysis patients, highlighting the need for careful monitoring of serum potassium levels 5.

Risk Factors and Associations

• Hyperkalemia has been associated with an increased risk of cardiovascular and renal events, with a nonlinear relationship between serum potassium levels and these outcomes 3.
• The risk of hyperkalemia with ramipril use may be higher in patients with certain underlying conditions, such as chronic renal insufficiency or those undergoing hemodialysis 5.
• Close monitoring of serum potassium levels is essential when prescribing ramipril, particularly in patients at high risk of hyperkalemia 4, 5.