From the Guidelines
Switching from lisinopril to losartan is a reasonable approach for managing a chronic cough in a patient with hypertension, as losartan has a lower incidence of cough compared to ACE inhibitors, with a similar efficacy in blood pressure control. ACE inhibitors like lisinopril cause cough in about 5-35% of patients, typically developing within weeks to months after starting therapy, due to the accumulation of bradykinin and substance P in the lungs, which ACE inhibitors prevent from breaking down 1. ARBs like losartan work differently by blocking angiotensin II receptors rather than inhibiting ACE, so they don't affect bradykinin metabolism and rarely cause cough, as demonstrated by the low incidence of cough associated with losartan, similar to that of the diuretic hydrochlorothiazide, in patients with a history of ACE inhibitor-induced cough 1. When making this switch, lisinopril can be discontinued and losartan started immediately, typically at 50 mg once daily, which can be increased to 100 mg if needed for blood pressure control. The cough from lisinopril usually resolves within 1-4 weeks after discontinuation, although it may be delayed in a subgroup of patients for up to 3 months 1. Some key points to consider when switching medications include:
- Monitoring blood pressure after switching medications to ensure adequate control, as individual responses to ARBs may differ from ACE inhibitors
- Losartan's efficacy in blood pressure control is similar to that of lisinopril, making it an appropriate alternative
- Both medication classes offer similar cardiovascular and renal protection, making losartan a suitable substitute that maintains therapeutic benefits while eliminating the troublesome cough, as supported by the ACCP guidelines, which recommend switching to an ARB, such as losartan, in patients with persistent or intolerable ACE inhibitor-induced cough 1.
From the FDA Drug Label
Cough Persistent dry cough (with an incidence of a few percent) has been associated with ACE-inhibitor use and in practice can be a cause of discontinuation of ACE-inhibitor therapy Two prospective, parallel-group, double-blind, randomized, controlled trials were conducted to assess the effects of losartan on the incidence of cough in hypertensive patients who had experienced cough while receiving ACE-inhibitor therapy Patients who had typical ACE-inhibitor cough when challenged with lisinopril, whose cough disappeared on placebo, were randomized to losartan 50 mg, lisinopril 20 mg, or either placebo (one study, n=97) or 25 mg hydrochlorothiazide (n=135). The double-blind treatment period lasted up to 8 weeks. The incidence of cough is shown in Table 1 below Table 1 Study 11 HCTZ Losartan Lisinopril Cough 25% 17% 69% Study 22 Placebo Losartan Lisinopril Cough 35% 29% 62%
Switching from lisinopril (an ACE inhibitor) to losartan (an Angiotensin II Receptor Blocker (ARB)) may be a reasonable approach for managing a chronic cough in a patient with hypertension, as the incidence of cough associated with losartan therapy is similar to that associated with hydrochlorothiazide or placebo therapy 2. Key points:
- Losartan has a lower incidence of cough compared to lisinopril.
- The incidence of cough with losartan is similar to that of hydrochlorothiazide or placebo.
- Switching to losartan may help manage chronic cough in patients with hypertension who experience cough with ACE inhibitors.
From the Research
Switching from Lisinopril to Losartan for Chronic Cough
- The decision to switch from lisinopril, an Angiotensin-Converting Enzyme (ACE) inhibitor, to losartan, an Angiotensin II Receptor Blocker (ARB), for managing chronic cough in hypertensive patients is supported by studies 3, 4.
- A study published in the Journal of Human Hypertension in 1995 found that the incidence of cough with losartan (29%) was significantly lower than that with lisinopril (72%, P < 0.01) and similar to that with hydrochlorothiazide (34%) 3.
- Another study published in Clinical Therapeutics in 1998 reported that the incidence of dry cough was significantly higher in the lisinopril group (87.5%) compared to the losartan (36.7%) and placebo (31.4%) groups, with no statistically significant difference between the losartan and placebo groups 4.
- The frequency of dry cough, as measured by a visual analogue scale, was also significantly lower in patients treated with losartan compared to those treated with lisinopril 3, 4.
- These findings suggest that switching from lisinopril to losartan may be a reasonable approach for managing chronic cough in patients with hypertension, as losartan is less likely to cause cough compared to ACE inhibitors like lisinopril 3, 4.