Can lisinopril cause tinnitus and a sensation of echoing in the ears?

Can Lisinopril Cause Tinnitus (Ringing) and Echo in the Ears?

Yes, lisinopril can cause tinnitus (ringing in the ears), though it is not listed as a common adverse effect in the FDA drug label, and the association appears to be indirect through its effects on blood pressure and vascular function.

Evidence from FDA Drug Label

The official FDA labeling for lisinopril 111 does not list tinnitus or auditory symptoms as recognized adverse effects. The primary warnings focus on:

• Angioedema (face, lips, tongue, throat swelling)
• Hypotension (low blood pressure)
• Renal impairment
• Hyperkalemia
• Fetal toxicity

Notably absent from the extensive adverse event profile is any mention of ototoxicity, tinnitus, or hearing-related symptoms.

Research Evidence on ACE Inhibitors and Tinnitus

However, research data suggests a more complex relationship:

A 2016 cross-sectional study found a significant association between tinnitus and ACE inhibitor use 2. This study of 284 subjects (144 with tinnitus, 140 controls) demonstrated:

• Hypertension prevalence was 44.4% in tinnitus patients vs. 31.4% in controls (p=0.024)
• ACE inhibitors showed a positive association with tinnitus (p=0.006)
• The association was particularly strong in older patients
• The authors suggested potential ototoxicity of these drugs may be involved in tinnitus pathophysiology

Mechanism and Clinical Context

The relationship between lisinopril and tinnitus likely involves:

1. Vascular effects: ACE inhibitors alter blood flow dynamics, which may affect cochlear perfusion
2. Blood pressure changes: Hypotension (a known effect of lisinopril 1) can reduce cochlear blood supply
3. Possible direct ototoxicity: Though not established, the research suggests this warrants investigation 2

Multiple comprehensive reviews on drug-induced ototoxicity 345 acknowledge that over 130 drugs can cause tinnitus, and antihypertensive medications are among the implicated classes, though ACE inhibitors are not traditionally considered primary ototoxic agents.

Clinical Approach

If a patient on lisinopril develops new-onset tinnitus:

• Temporal relationship matters: Document when tinnitus started relative to lisinopril initiation or dose changes
• Rule out other causes: Per tinnitus guidelines 6, obtain comprehensive audiological examination if tinnitus is unilateral, persistent, or associated with hearing loss
• Consider medication trial: If temporal association is strong and no other cause identified, discuss with prescriber about switching to an alternative antihypertensive class (e.g., ARBs, beta-blockers)
• Monitor blood pressure control: Ensure the patient isn't experiencing hypotensive episodes that could compromise cochlear perfusion

Important Caveats

• The "echo" sensation described may represent a distinct phenomenon from simple tinnitus and could suggest Eustachian tube dysfunction or other middle ear pathology unrelated to lisinopril
• Hypertension itself is associated with tinnitus 2, so the underlying condition rather than the treatment may be contributory
• The absence of tinnitus in FDA labeling doesn't exclude the possibility—post-marketing surveillance continues to identify rare adverse effects 7

Bottom line: While not an officially recognized adverse effect, clinical evidence supports that lisinopril may contribute to tinnitus in some patients, particularly older individuals. If the temporal relationship is convincing and other causes are excluded, switching antihypertensive therapy is reasonable.