In a patient with a cough caused by lisinopril 10 mg daily, who is also taking hydrochlorothiazide 25 mg daily and bisoprolol fumarate 10 mg daily with a blood pressure of 130/78 mmHg and weight of 161 lb, how should the lisinopril be discontinued and hypertension be managed?

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Discontinue Lisinopril and Switch to an ARB

Stop the lisinopril immediately and replace it with an angiotensin receptor blocker (ARB) such as losartan 50 mg daily or valsartan 80-160 mg daily. 1

Rationale for ARB Substitution

The 2006 ACCP evidence-based guidelines provide a Grade A recommendation (good quality evidence, substantial net benefit) to switch to an ARB when ACE inhibitor-induced cough occurs 1. This is the only uniformly effective treatment besides complete discontinuation. ARBs have demonstrated a cough incidence similar to placebo or diuretics (18-29%) compared to ACE inhibitors (72-97%) in patients with prior ACE inhibitor-induced cough 2, 3.

The mechanism is straightforward: ARBs block angiotensin II receptors directly without inhibiting ACE, thus avoiding the accumulation of bradykinin and substance P that triggers the cough reflex 1.

Current Blood Pressure Status

Your patient's BP of 130/78 mmHg is well-controlled on the current three-drug regimen. According to 2025 AHA/ACC guidelines, this patient is at goal 4. The existing combination of:

  • HCTZ 25 mg daily (thiazide diuretic)
  • Bisoprolol 10 mg daily (beta-blocker)

...provides a solid foundation that should maintain BP control when you substitute the ACE inhibitor with an ARB.

Specific Switching Protocol

  1. Stop lisinopril today - do not taper (no withdrawal syndrome with ACE inhibitors)

  2. Start ARB immediately - no washout period needed:

    • Losartan 50 mg daily, OR
    • Valsartan 80-160 mg daily, OR
    • Irbesartan 150 mg daily

  3. Continue HCTZ 25 mg and bisoprolol 10 mg unchanged

  4. Expect cough resolution within 1-4 weeks 1. In a small subset of patients, resolution may take up to 3 months, but this is uncommon.

Monitoring Plan

  • Recheck BP in 2-4 weeks to ensure continued control
  • Monitor serum potassium and creatinine within 1-2 weeks (ARBs can cause hyperkalemia, especially with concurrent diuretic use)
  • If BP rises above goal, uptitrate the ARB to maximum dose before adding additional agents

Important Caveats

Do not try a different ACE inhibitor - cough is a class effect occurring with all ACE inhibitors with no difference between individual drugs 1, 5. Rechallenge with any ACE inhibitor will almost always reproduce the cough.

Avoid cough suppressants - while medications like sodium cromoglycate, theophylline, or NSAIDs have been studied for suppressing ACE inhibitor-induced cough, they carry a Grade B recommendation (fair evidence, intermediate benefit) and should only be attempted if stopping the ACE inhibitor is "not an option" 1. Since you can easily switch to an ARB, this approach is unnecessary.

The rare case reports of ARB-induced cough 6 represent exceptional outliers and should not deter you from this evidence-based substitution strategy.

References

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