What are viable options for managing cough symptoms in a patient with hypertension (HTN)?

From the Guidelines

For patients with hypertension experiencing cough symptoms, the most viable option is to switch from ACE inhibitors to an angiotensin receptor blocker or an appropriate agent of another drug class, as this approach has a substantial net benefit and is supported by good quality evidence 1.

Management Options

• First-line treatments include dextromethorphan (15-30mg every 4-6 hours) for non-productive coughs or guaifenesin (200-400mg every 4 hours) for productive coughs, as neither significantly affects blood pressure.
• Benzonatate (100-200mg three times daily) is another effective option that works by numbing stretch receptors in the lungs.
• For nighttime cough relief, diphenhydramine (25mg at bedtime) can be helpful but may cause drowsiness.

Important Considerations

• It's essential to avoid decongestants containing pseudoephedrine or phenylephrine as these can raise blood pressure.
• Non-pharmacological approaches should also be implemented, including adequate hydration, using a humidifier, and elevating the head while sleeping.
• If the cough persists beyond 2-3 weeks or is accompanied by fever, chest pain, or shortness of breath, medical evaluation is necessary as the cough may indicate an underlying condition requiring different treatment.

ACE Inhibitor-Induced Cough

• ACE inhibitors can cause a persistent dry cough as a side effect, so patients should discuss with their doctor whether medication adjustment might be needed, as suggested by the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines 1.

From the FDA Drug Label

Purpose Cough suppressant Package/Label Principal Display Panel Compare to Delsym® active ingredient Dextromethorphan Polistirex Extended-Release Oral Suspension Cough Suppressant

• Cough Symptom Management Options for a patient with hypertension (HTN) include:
  • Dextromethorphan (PO), a cough suppressant 2
  • Dextromethorphan Polistirex Extended-Release Oral Suspension, which provides 12 Hour Cough Relief 2 Key Consideration: When managing cough symptoms in HTN patients, it is essential to choose options that do not adversely interact with their hypertension condition. Note: The provided drug labels do not explicitly address potential interactions with hypertension; therefore, caution and further clinical evaluation are necessary when selecting a cough management option for an HTN patient.

From the Research

Viable Options for Cough Symptom Management in HTN Patients

• Temporarily discontinuing ACEIs upon a reported incidence of cough and reintroducing after its remission 3
• Adding calcium channel blockers to ACEIs to manage cough symptoms 3, 4
• Switching to alternative drugs such as angiotensin receptor blockers (ARBs) in case of intolerable symptoms 5, 3
• Continuing ACEI treatment despite cough, as the cough may resolve naturally or completely disappear over time 4, 6
• Taking medication at bedtime to reduce the frequency of cough 4

Characteristics of ACE Inhibitor-Induced Cough

• Typically dry, nonproductive, and worse at night 7
• May interfere with sleep and be severe in some cases 7
• More frequently observed in women than in men 4
• May be associated with complications such as urinary stress incontinence and rectal and vaginal prolapse 7

Management Strategies

• Starting ACE inhibitor treatment as early as possible and devising ways to continue treatment for as long as possible 4
• Using measures to counteract cough, such as adding calcium channel blockers or diuretics to ACEIs 4
• Considering the use of alternative medications, such as ARBs, in case of intolerable cough symptoms 5, 3