What are the considerations for using Angiotensin Converting Enzyme (ACE) inhibitors in patients with lung disease?

ACE Inhibitors in Patients with Lung Disease: Considerations and Management

ACE inhibitors can be used in patients with lung disease, but caution is needed regarding cough, which is the most common adverse effect occurring in approximately 10% of patients. 1

Key Considerations for ACE Inhibitors in Lung Disease

ACE Inhibitor-Induced Cough

• Occurs in up to 20% of patients taking ACE inhibitors 1
• More frequent in blacks and women (less than 1% overall but higher in these populations) 1
• Mechanism: ACE inhibitors inhibit kininase and increase levels of bradykinin, which induces cough but also contributes to beneficial vasodilation 1
• Cough may develop immediately after starting therapy or months to a year later 2

Management Algorithm for ACE Inhibitor-Induced Cough

1. Evaluate the cough severity:

   • If cough is not severe, encourage continuation of ACE inhibitor due to long-term benefits 1
   • If cough is persistent and troublesome, consider alternatives

2. For persistent/troublesome cough:

   • Discontinue ACE inhibitor therapy (only uniformly effective treatment) 1
   • Switch to an Angiotensin Receptor Blocker (ARB) 1
   • ARBs have much lower incidence of cough and angioedema as they don't inhibit kininase 1

3. Pharmacologic options to suppress cough if ACE inhibitor must be continued 1:

   • Sodium cromoglycate
   • Theophylline
   • Sulindac
   • Indomethacin
   • Amlodipine
   • Nifedipine
   • Ferrous sulfate
   • Picotamide

Angioedema Considerations

• Occurs in <1% of patients taking ACE inhibitors 1
• Life-threatening reaction requiring lifetime avoidance of all ACE inhibitors 1
• ARBs may be considered as alternatives, but caution is advised as some patients develop angioedema with both ACE inhibitors and ARBs 1

Effects of ACE Inhibitors on Pulmonary Function

1. Potential benefits in heart failure patients:

   • Improves diffusing lung properties 3
   • Improves ventilation-perfusion matching during exercise 3
   • Restores alveolar diffusing capacity for carbon monoxide 3
   • Reduces dead space to tidal volume ratio during exercise 3

2. Genetic considerations:

   • ACE insertion/deletion (I/D) polymorphism affects response to therapy
   • DD genotype patients show higher vulnerability of alveolar-capillary membrane to fluid overload despite ACE inhibitor treatment 4

Patient Selection and Monitoring

Recommended for:

• Patients with heart failure and lung disease can generally receive ACE inhibitors 5
• Patients with primary airway disease (asthma, COPD) are not at increased risk of developing cough or bronchoconstriction from ACE inhibitors 5

Monitoring requirements:

• Renal function and serum potassium should be monitored regularly 1
• Blood pressure monitoring (caution with systolic BP <90 mmHg) 1
• Respiratory symptoms, particularly new or worsening cough

Special Considerations

• In patients with heart failure, ACE inhibitors may improve exercise tolerance, perfusion, and gas transfer despite higher risk of cough 5
• For patients with angioedema history, ARBs are preferred but should still be used with caution 1
• For patients with severe renal dysfunction (creatinine >2.5 mg/dL), specialist advice should be sought 1

By following this structured approach, ACE inhibitors can be safely used in most patients with lung disease while minimizing adverse respiratory effects.