Managing Cough in Patients on Lisinopril
For patients who develop a cough while taking lisinopril, switching to an angiotensin receptor blocker (ARB) such as losartan or valsartan is the recommended approach, as ARBs have a significantly lower incidence of cough compared to ACE inhibitors.
Why ACE Inhibitors Cause Cough
ACE inhibitors like lisinopril cause cough due to the accumulation of bradykinin and substance P in the airways. This is a class effect that occurs in:
- 5-10% of white patients of European descent
- Up to 50% in Chinese patients 1
- Overall incidence ranges from 5-35% of patients
Switching from ACE Inhibitor to ARB
Recommended ARB Options:
- Losartan: Start at 50 mg daily (can be titrated to 50-100 mg daily) 2
- Valsartan: Start at 80 mg daily (can be titrated to 160 mg twice daily) 3
Evidence Supporting ARB Switch:
- Clinical trials demonstrate that ARBs have a significantly lower incidence of cough compared to ACE inhibitors:
- In patients with a history of ACE inhibitor-induced cough, losartan had a 29% incidence of cough versus 72% with lisinopril 4, 5
- Valsartan showed a 19.5% incidence of cough versus 68.9% with lisinopril in patients with prior ACE inhibitor-induced cough 6
- The incidence of cough with ARBs is similar to that of hydrochlorothiazide or placebo 2, 7
Monitoring After Switching
- Blood Pressure: Monitor closely after switching to ensure adequate control
- Renal Function: Check within 1-2 weeks of starting the ARB
- Potassium Levels: Monitor closely, especially if the patient is also taking potassium-sparing diuretics or aldosterone antagonists 8
- Cough Resolution: Inform patients that cough may take 1-4 weeks to resolve after discontinuing the ACE inhibitor, though it may take up to 3 months in some cases 1
Important Considerations
- Do not attempt another ACE inhibitor: There is nearly 100% cross-reactivity for cough among ACE inhibitors 8
- Do not combine ARBs with ACE inhibitors: This increases cardiovascular and renal risk without additional benefit 8
- Rare cases of ARB-induced cough: Though uncommon, there have been isolated reports of cough with ARBs 9
Alternative Approaches
If there is a compelling reason to continue ACE inhibitor therapy despite cough (which is rare), consider:
- Pharmacologic therapy to suppress cough: sodium cromoglycate, theophylline, amlodipine, or nifedipine 1, 8
- However, this approach is generally not recommended as it may mask symptoms while continuing exposure to the triggering agent
Conclusion
The American College of Chest Physicians strongly recommends (Grade A recommendation) switching to an ARB for patients who develop ACE inhibitor-induced cough 1, 8. This approach effectively addresses the cough while maintaining cardiovascular protection.