What to do for a 90-year-old patient with hypertension, taking perindopril (Angiotensin-Converting Enzyme (ACE) inhibitor), who is complaining of a cough?

Management of ACE Inhibitor-Induced Cough in a 90-Year-Old Patient on Perindopril

For a 90-year-old hypertensive patient experiencing cough while on perindopril, discontinuation of the ACE inhibitor is the recommended approach, as it is the only uniformly effective treatment for ACE inhibitor-induced cough. 1

Diagnosis of ACE Inhibitor-Induced Cough

• ACE inhibitor-induced cough is a well-documented class effect occurring in approximately 5-35% of patients treated with these medications 1
• The cough is typically dry and associated with a tickling or scratching sensation in the throat 1
• The mechanism involves accumulation of bradykinin and substance P (which are normally degraded by ACE) in the upper airway, along with prostaglandins stimulated by bradykinin 1
• Cough may develop within hours of the first dose or be delayed for weeks to months after starting therapy 1

Management Algorithm

Step 1: Discontinue Perindopril

• Discontinue perindopril regardless of the temporal relationship between cough onset and medication initiation 1
• Resolution of cough typically occurs within 1-4 weeks after discontinuation, though it may take up to 3 months in some patients 1

Step 2: Alternative Antihypertensive Options

• Switch to an angiotensin receptor blocker (ARB) as first-line alternative

  • ARBs have a similar efficacy profile but do not cause cough at rates higher than placebo 1
  • ARBs do not affect ACE and therefore don't lead to bradykinin accumulation 2

• Other alternative antihypertensive classes to consider:

  • Calcium channel blockers
  • Diuretics
  • Beta-blockers (with caution in elderly patients)

Step 3: If ACE Inhibitor Must Be Continued

If there is a compelling reason to maintain ACE inhibitor therapy (which is rare):

• Consider pharmacologic interventions to suppress cough:
  • Sodium cromoglycate (inhaled) 1
  • Theophylline 1
  • Calcium channel antagonists (amlodipine, nifedipine) 1
  • Ferrous sulfate 1
  • NSAIDs like sulindac or indomethacin (use with caution in elderly) 1

Special Considerations for Elderly Patients

• ACE inhibitor-induced cough occurs more frequently in women and non-smokers 1
• In a 90-year-old patient, medication changes should be made with careful monitoring of blood pressure 1
• Consider starting alternative medications at lower doses and titrating slowly 1

Important Caveats

• Ensure the cough is not due to other causes that are common in elderly patients (heart failure, pulmonary disease, post-nasal drip) 1
• If perindopril is discontinued, monitor blood pressure closely to ensure adequate control with the new regimen 1
• In rare cases (approximately 30%), patients who previously experienced ACE inhibitor-induced cough may not develop it when rechallenged with the same medication 1
• The FDA drug label for perindopril specifically mentions persistent nonproductive cough as a known side effect that resolves after discontinuation of therapy 3

Remember that while alternative medications to suppress cough exist, discontinuation of the ACE inhibitor remains the most effective approach for managing this side effect 1.