What to do for a 90-year-old patient with hypertension on perindopril (angiotensin-converting enzyme inhibitor) 2.5mg daily who developed a cough?

Management of ACE Inhibitor-Induced Cough in a 90-Year-Old Patient with Hypertension

For a 90-year-old patient with hypertension who developed cough while on perindopril 2.5mg daily, you should discontinue the perindopril and switch to an angiotensin receptor blocker (ARB) as this is the most effective approach to resolve the cough while maintaining blood pressure control. 1

Diagnosis of ACE Inhibitor-Induced Cough

• ACE inhibitor-induced cough is a common side effect that occurs in approximately 10-20% of patients on these medications, with perindopril specifically having a reported cough incidence of about 10.96% 2
• The cough is typically dry, persistent, and often begins within days to weeks after starting the medication 1
• The diagnosis is confirmed by resolution of cough after discontinuation of the ACE inhibitor, usually within 1-4 weeks (though it may take up to 3 months in some cases) 1

Management Algorithm

Step 1: Discontinue the ACE Inhibitor

• Discontinue perindopril as this is the only uniformly effective treatment for ACE inhibitor-induced cough 1
• The cough should resolve within 1-4 weeks after stopping the medication 1

Step 2: Choose Alternative Antihypertensive Therapy

• Switch to an ARB as first-line alternative 1
  • ARBs have a similar mechanism of action to ACE inhibitors but do not affect bradykinin metabolism, which is believed to be the cause of cough 1
  • ARBs have been shown to have a significantly lower incidence of cough compared to ACE inhibitors 1
• For a 90-year-old patient, consider starting with a low-dose ARB and titrating as needed 1

Step 3: If ARB is Not an Option

• If ARBs are contraindicated or not tolerated, consider a calcium channel blocker (CCB) as an alternative 1
  • CCBs are particularly appropriate for patients over 55 years old 1
• Thiazide-like diuretics can also be considered if CCBs are not suitable 1

Step 4: If ACE Inhibitor Must Be Continued

• In rare cases where perindopril must be continued despite cough, consider pharmacologic therapy aimed at suppressing cough 1:
  • Options include sodium cromoglycate, theophylline, sulindac, indomethacin, amlodipine, nifedipine, ferrous sulfate, or picotamide 1
  • However, this approach is less effective than switching to an ARB 1

Special Considerations for Elderly Patients

• In elderly patients (>70 years), careful dose titration is important 3
• Monitor for orthostatic hypotension when initiating new antihypertensive therapy 3
• For this 90-year-old patient, blood pressure targets may be less aggressive to avoid adverse effects 1
• If switching to an ARB, start with the lowest effective dose and titrate slowly 1

Common Pitfalls to Avoid

• Don't assume all cough in patients on ACE inhibitors is due to the medication; consider other causes if cough persists after discontinuation 1
• Don't continue the ACE inhibitor if a suitable alternative is available, as pharmacologic management of the cough is less effective than switching medications 1
• Don't combine an ACE inhibitor with an ARB as this increases adverse effects without significant benefit 1
• Don't abruptly discontinue antihypertensive therapy without providing an alternative, especially in elderly patients 3

Blood Pressure Monitoring

• After switching from perindopril to an alternative medication, monitor blood pressure closely to ensure adequate control 1
• For elderly patients, target blood pressure should be individualized based on frailty and comorbidities 1
• If blood pressure is not adequately controlled on monotherapy, combination therapy may be necessary following appropriate guidelines 1