What is the next step in evaluating a patient who develops a dry cough while taking lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor)-HCTZ (Hydrochlorothiazide)?

Management of Dry Cough in a Patient Taking Lisinopril-HCTZ

The first step in managing a patient with dry cough while taking lisinopril-HCTZ is to discontinue the ACE inhibitor (lisinopril) regardless of the temporal relationship between medication initiation and cough onset. 1

Diagnostic Approach

Initial Assessment

• Consider ACE inhibitor-induced cough as the primary cause of dry cough in a patient taking lisinopril, as this is a well-documented class effect occurring in 5-35% of patients 1
• The cough is typically dry and associated with a tickling or scratching sensation in the throat 1
• Cough may develop within hours of the first dose or be delayed for weeks to months after starting therapy 1

Risk Factors for ACE Inhibitor-Induced Cough

• Female gender (higher incidence compared to males) 1
• Non-smokers are more susceptible than smokers 1
• Chinese ethnicity or East Asian descent 1
• Patients treated for congestive heart failure have higher incidence than those treated for hypertension 1

Management Algorithm

Step 1: Discontinue Lisinopril

• Stop the ACE inhibitor (lisinopril) component of the medication 1
• The diagnosis is confirmed if cough resolves after discontinuation, typically within 1-4 weeks 1
• Be aware that in some patients, cough may persist for up to 3 months after discontinuation 1

Step 2: Alternative Antihypertensive Therapy

• Replace with an angiotensin receptor blocker (ARB) as these have significantly lower incidence of cough compared to ACE inhibitors 1, 2, 3
• Studies show ARBs like telmisartan, valsartan, and candesartan have cough incidence comparable to placebo in patients with history of ACE inhibitor-induced cough 2, 3, 4
• Continue the hydrochlorothiazide component of the medication as it is not associated with cough 3

Step 3: Follow-up and Monitoring

• Assess for resolution of cough within 1-4 weeks after discontinuation 1
• Monitor blood pressure to ensure adequate control with the alternative medication 3
• If cough persists beyond expected resolution timeframe (up to 3 months), consider additional workup for other causes of chronic cough 1

Important Considerations

Pitfalls to Avoid

• Do not assume the cough has another etiology based on timing; ACE inhibitor-induced cough should be considered regardless of the temporal relationship between medication initiation and cough onset 1
• Do not attempt dose reduction of lisinopril, as ACE inhibitor-induced cough is not dose-dependent 1
• Avoid unnecessary diagnostic testing before a trial of ACE inhibitor discontinuation 1
• Be aware that ACE inhibitors may sensitize the cough reflex and potentiate other causes of cough 1

Special Situations

• In patients where ACE inhibitor therapy is strongly indicated and cannot be discontinued, some pharmacologic agents may help attenuate the cough, though complete resolution typically requires discontinuation 1
• In a minority of patients, cough may not recur after reintroduction of ACE inhibitor therapy 1
• Indomethacin has shown some efficacy in reducing ACE inhibitor-induced cough in some patients, but discontinuation remains the most effective approach 5

By following this approach, you can effectively manage dry cough in patients taking lisinopril-HCTZ while maintaining appropriate blood pressure control with alternative medications.