What is the recommended switch and dose for a patient experiencing a dry cough on perindopril (Angiotensin-Converting Enzyme (ACE) inhibitor) 4 mg/day?

Management of Dry Cough on Perindopril: Recommended Switch and Dosing

For a patient experiencing dry cough on perindopril 4 mg/day, switching to an angiotensin receptor blocker (ARB) is the recommended approach, with telmisartan 40 mg once daily as the preferred alternative. 1

Understanding ACE Inhibitor-Induced Cough

• ACE inhibitor-induced cough is a common side effect occurring in approximately 10-20% of patients taking these medications 1
• The cough is typically dry, persistent, and often begins within days to weeks after starting the medication 1
• Cough is thought to originate from multiple mechanisms, with the bradykinin theory being the most commonly accepted hypothesis 2
• 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

First-Line Recommendation: Switch to an ARB

• Substitution of an angiotensin receptor blocker (ARB) is the recommended approach when troublesome cough develops due to ACE inhibition 3, 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
• The incidence of cough with ARBs is not significantly different from placebo (ARB: 0.11%; placebo: 0.07%) 3
• Valsartan has been shown to cause significantly less cough (19.5%) compared to lisinopril (68.9%) in patients with a history of ACE inhibitor-induced cough 4

Specific ARB Recommendation and Dosing

• Telmisartan 40 mg once daily is the recommended starting dose when switching from perindopril 4 mg/day 1
• If blood pressure control is inadequate on 40 mg daily, the dose can be increased to 80 mg daily, which is the maximum recommended dose for telmisartan 1
• Start with the lowest effective dose and titrate slowly, especially in elderly patients 1

Alternative Approaches if ARBs Are Not Suitable

• If ARBs are contraindicated or not tolerated, consider a calcium channel blocker (CCB) as an alternative, particularly for patients over 55 years old 1
• Amlodipine has been shown to attenuate cough due to ACE inhibitors in randomized, double-blind, placebo-controlled trials 1
• Thiazide-like diuretics can also be considered if CCBs are not suitable 1

Monitoring After Medication Switch

• After switching from perindopril to an alternative medication, monitor blood pressure closely to ensure adequate control 1
• Target blood pressure should be individualized based on patient factors such as age, frailty, and comorbidities 1
• If blood pressure is not adequately controlled on monotherapy, combination therapy may be necessary 1

Important Considerations

• Cough is common in patients with heart failure, many of whom have smoking-related lung disease 3
• Before attributing cough to ACE inhibitors, exclude other causes such as pulmonary edema 3
• In some cases, cough may disappear despite continuing ACE inhibitor treatment 2
• The incidence of cough varies among individual ACEIs and is reported to be lowest with perindopril (<2% discontinuation rate due to cough) 5
• Cough appears to be more common in women and older patients 6