What alternative can I give to a patient who developed a cough after starting low-dose lisinopril (Angiotensin-Converting Enzyme inhibitor) 10mg?

Management of ACE Inhibitor-Induced Cough: Alternative Medications

For a patient who has developed cough after starting low-dose lisinopril (10mg), an angiotensin receptor blocker (ARB) is the recommended alternative medication as it provides similar cardiovascular benefits without causing cough. 1, 2

Understanding ACE Inhibitor-Induced Cough

• ACE inhibitor-induced cough is a common side effect occurring in approximately 5-20% of patients taking these medications 1, 2
• The cough is typically dry, persistent, and often begins within days to weeks after starting the medication 2
• Cough is caused by the accumulation of bradykinin and substance P when ACE is inhibited 2
• The cough usually resolves within 1-4 weeks after discontinuation of the ACE inhibitor 2

First-Line Alternative: Angiotensin Receptor Blockers (ARBs)

• ARBs are the recommended first-line alternative for patients who develop cough with ACE inhibitors 1, 2
• ARBs work through a similar mechanism as ACE inhibitors but do not affect bradykinin metabolism, which is believed to be the cause of cough 2
• Clinical trials have demonstrated that the incidence of cough with ARBs is significantly lower than with ACE inhibitors and similar to that of placebo or hydrochlorothiazide 3
• In controlled trials, the incidence of cough was 17-29% with losartan compared to 62-69% with lisinopril 3

Recommended ARB Options

• Losartan: Starting dose 25-50mg once daily, maximum dose 50-100mg once daily 1
• Valsartan: Starting dose 20-40mg twice daily, maximum dose 160mg twice daily 1
• Candesartan: Starting dose 4-8mg once daily, maximum dose 32mg once daily 1

Monitoring After Switching to an ARB

• Monitor blood pressure 1-2 weeks after initiating the ARB 1
• Check renal function (urea, creatinine, potassium) 1-2 weeks after starting treatment and after dose adjustments 1
• Aim for target doses as used in clinical trials, or the highest tolerated dose 1

Alternative Options if ARBs are Not Tolerated

• Calcium channel blockers (CCBs) can be considered if ARBs are contraindicated or not tolerated 2
• Thiazide-like diuretics are another alternative if CCBs are not suitable 2

Special Considerations

• While rare, cough has been reported with ARBs in some patients 4
• Angioedema can occur with both ACE inhibitors and ARBs, though it is less common with ARBs 1
• If a patient has experienced angioedema with an ACE inhibitor, extreme caution is advised when using an ARB 1

Important Pitfalls to Avoid

• Don't assume all cough in patients taking ACE inhibitors is drug-induced; consider other causes such as pulmonary edema or respiratory disease 1
• Confirm that the cough is ACE inhibitor-induced by observing resolution after discontinuation and recurrence with rechallenge 2
• Don't discontinue ACE inhibitor therapy prematurely for mild cough if the patient is receiving significant cardiovascular benefits 1
• When switching to an ARB, start with the recommended initial dose and titrate gradually to avoid adverse effects 1