ARB with Least Incidence of Cough
All ARBs have similarly low rates of cough that are comparable to placebo and significantly lower than ACE inhibitors, with no single ARB demonstrating superiority over others in terms of cough incidence.
Evidence from Guidelines and Clinical Trials
The available evidence does not differentiate between individual ARBs regarding cough incidence:
Class effect: ARBs as a class have cough rates similar to placebo or hydrochlorothiazide, and dramatically lower than ACE inhibitors 1. The mechanism explains this—ARBs do not inhibit ACE and therefore do not cause accumulation of bradykinin and substance P, the mediators responsible for ACE inhibitor-induced cough 1.
Losartan data: The most extensively studied ARB for cough is losartan, which showed a cough incidence of 29% in patients with prior ACE inhibitor-induced cough, compared to 72% with lisinopril and 34% with hydrochlorothiazide 2, 3. This 29% rate in a population selected for cough susceptibility demonstrates that losartan's cough rate approximates that of a diuretic 1, 4.
Valsartan data: In comparative trials, valsartan showed a cough incidence of 2.6% versus 7.9% with ACE inhibitors 5. In a specific study of patients with prior ACE inhibitor-induced cough, valsartan caused cough in only 20% of patients compared to 69% with lisinopril 5.
No comparative ARB studies: Importantly, no head-to-head trials have compared cough rates between different ARBs 1. The 2022 guidelines note "no sex-specific differences in cough" between ARBs 1.
Clinical Recommendation
When switching from an ACE inhibitor due to cough, any ARB is appropriate 1, 6, 4. The choice should be based on:
- Comorbidities: Select based on cardiovascular or renal indications rather than cough profile
- Dosing convenience: Once-daily formulations improve adherence
- Cost and availability: All ARBs have equivalent cough profiles
Practical Algorithm for ARB Selection
First-line options (based on guideline recommendations, not cough differences):
Monitoring after switch: Cough should resolve within 1-4 weeks, though may take up to 3 months in some patients 1, 6
Important caveat: Rare cases of ARB-induced cough have been reported in post-marketing surveillance 7, 8. One case report documented losartan-induced cough that resolved with enalapril substitution, demonstrating idiosyncratic reactions can occur 8.
Key Clinical Pitfalls
Angioedema risk: Although rare, patients with prior ACE inhibitor-associated angioedema may experience angioedema with ARBs; use caution during initial treatment 4, 7
Renal monitoring: ARBs require the same renal function and potassium monitoring as ACE inhibitors 4
Elderly patients: Start with lower doses (e.g., losartan 25 mg, telmisartan 40 mg) and monitor for orthostatic hypotension 6, 4