From the Guidelines
If someone develops a cough while taking an ACE inhibitor, the medication should be stopped if the cough is severe, disruptive to sleep, or significantly affects quality of life, and an alternative such as an angiotensin II receptor blocker (ARB) should be considered. In patients who develop a cough while taking an ACE inhibitor, the decision to stop the medication depends on the severity of the cough and its impact on the patient's quality of life 1. ACE inhibitor-induced cough is a common side effect that occurs in about 5-35% of patients and is typically dry, persistent, and often worse at night.
Key Considerations
- For patients with a mild cough that doesn't significantly impact their daily activities, continuing the medication while monitoring symptoms may be reasonable.
- However, if the cough is severe, disruptive to sleep, or significantly affects quality of life, switching to an alternative medication is recommended.
- The most appropriate alternative is usually an angiotensin II receptor blocker (ARB) such as losartan, valsartan, or irbesartan, which provide similar cardiovascular benefits without causing cough, as supported by the ACCP guidelines 1.
Management Approach
- The cough occurs because ACE inhibitors increase bradykinin levels in the lungs, which stimulates nerve endings and triggers the cough reflex.
- Importantly, the cough is not harmful but can take up to 4 weeks to resolve after stopping the ACE inhibitor.
- Patients should not stop their medication without consulting their healthcare provider first to ensure proper blood pressure management is maintained.
- In patients in whom persistent or intolerable ACE inhibitor-induced cough occurs, therapy should be switched, when indicated, to an ARB, with which the incidence of associated cough appears to be similar to that for the control drug, or to an appropriate agent of another drug class, as recommended by the ACCP guidelines 1.
From the FDA Drug Label
Presumably due to the inhibition of the degradation of endogenous bradykinin, persistent nonproductive cough has been reported with all ACE inhibitors, always resolving after discontinuation of therapy. ACE inhibitor-induced cough should be considered in the differential diagnosis of cough Presumably caused by inhibition of the degradation of endogenous bradykinin, persistent nonproductive cough has been reported with all ACE inhibitors, always resolving after discontinuation of therapy. Consider the possibility of angiotensin converting enzyme inhibitor induced-cough in the differential diagnosis of cough Cough Persistent dry cough (with an incidence of a few percent) has been associated with ACE-inhibitor use and in practice can be a cause of discontinuation of ACE-inhibitor therapy
Cough associated with ACE inhibitors is a known side effect.
- The incidence of cough is not well defined but is reported to occur in a few percent of patients.
- Discontinuation of ACE inhibitor therapy may be necessary if the cough is persistent and bothersome.
- Alternative antihypertensive therapy, such as an angiotensin receptor blocker (ARB), may be considered in patients who develop a cough while taking an ACE inhibitor 2, 3, 4.
From the Research
ACE Inhibitor-Induced Cough Management
- The development of a cough in patients taking ACE inhibitors is a common adverse effect, with an incidence rate ranging from 10% to 20% of patients 5, 6, 7.
- The mechanisms underlying ACE inhibitor-induced cough are likely linked to the suppression of kininase II activity, leading to an accumulation of kinins, substance P, and prostaglandins 7.
- Strategies for managing ACE inhibitor-induced cough include:
- Temporarily discontinuing the ACE inhibitor and reintroducing it after the cough has resolved 5.
- Adding calcium channel blockers to the ACE inhibitor regimen 5, 6.
- Switching to alternative drugs, such as angiotensin receptor blockers, if the cough is intolerable and other causes have been excluded 5, 8.
- In some cases, the cough may resolve naturally or disappear while the patient continues to take the medication 6.
- The use of pharmacologic treatments, such as cromolyn, baclofen, theophylline, sulindac, and local anesthetics, may also be considered to manage the cough 9.
Incidence and Characteristics of ACE Inhibitor-Induced Cough
- The incidence of cough varies among individual ACE inhibitors, with perindopril having the lowest incidence 5.
- Cough is more frequently observed in women than in men 6.
- The onset of cough can occur at any time, even months or a year after starting ACE inhibitor therapy 7.
- Concomitant use of calcium antagonists or diuretics may reduce the frequency of cough 6.
- Taking the medication at bedtime may also reduce the frequency of cough 6.