What is the best cough medication for patients with hypertension?

Best Cough Medication for Hypertensive Patients

For patients with hypertension requiring cough treatment, benzonatate (Tessalon Perles) is the safest first-line option because it has no cardiovascular effects and does not elevate blood pressure, unlike decongestant-containing products which should be avoided. 1

Primary Recommendation: Benzonatate

• Benzonatate is FDA-approved for symptomatic cough relief and works peripherally by anesthetizing stretch receptors in the respiratory passages without affecting blood pressure or the cardiovascular system. 1
• The medication begins working within 15-20 minutes with effects lasting 3-8 hours, and has no inhibitory effect on the respiratory center at recommended doses. 1
• This makes it ideal for hypertensive patients who need cough suppression without cardiovascular risk. 1

Critical Medications to AVOID in Hypertensive Patients

Oral Decongestants (Pseudoephedrine/Phenylephrine)

• Oral decongestants should be used with extreme caution or avoided entirely in patients with hypertension, as they can elevate blood pressure. 2
• While blood pressure elevation is "rarely noted" in normotensive patients and only "occasionally" in patients with controlled hypertension, the risk-benefit ratio does not favor their use when safer alternatives exist. 2
• Patients with cardiovascular disease represent a specific contraindication for oral decongestants. 2

Over-the-Counter Combination Products

• Most OTC combination cold medications are not recommended, with the exception of older antihistamine-decongestant combinations, though even these carry hypertension concerns. 2

Alternative Cough Suppressants Based on Cough Etiology

For Chronic Bronchitis

• Codeine (30 mg three times daily) or dextromethorphan (30 mg as needed) are recommended for short-term symptomatic relief in chronic bronchitis (Grade B recommendation). 2
• These central cough suppressants have fair evidence showing intermediate benefit for chronic bronchitis specifically. 2

For Upper Respiratory Infection (URI)

• Central cough suppressants like codeine and dextromethorphan have limited efficacy for URI-related cough and are not recommended (Grade D recommendation). 2
• First-generation antihistamines (like diphenhydramine) combined with decongestants are recommended for acute cough from the common cold, but the decongestant component poses hypertension risk. 2

For Post-Infectious or Persistent Cough

• Ipratropium bromide is the only inhaled anticholinergic specifically recommended for cough suppression (Grade A recommendation for URI/chronic bronchitis). 2, 3
• This represents a safer option than oral decongestants for hypertensive patients with persistent cough. 3

Special Consideration: ACE Inhibitor-Induced Cough

Recognition and Management

• If the hypertensive patient is taking an ACE inhibitor (like perindopril, enalapril, lisinopril), this is the most common medication-related cause of persistent dry cough, occurring in 5-35% of patients. 4, 5
• The cough is typically dry, associated with a tickling throat sensation, and caused by bradykinin and substance P accumulation. 4, 6, 7
• Discontinuing the ACE inhibitor is the only uniformly effective treatment, with cough resolution expected within 1-4 weeks (though may take up to 3 months). 4, 5

Switching Strategy

• The American College of Cardiology strongly recommends (Grade A) switching to an angiotensin receptor blocker (ARB) when ACE inhibitor-induced cough occurs. 4
• Losartan 25 mg once daily is the most studied ARB for patients with ACE inhibitor-induced cough, with titration to 50 mg if needed for blood pressure control. 4
• ARBs have cough rates similar to placebo (2-3%) compared to ACE inhibitors (7.9%) because they don't inhibit ACE and therefore don't cause bradykinin accumulation. 4, 5

Important Caveat

• While rare, one case report documented losartan-induced cough that resolved with enalapril substitution, demonstrating that ARB-induced cough can occur despite the theoretical mechanism. 8
• However, this represents an exceptional case, and the overwhelming evidence supports ARBs as having dramatically lower cough incidence. 4, 5

Practical Algorithm for Hypertensive Patients with Cough

1. First, determine if patient is on an ACE inhibitor - if yes, this is likely the cause; switch to an ARB. 4, 5

2. For symptomatic cough relief while maintaining blood pressure control:

   • First-line: Benzonatate (no cardiovascular effects). 1
   • Second-line: Ipratropium bromide inhaler (for persistent cough, especially post-infectious). 3
   • Third-line: Codeine or dextromethorphan (only for chronic bronchitis, not URI). 2

3. Avoid entirely:

   • Oral decongestants (pseudoephedrine/phenylephrine). 2
   • Most OTC combination products. 2

4. Monitor blood pressure when initiating any new cough medication, even those considered "safe," as individual patient responses vary. 2