What medications can cause hoarseness in patients, particularly those with a history of respiratory issues or pre-existing vocal cord problems?

Medications That Can Cause Hoarseness

The American Academy of Otolaryngology-Head and Neck Surgery identifies seven major medication classes that cause hoarseness through distinct mechanisms: inhaled corticosteroids (mucosal irritation/fungal laryngitis), ACE inhibitors (chronic cough), anticoagulants (vocal fold hematoma), bisphosphonates (chemical laryngitis), anticholinergics/antihistamines/diuretics (mucosal drying), sex hormones (hormonal alterations), and antipsychotics (laryngeal dystonia). 1

Primary Medication Categories

Inhaled Corticosteroids

• Most common medication-related cause of hoarseness in patients with asthma or COPD, producing dose-dependent mucosal irritation and fungal laryngitis 1
• Fluticasone propionate dry powder inhalers show particularly high rates: 20.4% overall prevalence of hoarseness, rising to 35.8% in women ≥65 years of age 2
• Women and elderly patients experience significantly higher rates of dysphonia regardless of inspiratory flow rates 2
• Strobovideolaryngoscopy reveals abnormal mucosal wave symmetry (76%), phase closure (74%), and glottic closure (63%) in affected patients 3

ACE Inhibitors

• Cause hoarseness through chronic cough mechanism rather than direct laryngeal effects 1
• Lisinopril FDA labeling specifically warns of laryngeal edema as part of angioedema risk, which can occur at any time during treatment 4
• Patients should report swelling of face, lips, tongue, or difficulty swallowing/breathing immediately 4

Anticoagulants and Antiplatelet Agents

• Warfarin (Coumadin), thrombolytics, and phosphodiesterase-5 inhibitors cause hoarseness via vocal fold hematoma formation 1
• This represents a structural injury mechanism requiring immediate laryngoscopy if hoarseness develops acutely in anticoagulated patients 1

Anticholinergics, Antihistamines, and Diuretics

• Produce hoarseness through drying effects on laryngeal mucosa 1
• Particularly problematic in elderly patients who already have age-related mucosal changes and reduced hydration 1

Bisphosphonates

• Cause chemical laryngitis as the mechanism of voice change 1
• This represents direct mucosal injury from medication contact with laryngeal tissues 1

Sex Hormones

• Danazol and testosterone alter sex hormone production/utilization, leading to voice changes 1
• These changes may be irreversible, particularly in female patients, making early recognition critical 1

Antipsychotics

• Both typical and atypical antipsychotics cause hoarseness through laryngeal dystonia 1
• This represents a movement disorder affecting laryngeal muscles rather than mucosal pathology 1

Critical Clinical Considerations for High-Risk Patients

Patients with Respiratory Disease

• Those using inhaled corticosteroids for asthma/COPD require specific counseling about hoarseness risk, proper inhaler technique, and mouth rinsing after use 1
• Laryngeal tuberculosis must be excluded in endemic regions when asthmatic patients on inhaled steroids develop hoarseness, as this can mimic steroid side effects 5

Patients with Pre-existing Vocal Cord Problems

• Any new medication from the above classes warrants heightened surveillance in patients with baseline vocal fold pathology 1
• Professional voice users (teachers, singers, clergy) require immediate evaluation if hoarseness develops after medication initiation, as delay can have significant occupational consequences 1

Management Algorithm

Immediate Actions When Medication-Induced Hoarseness Suspected

• Perform laryngoscopy or refer for visualization rather than empirically discontinuing medications, as other serious pathology must be excluded 1
• Document medication timing relative to hoarseness onset in the medical record 1
• For ACE inhibitor users with acute hoarseness and swelling symptoms, consider angioedema and provide emergency care 4

Medication-Specific Interventions

• Inhaled corticosteroids: Optimize technique, add spacer device, consider switching formulations or delivery systems, ensure mouth rinsing 3
• ACE inhibitors: Consider switching to angiotensin receptor blocker if chronic cough-induced hoarseness confirmed 1
• Anticoagulants: If vocal fold hematoma confirmed, manage anticoagulation carefully with hematology consultation 1

Common Pitfalls to Avoid

• Never attribute hoarseness to medications without laryngoscopic confirmation, especially in smokers or patients with risk factors for malignancy, as this delays cancer diagnosis 1, 6
• Do not empirically prescribe antibiotics, systemic corticosteroids, or anti-reflux medications for presumed medication-induced hoarseness before visualizing the larynx 1, 6
• Avoid dismissing hoarseness in elderly women using inhaled steroids as "expected side effect" without examination, given the 35.8% prevalence in this group 2
• Do not overlook that hoarseness from sex hormones or antipsychotics may represent irreversible changes requiring immediate medication adjustment 1