Can Lisinopril (angiotensin-converting enzyme inhibitor) cause tinnitus in patients?

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Can Lisinopril Cause Tinnitus?

Lisinopril and other ACE inhibitors are associated with tinnitus, though this is not listed among the most common adverse effects in major cardiology guidelines, and the evidence suggests a possible association rather than a definitive causal relationship.

Evidence from Guidelines on ACE Inhibitor Side Effects

The most comprehensive heart failure guidelines from the American College of Cardiology and American Heart Association identify the primary adverse effects of ACE inhibitors as 1:

  • Cough (5-10% in white patients, up to 50% in Chinese patients) - the most common reason for drug withdrawal
  • Angioedema (<1% of patients, more frequent in Black patients)
  • Hyperkalemia (especially with renal dysfunction or concurrent potassium-sparing agents)
  • Azotemia/renal dysfunction

Notably, tinnitus is not mentioned as a recognized adverse effect in these authoritative ACC/AHA guidelines 1.

Research Evidence Linking ACE Inhibitors to Tinnitus

Despite the absence of tinnitus in guideline-listed side effects, research studies suggest a potential association:

Cross-Sectional Study Findings

A 2016 study found that hypertension treatment with ACE inhibitors was significantly more prevalent in tinnitus patients (p = 0.006), suggesting possible ototoxicity 2. This study compared 144 tinnitus patients to 140 controls and found hypertension prevalence of 44.4% versus 31.4% respectively 2.

FDA Adverse Event Database Analysis

A 2024 analysis of the FDA Adverse Event Reporting System (FAERS) database examined 29,460 patients with drug-related tinnitus 3. While this study identified duloxetine, ciprofloxacin, and adalimumab as having the strongest associations with tinnitus, ACE inhibitors were not among the top 25 drugs most strongly associated with tinnitus reports 3.

Clinical Safety Studies

Long-term safety studies of lisinopril in 3,270 patients (including 2,688 hypertensives) over durations up to 43 months reported the most frequent adverse events as headache, dizziness, cough, nausea, diarrhea, and fatigue, with no mention of tinnitus 4.

Clinical Context and Interpretation

Distinguishing Correlation from Causation

The association between ACE inhibitors and tinnitus may be confounded by:

  • Hypertension itself is associated with tinnitus independent of treatment 2
  • Older patients with hypertension have higher tinnitus prevalence regardless of medication 2
  • Multiple antihypertensive drug classes (diuretics, calcium channel blockers) show similar associations 2

Tinnitus Guideline Perspective

The American Academy of Otolaryngology-Head and Neck Surgery's 2014 tinnitus guideline does not list ACE inhibitors among medications that cause or worsen tinnitus 1. The guideline specifically recommends against dietary supplements and notes that some antidepressants can worsen tinnitus, but makes no mention of ACE inhibitors 1.

Clinical Recommendations

If a patient on lisinopril develops tinnitus:

  1. Perform comprehensive otologic evaluation to identify other causes (hearing loss, Meniere's disease, vestibular disorders, vascular abnormalities) 1, 5

  2. Obtain audiologic examination if tinnitus is unilateral, persistent ≥6 months, or associated with hearing difficulties 5

  3. Consider imaging only if unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss are present 5

  4. Do not routinely discontinue lisinopril based solely on tinnitus, given:

    • The proven mortality and morbidity benefits of ACE inhibitors in heart failure and hypertension 1
    • The lack of strong evidence for causation
    • The availability of effective tinnitus management strategies

  5. If tinnitus is severe and persistent, consider trial discontinuation and rechallenge to establish causality, but only after excluding other causes 1

  6. Manage tinnitus symptomatically with cognitive behavioral therapy (strongest evidence), hearing aids if hearing loss present, and education/counseling 5

Important Caveats

  • Never confuse ACE inhibitor side effects with ARB side effects - while angioedema can occur with both, there is no established cross-reactivity for other adverse effects 1
  • The association between antihypertensive medications and tinnitus may reflect the underlying hypertension rather than drug effect 2
  • Tinnitus has multiple causes, and medication-induced tinnitus represents only a small subset of cases 1, 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Analysis of Drug-Related Tinnitus Based on the FDA Adverse Event Reporting System Database.

British journal of hospital medicine (London, England : 2005), 2024

5
Guideline

Tinnitus Treatment Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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