Management of ACE Inhibitor-Induced Cough
Stop lisinopril immediately and switch to an angiotensin receptor blocker (ARB) such as valsartan or losartan—this is the only uniformly effective treatment for ACE inhibitor-induced cough. 1
Understanding Your Cough
Your dry, non-productive cough is almost certainly caused by lisinopril, a well-documented class effect occurring in 5-35% of patients taking ACE inhibitors. 1 This makes ACE inhibitors the most common pharmaceutical cause of chronic dry cough. 1
Key characteristics that confirm ACE inhibitor-induced cough:
- Dry, tickling or scratching sensation in the throat 2, 1
- Non-productive (no mucus) 2
- Can develop anywhere from hours after the first dose to weeks or months later 1
- Not dose-dependent—reducing the dose will not help 1
- More common in women, non-smokers, and persons of Chinese or East Asian descent 1
Immediate Management Steps
The American College of Chest Physicians gives a Grade B recommendation (high-quality evidence) to discontinue the ACE inhibitor immediately, as this is the only uniformly effective intervention. 1
Step 1: Stop Lisinopril Now
- Do not attempt to reduce the dose—the cough is not dose-dependent and will persist at any dosage 1
- Do not switch to another ACE inhibitor (enalapril, ramipril, captopril, etc.)—all ACE inhibitors cause cough through the same mechanism and the cough will recur 2, 1
Step 2: Switch to an ARB
The ACC/AHA guidelines provide a Class I, Level A recommendation (the highest level of evidence) for substituting an ARB in patients intolerant to ACE inhibitors due to cough. 1
Recommended ARBs:
- Valsartan: Start 20-40 mg twice daily, titrate up to 160 mg twice daily 1
- Losartan: Start 25-50 mg once daily, titrate to 50-100 mg once daily 2
Critical timing: Allow at least 36 hours between your last lisinopril dose and starting the ARB to minimize risk of adverse effects. 1
Step 3: Monitor for Resolution
- Your cough will typically resolve within 1-4 weeks after stopping lisinopril 1
- The median resolution time is approximately 26 days (≈3.5 weeks) 1
- A minority of patients may require up to 3 months for complete resolution 1
Step 4: Follow-Up Testing
Check blood pressure, kidney function (creatinine), and potassium levels within 1-2 weeks after starting the ARB and after any dose changes. 1
What If the Cough Persists Beyond 4 Weeks?
If your cough has not resolved 4 weeks after stopping lisinopril, you should be evaluated for other causes: 1
- Gastroesophageal reflux disease (GERD)
- Heart failure-related pulmonary congestion (fluid in the lungs)
- Asthma or bronchial hyper-responsiveness
- Upper airway cough syndrome (post-nasal drip)
Critical Pitfalls to Avoid
Do NOT:
- Try a different ACE inhibitor—the cough is a class effect and will recur with any ACE inhibitor 2, 1
- Reduce the lisinopril dose—the cough is not dose-dependent 1
- Assume the timing rules out lisinopril—cough can develop months or even a year after starting therapy 1
- Undergo extensive testing before trying discontinuation—a therapeutic trial of stopping the medication is both diagnostic and therapeutic 1
Why ARBs Are the Solution
ARBs work through a different mechanism than ACE inhibitors and have a cough incidence comparable to placebo—meaning they essentially do not cause cough. 1 They provide the same cardiovascular and kidney protection as ACE inhibitors without the bradykinin accumulation that triggers the cough reflex. 1
Special Consideration for Heart Failure Patients
If you have heart failure, the European Society of Cardiology notes that ACE inhibitor-induced cough "rarely requires treatment discontinuation" unless the cough is very troublesome (e.g., interferes with sleep). 1 However, when the cough significantly impacts quality of life, switching to an ARB is entirely appropriate and maintains guideline-directed medical therapy. 1, 3
Important: If you have heart failure, your doctor must first exclude pulmonary edema (fluid in the lungs) as an alternative cause before attributing the cough solely to lisinopril. 1