How long does a cough caused by an angiotensin‑converting‑enzyme inhibitor (ACE inhibitor) typically take to resolve after discontinuation?

ACE Inhibitor-Induced Cough Resolution Timeline

ACE inhibitor-induced cough typically resolves within 1 to 4 weeks after discontinuation, with a median resolution time of approximately 26 days (≈3.5 weeks), though a minority of patients may require up to 3 months for complete resolution. 1, 2

Expected Timeline After Discontinuation

• Most patients (majority): Cough resolves within 1–4 weeks of stopping the ACE inhibitor 1, 2
• Median resolution time: Approximately 26 days (roughly 3.5 weeks) 2
• Delayed resolution subset: Up to 3 months may be required in some patients for complete symptom resolution 1, 2
• Early improvement: Cough intensity typically decreases by 50% within the first 3 days of cessation, with complete disappearance often by 10 days 3

Clinical Management Algorithm

Immediate Action

• Discontinue the ACE inhibitor immediately regardless of the temporal relationship between medication initiation and cough onset 1, 2
• The American College of Chest Physicians provides a Grade B recommendation that discontinuation is the only uniformly effective treatment 1, 2

Monitoring Period

• Actively monitor for cough resolution during the 1–4 week period following discontinuation 2
• If cough persists beyond 4 weeks, investigate alternative etiologies including gastroesophageal reflux disease, heart failure-related pulmonary congestion, or asthma 2

Medication Substitution

• Switch to an angiotensin receptor blocker (ARB) such as valsartan or losartan, which have cough incidence comparable to placebo 2
• The American College of Cardiology/American Heart Association gives a Class I, Level A recommendation (highest level) for using ARBs in patients intolerant to ACE inhibitors due to cough 2

Critical Pitfalls to Avoid

• Do not switch to a different ACE inhibitor – cough is a class effect mediated by bradykinin accumulation and will recur with any ACE inhibitor 1, 2, 4
• Do not reduce the ACE inhibitor dose – the cough is not dose-dependent and will persist at any dosage 2, 3
• Do not assume delayed onset excludes ACE inhibitors – cough may develop anywhere from hours to more than a year after therapy initiation 2, 4
• Be aware that ACE inhibitors sensitize the cough reflex, potentially amplifying cough from other underlying conditions 2

Special Considerations

Risk Factors for Prolonged Resolution

• Patients with heart failure experience ACE inhibitor-induced cough more frequently (26% incidence) than those with hypertension (14% incidence) 5
• Women have significantly higher rates of ACE inhibitor-induced cough compared to men 2, 5, 3
• Non-smokers and persons of Chinese or East Asian ancestry are at higher risk 2

Rechallenge Considerations

• Approximately 30% of patients with confirmed ACE inhibitor-induced cough do not develop cough after a third rechallenge, suggesting a limited repeat trial may be considered only when an ACE inhibitor is absolutely required 1
• However, switching to an ARB remains far more appropriate than attempting rechallenge 2