Can lisinopril (an ACE inhibitor) cause excessive sweating?

Can Lisinopril Cause Sweating?

Sweating (diaphoresis) is a recognized adverse effect of lisinopril, though it is uncommon and not among the most frequently reported side effects of this ACE inhibitor.

Evidence from FDA Drug Labeling

The FDA-approved prescribing information for lisinopril explicitly lists diaphoresis (sweating) as an adverse reaction under skin-related effects 1. This appears in the official drug label alongside other dermatological manifestations including urticaria, alopecia, photosensitivity, erythema, and flushing 1.

Frequency and Clinical Context

While sweating is documented as a potential adverse effect, it is not among the most common reasons patients discontinue lisinopril therapy 1. The most frequently reported adverse reactions leading to drug discontinuation in clinical trials were:

• Cough (occurs in 5-10% of patients of European descent, up to 50% in Chinese patients) 2
• Dizziness/syncope (3.5-3.9% more common than placebo) 2, 1
• Hypotension (particularly in heart failure patients) 1
• Angioedema (rare but serious, <1% of patients) 2

Mechanism and Drug Class Considerations

ACE inhibitors like lisinopril can affect sweating through multiple mechanisms 3:

• Central thermoregulatory effects at the hypothalamus or spinal centers
• Peripheral effects at sympathetic ganglia or the eccrine-neuroeffector junction
• Bradykinin accumulation (since ACE is identical to kininase, which degrades bradykinin) 1

The accumulation of bradykinin—a known vasodilator—may contribute to various ACE inhibitor side effects, potentially including altered sweating patterns 1.

Clinical Recommendations

If a patient reports excessive sweating on lisinopril:

1. Verify the temporal relationship between drug initiation/dose changes and symptom onset 1
2. Exclude other causes of hyperhidrosis (thyroid disease, infection, other medications, menopause) before attributing it to lisinopril 3
3. Consider dose reduction if sweating is bothersome but the drug is otherwise well-tolerated 3
4. Switch to an angiotensin receptor blocker (ARB) if symptoms persist and are troublesome, as ARBs do not affect bradykinin metabolism 2
5. Document the reaction but recognize this is generally not a dangerous adverse effect, unlike angioedema or severe hypotension 1

Important Caveats

• Sweating may occasionally be a symptom of hypotension rather than a direct drug effect—always check blood pressure in patients reporting new-onset sweating on lisinopril 1
• The absence of sweating (hypohidrosis) can also occur with certain medications and increases heat stroke risk, but this is not typically associated with ACE inhibitors 3
• Do not discontinue lisinopril without medical guidance, as it provides significant mortality and morbidity benefits in heart failure, post-MI patients, and those with reduced ejection fraction 2