cough associated with the use of ACE inhibitors
Last reviewed 11/2023
This is a dry, irritating cough that is associated with the use of ACE inhibitors. There is no specific treatment.
- the mechanism of the cough associated with ACE-I is unrelated to the inhibition
of the renin-angiotensin system because treatment with either angiotensin
receptor blockers or renin inhibitors does not cause similar problems (1)
- a possible mechanism is the accumulation of bradykinins or tachykinins
in the airways with consequent stimulation of vagal afferents that subserve
the cough reflex, particularly the nonmyelinated or C fibers
- this theory is supported by Lalloo et al. (2) who postulated that ACE-I-related cough probably results from inhibition of the degradation of kinins, particularly bradykinin in the airways
- a possible mechanism is the accumulation of bradykinins or tachykinins
in the airways with consequent stimulation of vagal afferents that subserve
the cough reflex, particularly the nonmyelinated or C fibers
Data about the incidence of cough associated with ACE inhibitors are conflicting (1)
- has been reported to be as low as 1-2% in retrospective or postmarketing studies. Highs of 37-39% have been reported in controlled trials
- in a study using a dechallenge and rechallenge method, the incidence of
cough was compared for four different ACE inhibitors (1)
- the cough incidence were as follows:
- (1) Cilazapril 22.86%
- (2) Enalapril 21.95%
- (3) Perindopril 10.96%
- (4) Imidapril 13.16% .
- the cough incidence were as follows:
With respect to resolution of the cough and continuation of ACEI treatment, a lower dose may be tolerated but it may be necessary to withdraw the drug; switching to another ACE inhibitor is unlikely to help.
Notes:
- asthma
- ACEIs - symptoms of airway obstruction in relation to treatment with angiotensin converting enzyme inhibitors seem to be a rare but potentially serious reaction generally occurring within the first few weeks of treatment (3,4)
Reference:
- 1) Tumanan-Mendoza BA et al. Dechallenge and rechallenge method showed different incidences of cough among four ACE-Is. J Clin Epidemiol. 2007 Jun;60(6):547-53. Epub 2006 Oct 25.
- 2) Lalloo UG et al. Pathophysiology and clinical presentation of cough. J Allergy Clin Immunol 1996; S91-S96.
- 3) John Rees, Dipak Kanabar, Shriti Pattani. ABC of Asthma, 6th Edition
- 4) Lunde H et al. Dyspnoea, asthma, and bronchospasm in relation to treatment with angiotensin converting enzyme inhibitors. BMJ. 1994 Jan 1;308(6920):18-21.
- 5) Drug & Therapeutic Bulletin 1995; 33(1):1-3.