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

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% .

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)

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