Antihypertensive medications associated with cough
Pro Research Analysisby 
Searched over 200M research papers
ACE Inhibitors and Cough: Mechanisms and Incidence
Angiotensin-converting enzyme inhibitors (ACE inhibitors or ACEIs) are a well-known class of antihypertensive medications frequently associated with the side effect of cough. The cough is typically dry, nonproductive, and often worse at night, sometimes interfering with sleep and daily activities. The incidence of cough among patients taking ACE inhibitors ranges from 5% to 20%, with some studies reporting even higher rates in certain populations. Women appear to be more susceptible to this side effect than men Poole1991Israili1992Borghi2023+2 MORE.
The mechanism behind ACE inhibitor-induced cough is believed to involve the accumulation of inflammatory mediators such as bradykinin and substance P, which are normally broken down by the angiotensin-converting enzyme. When this enzyme is inhibited, these substances build up in the respiratory tract, leading to the characteristic cough Poole1991Israili1992Borghi2023+1 MORE.
Severity and Impact of ACE Inhibitor-Associated Cough
While the cough is often mild, it can be severe in some cases, leading to complications such as sleep deprivation, stress incontinence, and even rectal or vaginal prolapse in women. The cough can be so bothersome that it leads to discontinuation of the medication. Importantly, the cough usually resolves within days after stopping the ACE inhibitor Poole1991York.1990.
Differences Among ACE Inhibitors
Although all ACE inhibitors carry a risk of inducing cough, the likelihood may vary between specific agents. For example, moexipril, ramipril, and fosinopril are associated with a higher risk, while spirapril and captopril have a lower risk. However, the overall risk is similar across the class, and switching from one ACE inhibitor to another may not always resolve the cough Borghi2023Hu2023.
Genetic Factors
Research has explored whether genetic differences, such as polymorphisms in the bradykinin receptor gene, might influence the risk of developing cough with ACE inhibitors. However, current evidence does not show a significant correlation between these genetic factors and the likelihood of experiencing this side effect .
Angiotensin II Receptor Blockers (ARBs) and Cough Risk
Angiotensin II receptor blockers (ARBs), such as losartan and telmisartan, are another class of antihypertensive drugs that block the effects of angiotensin II without affecting bradykinin breakdown. Studies consistently show that ARBs are associated with a much lower incidence of cough compared to ACE inhibitors, with rates similar to placebo. This makes ARBs a preferred alternative for patients who develop cough on ACE inhibitors Ellis1996Lacourciére1994Lacourciére1999+1 MORE.
Other Antihypertensive Medications
Other classes of antihypertensive drugs, such as calcium channel blockers (CCBs), are not commonly associated with cough. When patients are at risk for or develop cough with ACE inhibitors, switching to an ARB or CCB is recommended based on individual patient needs and comorbidities .
Conclusion
ACE inhibitors are strongly associated with the development of a dry, persistent cough in a significant proportion of patients, primarily due to the accumulation of bradykinin and related substances. The risk varies slightly among different ACE inhibitors but is generally present across the class. ARBs offer a suitable alternative with a much lower risk of cough, and other antihypertensive classes like CCBs are also options for those affected. Recognizing and managing this side effect is important to ensure optimal blood pressure control and patient quality of life Poole1991Israili1992Ellis1996+5 MORE.
Sources and full results
Most relevant research papers on this topic