ARBs and risk of cough
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ARBs and Cough Risk Compared to ACE Inhibitors
Multiple studies consistently show that angiotensin receptor blockers (ARBs) are associated with a much lower risk of cough compared to angiotensin-converting enzyme inhibitors (ACE inhibitors). ACE inhibitors are well known to cause cough in 5% to 20% of patients, while ARBs have a cough risk similar to placebo and much lower than ACE inhibitors 15678910. This difference is mainly because ACE inhibitors increase bradykinin levels, which can trigger cough, while ARBs do not affect bradykinin 610.
ARBs and Cough Risk Compared to Placebo
Studies show that the risk of cough with ARBs is not significantly different from placebo. In randomized controlled trials, the rate of cough in patients taking ARBs was almost the same as those taking placebo, indicating that ARBs do not increase cough risk above the background rate 18.
ARBs and Cough in Special Populations
In children, the incidence of cough with ARBs is also low and similar to that seen with ACE inhibitors, but overall, children report less cough than adults on these medications . In patients with diabetes and kidney disease, ARBs do not increase the risk of cough, while ACE inhibitors do .
ARBs and Cough in COVID-19 Patients
One study found that ARB use was independently associated with persistent cough after COVID-19 infection, although this finding is not widely reported in other studies and may be specific to the context of COVID-19 recovery .
Bias in Cough Reporting in Clinical Trials
The frequency of cough reported in ARB trials can be influenced by the choice of comparator drug. When ACE inhibitors, which are known to cause cough, are used as comparators, cough may be reported more frequently in both groups due to heightened awareness, potentially biasing results .
Clinical Recommendations
Given the much lower risk of cough and similar effectiveness in lowering blood pressure, ARBs are often recommended as alternatives for patients who develop cough with ACE inhibitors 1567810. Some experts suggest considering ARBs as a first-line option, especially in patients at higher risk for cough or angioedema .
Conclusion
ARBs have a significantly lower risk of causing cough compared to ACE inhibitors and a risk similar to placebo. This makes ARBs a preferred option for patients who are intolerant to ACE inhibitors due to cough, and they are increasingly considered as a first-line therapy for hypertension and related conditions.
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