Dry cough with lisinopril
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Dry Cough Associated with Lisinopril: Incidence and Alternatives
Introduction to ACE Inhibitor-Induced Cough
Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, are commonly prescribed for hypertension. However, a persistent dry cough is a well-documented side effect of these medications. This article synthesizes research findings on the incidence of dry cough with lisinopril and explores alternative treatments that may mitigate this adverse effect.
Incidence of Dry Cough with Lisinopril
High Incidence Rates
Several studies have consistently reported a high incidence of dry cough in patients treated with lisinopril. For instance, a multicenter study found that 60% of patients on lisinopril experienced a dry cough, significantly higher than those on telmisartan (15.6%) or placebo (9.7%). Another study reported an even higher incidence, with 68.9% of patients on lisinopril developing a cough compared to 19.5% on valsartan and 19.0% on hydrochlorothiazide.
Comparison with Other ACE Inhibitors
The incidence of cough with lisinopril is comparable to other ACE inhibitors. A study comparing lisinopril, perindopril, and ramipril found that 8.82% of patients on lisinopril reported a cough, slightly higher than those on perindopril (5.4%) and ramipril (6.89%) . This suggests that while lisinopril may have a slightly higher incidence, the risk of cough is a common issue across all ACE inhibitors.
Mechanism of ACE Inhibitor-Induced Cough
The exact mechanism behind ACE inhibitor-induced cough is not fully understood, but it is believed to involve the accumulation of bradykinin and substance P, which are normally degraded by ACE. These substances can stimulate lung afferent C fibers, leading to a persistent dry cough. Prostaglandins may also play a role, as suggested by studies showing that nonsteroidal anti-inflammatory drugs (NSAIDs) can alleviate the cough in some patients .
Alternatives to Lisinopril
Angiotensin II Receptor Blockers (ARBs)
Angiotensin II receptor blockers (ARBs) like losartan and valsartan have been shown to cause significantly fewer instances of dry cough compared to lisinopril. In a study involving patients with a history of ACE inhibitor-induced cough, only 36.7% of those on losartan reported a cough, compared to 87.5% on lisinopril. Another study found that valsartan had a cough incidence of 19.5%, much lower than lisinopril's 68.9%.
Telmisartan
Telmisartan, another ARB, also demonstrated a lower incidence of cough. In a study comparing telmisartan, lisinopril, and placebo, only 15.6% of patients on telmisartan reported a cough, compared to 60% on lisinopril. This makes telmisartan a viable alternative for patients who experience cough with lisinopril.
Conclusion
Dry cough is a common and troublesome side effect of lisinopril and other ACE inhibitors, likely due to the accumulation of bradykinin and substance P. Angiotensin II receptor blockers such as losartan, valsartan, and telmisartan offer effective alternatives with a significantly lower risk of inducing cough. For patients experiencing this side effect, switching to an ARB may provide relief while maintaining antihypertensive efficacy.
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