Management of ACE Inhibitor-Induced Cough

Diagnosis and Prevalence

ACE inhibitor-induced cough is a well-documented class effect occurring in approximately 5-35% of patients treated with these medications 3
The cough is typically dry and associated with a tickling or scratching sensation in the throat 3
The mechanism involves accumulation of bradykinin and substance P in the upper airway, along with prostaglandins stimulated by bradykinin 1, 4
Cough may develop within hours of the first dose or be delayed for weeks to months after starting therapy 5

Discontinue perindopril regardless of the temporal relationship between cough onset and medication initiation 1, 2
Resolution of cough typically occurs within 1-4 weeks after discontinuation, though it may take up to 3 months in some patients 1, 4
Switch to an angiotensin receptor blocker (ARB) as first-line alternative 6
ARBs have a similar efficacy profile but do not cause cough at rates higher than placebo 6
Consider alternative antihypertensive classes, such as calcium channel blockers 1

ACE inhibitor-induced cough occurs more frequently in women and non-smokers 5
In a 90-year-old patient, medication changes should be made with careful monitoring of blood pressure 7
Consider starting alternative medications at lower doses and titrating slowly 7
Ensure the cough is not due to other causes that are common in elderly patients (heart failure, pulmonary disease, post-nasal drip) 8, 7

Consider pharmacologic interventions to suppress cough, such as sodium cromoglycate (inhaled) 1, 4
Theophylline may also be used to suppress cough 1, 4
Calcium channel antagonists (amlodipine, nifedipine) may be used to suppress cough 1, 4
Ferrous sulfate may be used to suppress cough 1, 4
NSAIDs like sulindac or indomethacin may be used with caution in elderly patients to suppress cough 1, 4