Management of ACE Inhibitor-Induced Cough in Secondary Hypertension

Introduction to ARB Therapy

The American College of Cardiology recommends switching to an angiotensin receptor blocker (ARB) immediately, starting with losartan 25 mg once daily, as this is the only uniformly effective solution for ACE inhibitor-induced cough while maintaining blood pressure control 1, 2
ARBs do not inhibit ACE and therefore don't cause bradykinin accumulation, which is the mechanism behind ACE inhibitor-induced cough, making them a Grade A recommendation when ACE inhibitor-induced cough occurs 1, 2

Start losartan 25 mg once daily as the most studied ARB for ACE inhibitor-induced cough 2
Alternative ARBs if losartan is not tolerated: candesartan 4-8 mg once daily or valsartan 20-40 mg twice daily 2
Cough should resolve within 1-4 weeks, though may take up to 3 months in some patients 1, 2
The International Society of Hypertension guidelines recommend that for patients already on a calcium channel blocker with inadequate control, adding an ARB is the next logical step 3
Titrate losartan to 50 mg once daily if BP remains uncontrolled after 1-2 weeks 2
Monitor blood pressure, renal function, and potassium within 1-2 weeks after ARB initiation 2

Ensure the secondary cause is being adequately addressed, as medication alone may be insufficient 3
Target BP <130/80 mmHg, achieving control within 3 months 3
If BP remains uncontrolled despite optimal therapy, refer to a provider with hypertension expertise 3

Although uncommon, angioedema has been reported with ARBs in patients who previously experienced angioedema with ACE inhibitors; monitor closely during initial treatment 2
Monitor for hyperkalemia and renal function changes, as ARBs can cause these complications similar to ACE inhibitors, particularly important in secondary hypertension where renal disease may be the underlying cause 2