Management of ACE Inhibitor-Induced Cough

Diagnosis and Management

The American College of Chest Physicians recommends that ACE inhibitor-induced cough is a common side effect that occurs in approximately 10-20% of patients on these medications, with the cough typically being dry, persistent, and often beginning within days to weeks after starting the medication 1
The diagnosis is confirmed by resolution of cough after discontinuation of the ACE inhibitor, usually within 1-4 weeks (though it may take up to 3 months in some cases) 1, 2

The American Heart Association suggests discontinuing the ACE inhibitor as the only uniformly effective treatment for ACE inhibitor-induced cough, with the cough resolving within 1-4 weeks after stopping the medication 1, 3, 4
Switching to an angiotensin receptor blocker (ARB) is recommended as first-line alternative, as ARBs have a similar mechanism of action to ACE inhibitors but do not affect bradykinin metabolism, which is believed to be the cause of cough 1, 3, 5
The European Society of Hypertension recommends starting with a low-dose ARB and titrating as needed for elderly patients 6, 7

If ARBs are contraindicated or not tolerated, consider a calcium channel blocker (CCB) as an alternative, particularly for patients over 55 years old 6, 7, 8, 9
Thiazide-like diuretics can also be considered if CCBs are not suitable 6, 7

For elderly patients, blood pressure targets may be less aggressive to avoid adverse effects, and careful dose titration is important when initiating new antihypertensive therapy 8
If switching to an ARB, start with the lowest effective dose and titrate slowly 6, 7

After switching from perindopril to an alternative medication, monitor blood pressure closely to ensure adequate control, and target blood pressure should be individualized based on frailty and comorbidities 8
If blood pressure is not adequately controlled on monotherapy, combination therapy may be necessary following appropriate guidelines 6, 7

The American College of Cardiology recommends switching from an ACE inhibitor to an ARB, such as telmisartan, for patients with ACE inhibitor-induced cough, as ARBs do not inhibit ACE and therefore don't cause bradykinin accumulation, with a Grade A recommendation for this switch when ACE inhibitor-induced cough occurs, although the specific recommendation is not provided in the given citations 10

For a 90-year-old patient, the recommended starting dose of telmisartan is 40 mg once daily, according to the Journal of the American College of Cardiology, with the dose potentially being increased to 80 mg daily if blood pressure control is inadequate 10
If blood pressure control is inadequate on 40 mg daily, the dose can be increased to 80 mg daily, which is the maximum recommended dose for telmisartan, as recommended by the American College of Cardiology 10

ACE inhibitor-induced cough is a well-documented side effect occurring in 5-35% of patients taking ACE inhibitors, caused by the accumulation of bradykinin and substance P when ACE is inhibited 11
Amlodipine has been shown to attenuate cough due to ACE inhibitors in randomized, double-blind, placebo-controlled trials 11
The American College of Chest Physicians guidelines specifically mention calcium channel antagonists including amlodipine as agents demonstrating the ability to attenuate cough due to ACE inhibitors 11
In patients for whom ACE inhibitor therapy cannot be discontinued, amlodipine is recommended as a pharmacologic therapy aimed at suppressing cough 12

First-line approach: Discontinue the ACE inhibitor as this is the only uniformly effective treatment 12