Management of Angiotensin Receptor Blocker-Induced Cough

Introduction to Angiotensin Receptor Blocker-Induced Cough

The American College of Cardiology and American Heart Association recommend discontinuing the offending angiotensin receptor blocker (ARB) and switching to an alternative antihypertensive medication for patients experiencing ARB-induced cough, which typically presents as a dry cough associated with a tickling sensation in the throat, with a mechanism less well understood than ACE inhibitor cough 1
ARB-induced cough may develop within hours of the first dose or be delayed for weeks to months after starting therapy, occurring in a smaller percentage of patients compared to ACE inhibitors, which have a documented incidence of 5-35% 1

The American College of Cardiology recommends discontinuing the ARB regardless of the temporal relationship between cough onset and medication initiation to confirm the ARB as the cause of the cough, with diagnosis confirmed if cough resolves within 1-4 weeks after discontinuation, though it may take up to 3 months in some cases 1
It is essential to rule out other causes of cough, such as respiratory infections, asthma, GERD, post-nasal drip, and heart failure exacerbation, before attributing the cough to the ARB 1
The diagnosis of ARB-induced cough is confirmed by cough resolution after discontinuing the medication, usually within 1-4 weeks, but may take up to 3 months 1, 2

Discontinuing the ARB is the first-line approach and the only uniformly effective treatment for ARB-induced cough, with expectation of resolution within 1-4 weeks, though it may take up to 3 months 1
Alternative antihypertensive options, such as calcium channel blockers, thiazide diuretics, and beta-blockers, can be considered after discontinuing the ARB 1
If discontinuation is not possible, pharmacologic agents like inhaled sodium cromoglycate, theophylline, NSAIDs, calcium channel blockers, and ferrous sulfate may attenuate cough, although their effectiveness may vary 1

Some agents have demonstrated the ability to reduce ARB-induced cough in controlled trials, including:

Agent	Effectiveness
Inhaled sodium cromoglycate	Reduces cough
Theophylline	Reduces cough
Sulindac	Reduces cough
Indomethacin	Reduces cough
Calcium channel blockers (amlodipine, nifedipina)	Reduces cough
Ferrous sulfate	Reduces cough

The American College of Cardiology recommends monitoring blood pressure to ensure adequate control with the new medication and following up within 1-2 weeks after changing therapy to assess for resolution of cough and blood pressure control 3, 1
If cough persists beyond 4 weeks after discontinuation, it is essential to consider other etiologies and adjust the treatment plan accordingly 3, 1

Patients with asthma require cautious selection of alternative agents, as some may exacerbate asthma symptoms, and it is crucial to consider the potential risks and benefits of each option 1
The American College of Cardiology and British Journal of Sports Medicine note that verapamil has side effects including flushing, headache, edema, and negative inotropic effects, which should be used with caution in patients with impaired left ventricular function 4, 5
Verapamil should be used with caution in patients with impaired left ventricular function due to its negative inotropic effects and is contraindicated if β-blockers have been taken by the patient because of the risk of profound bradycardia and hypotension, as recommended by the British Journal of Sports Medicine 5
For patients with no history of asthma or reactive airway disease, verapamil is preferred over captopril to avoid ACE inhibitor-induced cough, according to the American College of Cardiology 4, 5
ACE inhibitor-induced cough is often misattributed to other causes, leading to unnecessary testing and treatment, and resolution of cough within 1-4 weeks after discontinuation confirms ACE inhibitor as the cause, as noted by the American College of Cardiology 4, 5
The best alternative for patients with ACE inhibitor-induced cough is an ARB, which has a significantly lower incidence of cough 1, 6, 2