Cough: the annoying and persistent side effect of ACE inhibitors

All medications come with side effects, some minor, some severe, some dangerous, some simply annoying. The class of drugs called angiotensin-converting enzyme (ACE) inhibitors are indicated for controlling blood pressure, preventing stroke, and managing heart failure. Some of the most common side effects of ACE inhibitors are

• cough
• elevated blood potassium levels,
• low blood pressure, dizziness,
• headache,
• drowsiness,
• weakness,
• abnormal taste (metallic or salty taste), and
• rash

A recent meta-analysis revealed that ACE inhibitor associated coughs are more common than previously thought and are becoming such a nuisance that patients tend to stop taking the drugs. The coughs can range from “just a little scratchy throat to a quite severe hacking cough.” The cough may persist for weeks

Health professionals are complaining that this side effect have been and are still underreported in the labels of these drugs as well as in the clinicians’ reliable source of information, the Physicians’ Desk Reference (PDR). According to study author Dr. Franz Messerli  of St Luke’s Roosevelt Hospital in New York):

“The PDR is supposed to be the most trusted information on which physicians base their therapeutic decisions in the US, so it’s a bit puzzling that for a nuisance side effect such as cough, the information is so unreliable.”

 Furthermore, they believe that the pharmaceutical companies know that the incidence of this type of side effects associated with ACE inhibitors are increasing but are not making the effort to update the labels. These drugs are now available in generic form but the generic labels were not updated as well.

The most common ACE inhibitors approved for marketing in the US are:

• benazepril (Lotensin)
• captopril (Capoten)
• enalapril (Vasotec)
• fosinopril (Monopril)
• lisinopril (Prinivil, Zestril)
• moexipril (Univasc)
• perindopril (Aceon)
• quinapril (Accupril)
• ramipril (Altace)
• trandolapril (Mavik)

If one ACE inhibitor triggers coughing, it is mostly likely that other drugs in the same class will have a similar effect. What should a patient do when the cough becomes too much of a nuisance?

“The best option for patients if they feel the cough is too troublesome is to switch to an angiotensin receptor blocker (ARB)…”

However, ARBs are generally more expensive than ACE inhibitors, with very few generic options.

In the meantime, health experts are calling for updates on ACE inhibitors labelling.

According to Dr Victor L. Serebruany of Johns Hopkins University

“There is and will be no easy solutions, since pharmaceutical companies are somewhat resisting adequate reporting of adverse reactions, protecting the safety profile image of their products.”