Lisinopril was the third most prescribed medication United States in 2010 and lisinopril cough is the most common lisinopril side effect seen in everyday practice. (In this article I will refer to lisinopril cough rather than angiotensin converting enzyme inhibitor cough as a matter of convenience because lisinopril is by far the most commonly prescribed medication the class.) Since it is so common you would expect that making a diagnosis of lisinopril cough should be quite simple, and sometimes it is. Other times differentiating lisinopril cough from other causes of cough can be pretty complicated. Most of the time in the office we can suspect lisinopril cough because the patient did not have the cough prior to starting lisinopril and it tends to be a dry twitchy cough that just will not go away. The problem lies in fact that lisinopril cough often doesn’t stop immediately on discontinuation the medication and that many of the patients using lisinopril have other potential causes of cough.
I used to think that lisinopril cough always started in the first month or so of using lisinopril, but it’s clear that a small minority of patients will develop a lisinopril cough months or longer after starting lisinopril. In addition although most patients find their lisinopril cough decreasing shortly after stopping lisinopril and resolving within a few weeks, there are patients where the cough can persist for many weeks or even months.
Although most people think of cough as a symptom of a respiratory infection or an allergic problem like asthma or hay fever, it is becoming increasingly clear that esophageal acid reflux is a common cause of cough. Cough related to reflux can either be due to occult minor aspiration of gastric contents into the trachea or from irritation of the esophagus leading to cough without aspiration. Reflux related cough is another type of cough can take a long time to resolve even on aggressive anti-reflux therapy, and so be difficult to diagnose with certainty. If a patient is also on lisinopril the sorting out which problem is causing the cough can be a challenge.
Lisinopril is used primarily for the treatment of high blood pressure and congestive heart failure. It is also used for prevention of kidney disease in patients with diabetes. All of these conditions are seen more often in older adults, obese patients and often in patients with multiple complex medical conditions. This can make physicians reluctant to discontinue lisinopril because every medication change in a complex patient can upset a delicate balance, so if a patient is doing well except for the cough it is tempting to now want to make any medication changes. Thankfully now switching to an angiotensin receptor blockers is a fairly easy medication alternative, especially with losartan now available as an inexpensive generic ARB with losartan soon to follow.
Lisinopril cough is felt to happen because the site of action of lisinopril is in the lungs where it prevents the conversion of angiotensin I into angiotensin II. It is not completely clear what causes the cough but the known fact that angiotensin converting enzyme inhibitors function at a cellular level in the lung seems to be the key. Angiotensin I is produced in the kidney and released to the circulation. The angiotensin I in the bloodstream circulates through the lungs where it is converted into angiotensin II in a process requiring an enzyme called angiotensin converting enzyme. ACE inhibitors like lisinopril block the site where angiotensin I fits at the angiotensin converting enzyme therefore blocking the production of angiotensin II which is the active form of angiotensin. Angiotensin II works in the peripheral arterioles to cause constriction of the tiny arteries and therefore elevation of blood pressure. The angiotensin receptor blockers (ARB) function at this receptor in the peripheral arterioles and so ARB medications are much less commonly associated with cough. Unfortunately cough is an occasional but very infrequent cause of cough which can further complicate trying to decide whether the cough was related to lisinopril if it doesn’t resolve quickly and switching medications.
The incidence of lisinopril cough is almost certainly higher than the incidence noted in the original studies of lisinopril quoted at 1% for patients with congestive heart failure 3.5% for patients with hypertension, but the exact incidence of lisinopril cough is really unclear.
When I see a patient on lisinopril with cough I first try to put the cough into perspective. If the cough started as part of a typical upper respiratory infection with congestion, fever or chills, sore throat or other similar symptoms I will tend to advise the patient that the cough will likely resolve as the illness passes. Problems like post-bronchitic bronchospasm, where cough persists for weeks or months after an episode of acute bronchitis can be a challenge sometimes, but usually this approach works. On the other hand if the cough is a fairly mild cough that persists or gradually progresses to be much more annoying then I usually suggest that we stop the lisinopril and use an alternative medication, usually a generic ARB like losartan. Then we wait and see if cough resolves over the next few weeks. If cough persists more than a few weeks it comes a bit trickier. If the cough seems to be gradually diminishing I usually try to convince the patient with a longer. If the cough is not improvingat all we need to look harder for another cause.
Most of the time lisinopril cough is usually fairly simple problem to diagnose and manage because most physicians recognize cough as among the most common of lisinopril side effects, but like almost everything in medicine things are sometimes more complicated than they appear and cough is a symptom that can be a diagnostic and therapeutic challenge.
One Nation – Under Pressure
By Brooke Douglas, RD, CD
High blood pressure. The words don’t exactly strike fear into most American’s hearts. After all, it’s not painful, like cancer. It doesn’t sound deadly, like heart disease. But it’s literally a time bomb in our blood vessels that threatens our heart, brain and kidneys. Make no mistake – it’s a killer! So what makes our blood pressure rise? Too much salt, extra body weight and spending too much of your time sedentary. But wait! Don’t blame it all on the salt shaker. Only 7% of the excess salt in the average American’s diet comes from the salt shaker. The remaining 93% comes from all the processed and convenience foods we buy at the vending machine, at the local corner store, at the grocery store (for quick dinners) and at fast food and dine-in restaurants.
If your doctor has told you to cut back on your salt intake…you will have to do more than put the salt shaker away.
As for extra body weight (lose weight) and inactivity (begin a modest exercise program and spend less of your day sedentary), applying the following tips may help you on your quest to lower your blood pressure.
Here are some sodium-cutting tips you can try today:
Introduce additional flavor to your foods with herbs and spices like garlic, oregano, basil, pepper, thyme and sesame. These all add flavor without the extra sodium. If a recipe calls for salt, cut the amount called for in half and taste it before adding more.
Make healthy choices at the grocery store. Processed foods (anything in a box or bag) tend to be high in sodium because it helps preserve foods longer and increase flavor. Always read labels for the foods you buy, including the sodium content on the nutrition facts label and the ingredients list.
Remember that “low-fat” or “low-calorie” doesn’t mean healthy. These diet foods can also be higher in sodium because manufacturers hope that added sodium, a flavor-enhancer, will bring back the flavor that is missing since fat and other higher-calorie ingredients are removed. This is especially true for frozen dinners, which are often loaded with extra salt.
Choose low-, no- or reduced-sodium versions of your favorite soups, frozen meals, canned foods, and snacks. Even butter is available without added salt!
Choose fresh or frozen veggies over canned varieties, which often contain added salt to help increase shelf life. If you can’t find sodium-free varieties of canned vegetables, rinse the can’s contents in a colander under water before cooking to remove excess salt.
Olives, pickles and other items packed in brine are saturated in salt, as are many smoked and cured meats, like salami and bologna. Limit your intake of these high-sodium foods and be on the lookout for lower-sodium varieties.
Fast foods are high in more things than just fat. Many of these meals, sandwiches and fries contain more than your daily recommended intake of sodium in just one serving. When consulting restaurant websites to make healthy choices, pay attention to sodium levels as well. By keeping your portions in check (order a junior burger or small French fry instead of the big burgers and super fries) will help control your sodium (and caloric) intake.
Thanks much to Brooke for returning as our first-of-the-month guest contributor. She does a great job with nutrition advice, so if you are concerned about your or a loved one’s blood pressure give her a call. Did you know that your insurance might cover several visits with a Registered Dietitian? Let Brooke help you navigate the insurance maze to determine whether your insurance will pay for you to having some nutrition coaching with a Registered Dietitian. You can find her at Nutrition Authority.
You may also enjoy this CDC widget:
Salt Intake Widget