Does lisinopril cause a cough?

In this article:

• Lisinopril cough
• Why does it make you cough?
• Who is at risk?
• What does it feel like?
• Managing the cough
• When to see a doctor
• Living with lisinopril cough

In this article

• Lisinopril cough
• Why does it make you cough?
• Who is at risk?
• What does it feel like?
• Managing the cough
• When to see a doctor
• Living with lisinopril cough

Lisinopril is a prescription medication that is FDA approved to treat high blood pressure and certain other cardiovascular conditions. It belongs to a class of drugs called angiotensin-converting enzyme (ACE) inhibitors and is sold under various brand names, including Zestril (tablets) and Qbrelis (liquid).

ACE inhibitors block the conversion of the peptide hormone angiotensin I to angiotensin II, a powerful chemical that narrows and tightens blood vessels, a process called vasoconstriction. A reduction in angiotensin II levels relaxes blood vessels, improves blood flow, and reduces strain on the heart. These effects are helpful for managing heart conditions such as heart failure; however, some people may experience side effects such as a cough when taking blood pressure medications like lisinopril. Find out when that tickle in your throat might not be from the common cold.

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Can lisinopril cause a cough?

A persistent dry cough is a common side effect of lisinopril. This side effect can affect 5% to 20% of people taking the medication, says Samuel Robinson, DO, a board-certified family medicine provider with Sutter Medical Group in Folsom, California.

Dr. Robinson explains that the cough can start from a few days to months after starting lisinopril, and the cough is usually mild to moderate for most people. Also, the cough typically lasts for as long as you are taking the medication and often does not resolve unless you stop taking the drug.

While ACE inhibitors like lisinopril have side effects like cough, it is worth noting that they are generally well-tolerated and are a common treatment option for cardiovascular conditions. Also, not everyone will experience lisinopril-induced cough. Some people are at higher risk than others.

Why does lisinopril make you cough?

The mechanism of action of ACE inhibitors is to block the enzyme ACE, which converts angiotensin I into angiotensin II. The ACE enzyme also breaks down certain active peptides, such as bradykinin. When its action is blocked, it produces a therapeutic effect but also increases bradykinin levels, which can contribute to the cough side effect.

“The proposed mechanism by which these drugs cause cough is an increase in bradykinin and substance P,” says Taylor Clark, Pharm.D., a clinical assistant professor of pharmacy practice at Binghamton University, State University of New York. Bradykinin is associated with inflammation, promotion of vasodilation to promote blood flow, and sensitization of nerve endings to increase pain. 

Dr. Clark explains that when an ACE inhibitor like lisinopril is administered, it inhibits the ACE enzyme from breaking down molecules such as bradykinin, leading to an increase in bradykinin concentration in the blood. “The increased bradykinin is believed to increase sensitivity of nerves in the airway, resulting in bronchoconstriction and cough,” she says. 

Notably, the mechanism of action of ACE inhibitors differs slightly from that of angiotensin receptor blockers (ARBs). ARBs work on the same system in the body as ACE inhibitors, but work at a later stage in the process. They directly inhibit the angiotensin-II receptors type-1 and are often prescribed as an alternative treatment for people with low tolerance to ACE inhibitors, as they are much less likely to be associated with coughs as a side effect.  

Who is at risk for a lisinopril cough?

According to Dr. Robinson, women and older adults are at the most significant risk of developing a cough. People with certain medical conditions, such as respiratory illnesses or a genetic disposition to this adverse effect, may also be at higher risk. 

• People assigned female at birth (AFABs): Health experts don’t yet have a complete understanding of why the incidence of lisinopril-induced chronic cough is higher for AFABs, but it is proposed that this may be due to differences in how bradykinin peptides are metabolized and potential genetic polymorphisms that affect cough reflex sensitivity—having protective effects for males while increasing the risk in females. 
• Older people: Some older and newer studies suggest you may be at a higher risk of experiencing cough-induced lisinopril if you are 60 years or older. This may be due to age-related changes in the body, underlying medical conditions, or possibly a higher sensitivity of their cough reflex.
• Having certain genetic predispositions: People genetically predisposed to cough from ACE inhibitors have shown reduced aminopeptidase P activity. Aminopeptidase P is an enzyme that plays an important role in bradykinin degradation.
• People with certain underlying medical conditions: An ACE inhibitor-induced cough is reported to be more common in people with coronary artery disease and respiratory conditions like pulmonary congestion. 

What does a lisinopril cough feel like?

Because there are several possible causes of cough, it may be hard to tell when it’s lisinopril-induced. Lisinopril typically causes a cough with the following characteristics:

• A dry, hacking cough
• Unproductive cough, i.e., not associated with any phlegm or mucus production
• Scratchy or tickly sensation in the throat
• Persistent cough

“For those that do experience the cough related to lisinopril, the cough typically lasts for as long as the patient is taking the medication and, in many cases, does not resolve unless the medication is stopped,” Dr. Robinson says.

Dr. Clark also explains that, unlike coughs associated with respiratory illness or allergies, ACE-induced cough typically occurs in the absence of other symptoms, such as a runny nose, post-nasal drip, and itchy eyes. “The cough typically begins within 1-2 weeks of starting an ACE inhibitor; however, it may take up to 6 months to manifest.”

Managing the lisinopril cough

According to Drs. Robinson and Clark, the common course of action to take when a person develops a cough induced by lisinopril is to discontinue the medication (under the guidance of a healthcare provider) and switch to a medicine from a different class of drugs. 

However, your healthcare provider may choose a different approach based on your unique situation or medical needs.

Exploring medications from other drug classes

“There are alternative treatment options for most conditions treated with ACE inhibitors; thus, medications without this side effect may be a better treatment option,” Dr. Clark says. One common alternative class of medication healthcare professionals typically recommend is ARBs. 

While ARBs have a slightly different mechanism of action, they offer similar benefits for managing heart conditions and high blood pressure. Popular ARBs include Cozaar (losartan) and Diovan (valsartan). 

Switching to another ACE inhibitor

Cough incidence may vary based on the particular ACE inhibitor medication you are taking. Switching from your current ACE inhibitor to another ACE inhibitor associated with a lower incidence of cough in clinical practice, such as benazepril or enalapril, may be an effective option for you. 

Combining with other medications

Some research suggests that combining ACE inhibitors with other treatments may reduce cough incidence, but this is not well-established. In certain cases where the specific benefits of an ACE inhibitor are important, healthcare providers may consider adding another blood pressure medicine, such as a calcium channel blocker, to a low-dose ACE inhibitor. Commonly prescribed calcium channel blockers include amlodipine or nifedipine.

The re-challenge approach

In some cases, if your healthcare provider believes an ACE inhibitor is the ideal treatment for you, they may consider a re-challenge to see if reintroducing the medication induces a cough again. 

This approach involves temporarily stopping your ACE inhibitor, during which the cough subsides. This may take about 4 weeks, and after the symptoms disappear, the drug can be reintroduced. Cough may not recur in some people after reintroducing the medication, but if it does, your healthcare provider will discuss the next course of action.

When to talk to your healthcare provider

Many people on lisinopril will not develop a cough. But if you are concerned about it or believe you are at high risk, consider speaking with your healthcare provider. 

Also, if you start coughing after starting lisinopril or another ACE inhibitor, it’s best to let your healthcare provider know and discuss the best course of action for you.

It is important that you never discontinue your medication without consulting your healthcare provider, as abruptly stopping your treatment, especially without switching to an appropriate alternative, can worsen your condition and other underlying diseases. 

Living with a lisinopril cough

If the cough is mild and not undermining your quality of life, your healthcare provider may suggest you continue the medication, especially if they believe the pros outweigh the cons. 

Certain management strategies may help while you watch and wait, such as:

• Drinking more water
• Drinking warm fluid, such as soup, broth, and herbal tea
• Use a cool-mist humidifier
• Using throat lozenges
• Take honey or honey syrups/supplements

A cough suppressant typically will not treat lisinopril-induced cough, as it doesn’t address the underlying cause.