ACE inhibitor cough: why it happens and what to do about it

ACE inhibitors are medicines that help the blood vessels widen and relax. The British Heart Foundation explains that they are used to treat high blood pressure, after a heart attack and in heart failure. Common examples include ramipril, captopril, enalapril, lisinopril and perindopril.

One of the best-known side effects is a dry cough. The NHS describes it as a dry, persistent cough that does not get better, listed among the common side effects of ramipril. The NHS page for lisinopril similarly lists a dry cough that does not go away.

Not everyone who takes an ACE inhibitor gets the cough. The British Heart Foundation notes that most people will not experience side effects, and that different medicines in the group have different side effects.

There is no single test for an ACE inhibitor cough, so doctors look at the pattern. A new dry cough that began after starting, or increasing the dose of, an ACE inhibitor is the typical story. NICE CKS classes cough as acute if it lasts less than 3 weeks, sub-acute at 3 to 8 weeks and chronic at more than 8 weeks, and says chronic cough is most commonly caused by smoking, ACE inhibitors, upper airway cough syndrome, asthma, gastro-oesophageal reflux disease or eosinophilic bronchitis.

The NHS says most coughs are caused by a cold or flu and will usually clear up on their own within 3 to 4 weeks. Other causes it lists include smoking, heartburn, allergies, infections such as bronchitis or COVID-19, and mucus dripping down the throat. It adds that a cough is rarely a sign of something serious such as lung cancer. Because a cough can have several causes, it is worth getting checked rather than assuming it is the tablets.

The NHS advises seeing a GP if you have had a cough for more than 3 weeks, are losing weight for no reason or have a weakened immune system. It says to ask for an urgent GP appointment or call NHS 111 if the cough is very bad or quickly gets worse, you feel very unwell, you have chest pain, you find it hard to breathe, or you are coughing up blood.

Separately, the NHS says to call 999 or go to A&E if you have swelling of the lips, tongue or face while taking ramipril, which may be a sign of angioedema, or a serious allergic reaction with throat tightness or difficulty breathing. This is different from the cough, but it is a reason to take new symptoms on an ACE inhibitor seriously.

Do not stop an ACE inhibitor suddenly because of a cough without advice. The NHS advice for lisinopril is to keep taking your medicine unless you are advised to stop, and to speak to a pharmacist or doctor if side effects bother you.

Because the cough comes from the medicine, ordinary cough remedies tend to be disappointing. The NHS says cough medicines do not usually help coughs caused by ramipril, and that general self-care for a cough, such as rest, plenty of fluids and hot lemon and honey (not for babies under 1 year), has only limited evidence. The NHS also notes that decongestants and codeine-containing cough medicines will not stop a cough.

The practical step is to review the medicine. The NHS says to talk to your doctor if the cough carries on, bothers you or stops you sleeping, as another medicine may be better. The British Heart Foundation says that if you have side effects on an ACE inhibitor, a doctor may prescribe an ARB, a different type of blood pressure and heart medicine. Your GP or the clinic that started the medicine will weigh up why you were prescribed it and which alternative is suitable.

Monitoring continues whichever medicine you take. The British Heart Foundation says that on an ACE inhibitor you will have regular blood pressure checks and regular blood tests to check how your kidneys are working and your electrolyte levels.

The NHS says that side effects often improve as your body gets used to a medicine, and for ramipril the cough sometimes gets better on its own. If it does not, it can be wearing, particularly at night. Keep a note of when the cough started in relation to the medicine and whether it disturbs sleep, as this helps your GP decide. Avoid smoking, which both NHS and NICE sources list as a cause of cough.

The British Heart Foundation also advises checking with a doctor or pharmacist before taking other medicines while on an ACE inhibitor, as some over-the-counter products, such as NSAIDs like ibuprofen, can stop the medicine working properly.

ACE inhibitors are prescribed in primary care and by hospital specialists, and a medicine review is usually a GP matter within the NHS. If a cough persists after the medicine has been changed, NICE CKS says referral to a respiratory physician should be arranged for people with a cough that does not respond to a trial of treatment or if the diagnosis is uncertain. Private respiratory assessment is also available, but the first step is the same: tell your prescriber.