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Continue the current antihypertensive regimen
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Continue the current antihypertensive regimen at a lower dose
Discontinue the current antihypertensive regimen
Discontinue the current antihypertensive regimen and add losartan
Discontinue the current antihypertensive regimen and add metoprolol
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This patient with a new-onset dry cough after the initiation of antihypertensive therapy was likely started on an angiotensin converting enzyme (ACE) inhibitor, such as lisinopril. Cough is a common side effect of ACE inhibitor use and is managed with substituting an angiotensin receptor blocker (ARB), such as losartan.The pathophysiology of cough related to ACE inhibitor use is not fully understood, but is likely due to accumulation of kinins, such as bradykinin, that cause airway irritation. For patients who have a good response in blood pressure with ACE inhibitor therapy, but develop cough, substitution with an ARB is appropriate. ARB's block angiotensin II receptors, therefore lowering blood pressure via a mechanism similar to that of ACE inhibitors. Cough is not a common side effect of ARBs, and most patients have resolution of their cough within approximately a week of stopping ACE inhibitor therapy.Mahmoudpour et. al review side effects related to ACE inhibitor use. They describe the pathophysiologic mechanism that leads to the development of cough. They also discuss angioedema, a separate yet important side effect of ACE inhibitor use.Illustration A highlights the different mechanisms of action of ACE inhibitors and ARBs. Incorrect Answers:Answer 1: Continuing the patient's current regimen would not be likely to improve the patient's cough, as it is directly related to ACE inhibitor use.Answer 2: Reducing the dose of the patient's current regimen would not be likely to improve the patient's cough. The most appropriate next step in action is to discontinue ACE inhibitors.Answer 3: Discontinuing the patient's current antihypertensive would likely improve his cough. However, this patient should be on antihypertensive therapy, so a substitute must be initiated. Answer 5: While discontinuing this patient's current ACE inhibitor would resolve his cough. However, metoprolol is not commonly a first-line medication for management of hypertension. An ARB would be a better substitute given this patient's response to ACE inhibitors.Bullet Summary: Patient's that develop cough secondary to angiotensin converting enzyme inhibitor therapy should be switched to an angiotensin receptor blocking medication such as losartan.
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