Can ARBs Cause a Cough? Understanding the Difference with ACE Inhibitors

October 12, 2025 •

3 min read

While a persistent dry cough is a well-known side effect of ACE inhibitors, affecting up to 35% of patients in some studies, the question of whether ARBs can cause a cough is equally important for many on blood pressure medication. The good news is that angiotensin II receptor blockers (ARBs) are associated with a much lower incidence of cough compared to ACE inhibitors. This difference is directly tied to their distinct mechanisms of action within the body's renin-angiotensin system.

Quick Summary

ARBs (angiotensin II receptor blockers) are a class of blood pressure medications. They cause a cough far less often than ACE inhibitors because they don't affect bradykinin levels. While rare, an ARB-induced cough can occur, prompting a doctor's evaluation.

Key Points

Low Incidence: The risk of a cough with ARBs is very low, significantly less than with ACE inhibitors, and comparable to placebo in many studies.
Mechanism Difference: ARBs do not cause the buildup of bradykinin in the airways, which is the primary cause of the characteristic dry cough associated with ACE inhibitors.
ARBs as an Alternative: For patients who develop an ACE inhibitor-induced cough, switching to an ARB is a common and effective medical strategy.
Consider Other Causes: If a cough develops while on an ARB, it is more likely caused by an underlying condition like allergies or a respiratory infection.
Rare Angioedema Risk: While exceedingly rare, angioedema can occur with ARBs and may present with throat symptoms, requiring immediate medical attention.
Consult a Doctor: Patients should not stop their medication independently and should always speak with a healthcare provider to determine the cause of a cough.

ARBs and Cough: A Rare Occurrence

The incidence of cough with angiotensin II receptor blockers (ARBs) is very low, often reported to be comparable to a placebo. In contrast, angiotensin-converting enzyme (ACE) inhibitors are notorious for causing a persistent, dry cough in a significant number of patients. The primary reason for this distinction lies in how each class of drug interacts with the body's regulatory systems.

The Mechanism Behind an ACE Inhibitor Cough

To understand why ARBs are less likely to cause a cough, it's helpful to first understand why ACE inhibitors do. Both drug classes are used to manage blood pressure by targeting the renin-angiotensin-aldosterone system (RAAS), but they act on different points in the pathway. ACE inhibitors block the angiotensin-converting enzyme (ACE), which plays a role in forming angiotensin II and breaking down bradykinin. By blocking ACE, these medications lower blood pressure but also cause bradykinin to build up, leading to a cough.

The ARB Difference: A Different Approach

ARBs, such as losartan (Cozaar) and valsartan (Diovan), work differently. Instead of blocking the ACE enzyme, they prevent angiotensin II from binding to its receptor. This mechanism does not interfere with bradykinin breakdown, resulting in a significantly lower risk of cough compared to ACE inhibitors. Consequently, ARBs are often prescribed as an alternative for patients who cannot tolerate an ACE inhibitor cough.

Potential Explanations for a Rare ARB Cough

While a cough is uncommon with ARBs, it can still occur. Potential reasons include underlying respiratory conditions like allergies or asthma, individual sensitivity to the medication, a lingering cough after switching from an ACE inhibitor, or, very rarely, angioedema. Angioedema, a serious swelling, requires immediate medical attention.

Comparison of ARBs vs. ACE Inhibitors and Cough


Feature	ARBs (e.g., Losartan)	ACE Inhibitors (e.g., Lisinopril)
Mechanism of Action	Blocks angiotensin II from binding to its AT1 receptor.	Blocks the angiotensin-converting enzyme (ACE).
Effect on Bradykinin	Does not increase bradykinin levels.	Causes an accumulation of bradykinin.
Incidence of Cough	Low, often comparable to placebo (less than 3%).	High, affecting 5-35% of patients.
Onset of Cough	Not typically associated with cough; if one occurs, it may be delayed or not drug-related.	Typically develops within the first weeks or months of treatment.
Preferred for Cough	Standard alternative for patients who develop a cough on an ACE inhibitor.	Often switched to an ARB if cough develops.
Incidence of Angioedema	Very rare; lower than ACE inhibitors.	Rare but more common than with ARBs.

Managing a Persistent Cough

If you develop a persistent cough while taking an ARB, consult your healthcare provider. Do not discontinue your medication without medical advice. Your doctor can investigate the cause, which may involve evaluating for other conditions or, in rare instances, considering a dosage adjustment or switching medications.

Conclusion

Cough is a far less common side effect with ARBs compared to ACE inhibitors due to their differing effects on bradykinin. ARBs are a valuable alternative for patients who experience an ACE inhibitor cough. Should a cough occur while on an ARB, it's typically linked to an underlying issue, but medical evaluation is necessary to determine the cause.

For additional information on cardiovascular health and pharmacology, resources like the National Institutes of Health can be helpful.

Note: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional before making any decisions about your treatment or health.

Frequently Asked Questions

ARBs work differently than ACE inhibitors. ACE inhibitors block the enzyme that breaks down bradykinin, causing it to accumulate in the lungs and trigger a cough. ARBs do not affect bradykinin levels, which is why a cough is a much less common side effect.

You should contact your healthcare provider to determine the cause. The cough is most likely unrelated to the ARB, but a doctor can evaluate for other issues and decide on the best course of action.

Yes, switching from an ACE inhibitor to an ARB is a standard medical practice for patients who develop a persistent cough. Because ARBs have a different mechanism of action that avoids the bradykinin accumulation, the cough almost always resolves after the switch.

A cough directly caused by an ARB is very rare. If a cough does appear, it is more likely due to other causes. In contrast, an ACE inhibitor cough typically starts within weeks or a few months of beginning the medication.

No single ARB has been definitively proven to cause a cough more than others. As a class, ARBs are known for their low incidence of cough. However, individual patient responses can vary.

Angioedema is a rare but serious side effect involving rapid swelling of the deep skin layers, especially around the face, lips, and throat. It is significantly less common with ARBs than with ACE inhibitors, but it can still occur.

It is possible for a persistent cough from an ACE inhibitor to linger for a few weeks after switching to an ARB, but it is not a sustained side effect of the ARB itself. If a cough continues, other medical conditions should be investigated.