Lisinopril is an effective and widely prescribed medication used to treat high blood pressure (hypertension) and heart failure [1.2.3]. As an Angiotensin-Converting Enzyme (ACE) inhibitor, it works by relaxing blood vessels, which lowers blood pressure. However, one of its most well-known side effects is a persistent, dry cough.
The Pharmacological Reason: Why Lisinopril Causes a Cough
The primary mechanism behind the lisinopril-induced cough involves a substance called bradykinin [1.3.1]. The Angiotensin-Converting Enzyme (ACE) not only plays a role in blood pressure regulation but is also responsible for breaking down bradykinin in the body. When lisinopril inhibits ACE, the levels of bradykinin and another protussive (cough-inducing) mediator, substance P, accumulate in the respiratory tract [1.3.1, 1.3.2]. This buildup can lead to airway irritation and bronchoconstriction, triggering the cough reflex [1.3.2].
Characteristics of the 'ACE Inhibitor Cough'
The cough associated with lisinopril and other ACE inhibitors has distinct features. It is almost always described as dry, non-productive (meaning no phlegm or mucus), and persistent [1.6.3]. Many people experience it as a tickling or scratching sensation in the throat [1.6.1]. The severity can range from a minor annoyance to a hacking cough that significantly impacts quality of life and disrupts sleep [1.2.3, 1.3.5].
Onset and Resolution
The cough can begin anytime, from within hours of the first dose to several months after starting therapy [1.6.2, 1.6.4]. The only consistently effective treatment is to stop taking the medication, but this must only be done under the supervision of a healthcare provider [1.4.4, 1.4.6]. After discontinuing lisinopril, the cough typically resolves within one to four weeks, although in some cases, it can linger for up to three months [1.6.2].
How Common Is This Side Effect?
Studies show a wide range in the prevalence of ACE inhibitor-induced cough, affecting anywhere from 5% to 35% of patients [1.2.1, 1.2.4]. One study noted a prevalence of 19.8% [1.2.2]. Research also indicates that the cough may be more common in women [1.2.2, 1.2.6].
Managing a Lisinopril-Induced Cough
If you develop a bothersome cough while taking lisinopril, the first and most crucial step is to talk to your doctor. You should never stop taking a prescribed medication without medical guidance [1.2.3]. Over-the-counter cough medicines are generally not effective for this type of cough because they do not address the underlying mechanism [1.4.2, 1.4.3]. The most common and effective management strategy is for your doctor to switch you to a different class of blood pressure medication.
Medication Alternatives to Lisinopril
The primary alternative for patients who experience a cough on an ACE inhibitor is an Angiotensin II Receptor Blocker (ARB) [1.5.2, 1.5.4]. ARBs work in a similar pathway to manage blood pressure but do not inhibit ACE and therefore do not lead to the accumulation of bradykinin [1.9.2]. As a result, their risk of causing a cough is significantly lower, similar to that of a placebo [1.9.1].
| Drug Class | How It Works | Cough Risk | Examples |
|---|---|---|---|
| ACE Inhibitors | Blocks the enzyme that converts Angiotensin I to Angiotensin II; increases bradykinin. | High (5-35%) [1.2.1] | Lisinopril, Enalapril, Ramipril |
| Angiotensin II Receptor Blockers (ARBs) | Blocks the action of Angiotensin II at its receptor site; does not affect bradykinin. | Very Low [1.9.4] | Losartan, Valsartan, Candesartan |
| Calcium Channel Blockers (CCBs) | Prevents calcium from entering cells of the heart and arteries, relaxing blood vessels. | Not Associated with Cough [1.3.3] | Amlodipine, Diltiazem |
| Diuretics (Water Pills) | Helps the kidneys remove excess salt and water from the body. | Not Associated with Cough | Hydrochlorothiazide (HCTZ), Furosemide |
| Beta-Blockers | Makes the heart beat more slowly and with less force, thereby lowering blood pressure. | Not Typically Associated with Cough | Metoprolol, Atenolol |
Other Important Lisinopril Side Effects
Besides a cough, lisinopril can cause other side effects like dizziness, headache, and fatigue [1.4.3]. A rare but serious side effect is angioedema, which is a rapid swelling of the face, tongue, and throat that can be life-threatening and requires immediate medical attention [1.7.2, 1.7.5]. Abdominal pain can also be a symptom of a type of angioedema affecting the intestines [1.7.2].
For more information on managing blood pressure, you can visit the American Heart Association.
Conclusion
Lisinopril is a highly effective medication for managing cardiovascular conditions, but the potential for a persistent cough is a significant drawback for a portion of users. This cough is a direct result of the drug's mechanism of action on bradykinin levels. Fortunately, it is not dangerous and can be resolved by working with a healthcare provider to switch to an alternative medication, such as an ARB, that offers similar benefits without this specific side effect. Open communication with your doctor is key to finding a treatment regimen that effectively controls blood pressure while maintaining your quality of life.
