If you take a blood pressure tablet whose name ends in -pril, such as lisinopril, enalapril, ramipril, perindopril or captopril, and you have developed a dry, tickly cough that will not settle, the tablet may be the cause. These medicines are called ACE inhibitors, and a persistent dry cough is one of their best-known side effects.

The cough is a nuisance rather than a danger. It is not dangerous in itself, and it almost always clears once the medicine is stopped, although this can take a few weeks. The usual answer is not to put up with it for years, and not to stop the tablet on your own, but to ask your prescriber about switching to a closely related medicine that rarely causes cough.

Summary

ACE inhibitors (names ending in -pril) can cause a dry, persistent cough. Reported rates range from 5% to 35% of people taking them (American College of Chest Physicians guideline).
It can start at any time, from within hours of the first dose to months later.
Cough medicines do not usually help this type of cough (NHS).
Stopping the ACE inhibitor is the only reliable cure. The cough usually clears 1 to 4 weeks after stopping, but can linger for up to 3 months.
The usual switch is an ARB (names ending in -sartan, such as losartan or candesartan). In trials, ARBs caused cough about as often as a placebo.
Do not stop your tablet without advice. Your blood pressure can rise again.
Swelling of the lips, tongue, face or throat is an emergency. This is angioedema, a different and serious side effect.

Which medicines are ACE inhibitors?

ACE stands for angiotensin-converting enzyme. The NHS describes ramipril, a typical example, as a medicine that widens your blood vessels and makes it easier for your heart to pump blood around your body. It is widely used to treat high blood pressure and heart failure, and is prescribed after a heart attack.

Common names you will see on a pharmacy label include:

enalapril
lisinopril
ramipril
perindopril
captopril

If the name on your box is unfamiliar, check the active ingredient on the label or ask your pharmacist.

Why ACE inhibitors cause a cough

The enzyme these medicines block does two jobs. It makes a hormone that tightens blood vessels, and it also breaks down a substance called bradykinin. When the enzyme is blocked, bradykinin builds up. The US prescribing information for lisinopril says the cough is "presumably due to the inhibition of the degradation of endogenous bradykinin", and that it "has been reported with all ACE inhibitors".

That has two practical consequences:

Swapping one ACE inhibitor for another rarely solves the problem. The cough is a class effect, not a fault of one brand.
Bradykinin can irritate the nose and throat too. A short case report in the medical literature describes two patients whose postnasal drip and blocked nose cleared after their ACE inhibitor was replaced with an ARB. These upper-airway symptoms are less often recognised than the cough.

What the cough feels like

The NHS medicine pages describe it as "a dry, persistent cough that does not get better" (ramipril) and "a dry cough that does not go away" (lisinopril). The lisinopril prescribing information calls it a "persistent nonproductive cough", meaning it does not bring up phlegm.

How common is it?

The American College of Chest Physicians (ACCP) guideline on ACE inhibitor cough reports an incidence of 5% to 35% across studies.

When does it start?

According to the same guideline, onset ranges from within hours of the first dose to months after starting treatment. A cough that begins a year into treatment can still be caused by the tablet. The guideline advises that in anyone with a chronic cough who takes an ACE inhibitor, the medicine "should be considered as wholly or partially causative", whatever the timing.

How long does the cough last after stopping?

The ACCP guideline says resolution "typically occurs within 1 to 4 weeks" after stopping, but the cough "may linger for up to 3 months". So if you switch medicines and are still coughing two weeks later, that does not mean the switch failed. Give it time, and tell your prescriber if it has not cleared by about three months.

What actually helps

Cough medicines

The NHS ramipril page is direct: "Cough medicines do not usually help for coughs caused by ramipril." So before you spend money on cough syrups, know that they are unlikely to fix this.

Waiting it out

The NHS also notes that "sometimes the cough gets better on its own if you keep taking ramipril". If the cough is mild and does not bother you, you may choose to wait, with your prescriber's agreement. Their advice is to talk to your doctor if the cough "carries on, bothers you or stops you sleeping, as another medicine may be better."

Stopping the ACE inhibitor (with your prescriber)

The ACCP guideline states that "the only uniformly effective treatment for ACE inhibitor-induced cough is the cessation of treatment". Stopping must be planned with your prescriber, because the condition the tablet treats still needs treating. The NHS says that if you stop taking ramipril, "your blood pressure could rise back up again".

Switching to an ARB

The most common replacement is an angiotensin receptor blocker (ARB). The NHS says that if you cannot take an ACE inhibitor because of side effects such as a dry cough, "this will usually be a medicine called an angiotensin receptor blocker, such as candesartan, irbesartan, losartan or valsartan."

The evidence on cough is reassuring:

A 2012 systematic review and meta-analysis in the American Journal of Cardiovascular Drugs looked at 11 randomised trials comparing ARBs with ACE inhibitors, diuretics or placebo (plus one dose-comparison trial) in people who could not tolerate ACE inhibitors. ARBs had fewer cough events than ACE inhibitors (risk ratio 0.37; in plain terms, about a third of the cough risk of an ACE inhibitor) and a cough rate similar to placebo (risk ratio 1.01; about the same as a dummy tablet).
The same review concluded that restarting an ACE inhibitor (rechallenge) "should be discouraged" in people who have already had intolerance to one.

UK prescribing guidance based on NICE's hypertension guideline (NG136) lists an ARB as the option when an ACE inhibitor is "not tolerated e.g. due to cough". The 2011 South African hypertension guideline likewise lists "ACE-I cough or intolerance" as a compelling reason to use an ARB, and says the choice between the two classes should be guided by cost and tolerability.

Other options

ARBs are not the only alternative. Depending on what the tablet is treating, your prescriber may choose a different type of blood pressure medicine altogether. If that turns out to be amlodipine, it has its own common side effect, covered in amlodipine side effects and swollen ankles. Where the ACE inhibitor was prescribed for heart failure or after a heart attack, the choice is more specialised, so the decision belongs with your doctor.

Step by step: what to do if you think your tablet is causing a cough

Do not stop the tablet suddenly because of a cough. Keep taking it until you have spoken to your prescriber or pharmacist. (Swelling of the lips, tongue, face or throat is different: get emergency help straight away.)
Check the name. Look at the active ingredient on your box. Does it end in -pril?
Note the details. When did the cough start? Is it dry? Is it worse at night or when lying down? (Breathlessness when lying flat can also be a sign of heart failure; see below.) Do you have any other symptoms (see the warning signs below)?
Check for other causes. A cough has many causes. If your cough has lasted more than two weeks, or you have any of the TB warning signs below, ask to be tested for TB, whatever medicine you take.
Book a review. Ask your doctor, nurse or pharmacist directly: "Could this be my ACE inhibitor? Could I switch to an ARB?"
After a switch, be patient. Expect the cough to fade over 1 to 4 weeks, and possibly up to 3 months.
Keep monitoring your blood pressure. A new medicine needs checking to make sure it controls your readings. Our guide to blood pressure readings explains the numbers to watch.
Record it. Ask for "ACE inhibitor cough" to be recorded in your notes, so you are not restarted on another -pril at a different clinic.

Do not blame the tablet for every cough

An ACE inhibitor cough is common, but it is not the only possibility, and in much of Africa tuberculosis (TB) must always be considered. The Médecins Sans Frontières clinical guidelines list "prolonged cough (more than 2 weeks)" as a common feature of lung TB, and advise that in areas where TB is common, it should be considered in anyone with breathing symptoms lasting more than two weeks.

Get checked for TB promptly if your cough comes with any of these:

coughing up blood
weight loss you cannot explain
fever or night sweats
loss of appetite or unusual tiredness
breathlessness

A cough that brings up phlegm, or comes with a fever, also needs checking by a clinician rather than being put down to your tablet.

If you take your tablet for heart failure, or you have never been checked for it, a cough can also be a sign of heart failure. The NHS lists "coughing at night" and "coughing up frothy pink phlegm" as heart failure symptoms. Get an urgent appointment the same day if you feel breathless when lying down or during everyday activity, are coughing up frothy pink phlegm, or have suddenly gained weight or have new swelling of your feet, ankles or legs. Call 999 or your local emergency number if you have severe difficulty breathing or your lips or skin turn pale, blue or grey.

Angioedema: the serious side effect to know about

ACE inhibitors can also cause angioedema, which is swelling under the skin. It is driven by the same bradykinin build-up as the cough, but it is far more serious, because swelling of the tongue or throat can block the airway.

What the official sources say:

The lisinopril prescribing information says angioedema "may occur at any time during treatment" and that angioedema with swelling of the voice box (laryngeal oedema) "may be fatal".
Both the lisinopril label and the NHS say the risk is higher in Black patients. The NHS puts it as: "you have a higher chance of getting angioedema if you have black skin."
The 2011 South African hypertension guideline lists angioedema as a contraindication to ACE inhibitors and notes it is more common in Black patients than in white patients.
A review in the Journal of Clinical Hypertension reported that in the OCTAVE trial, angioedema occurred in 0.68% of 12,557 people taking enalapril over 6 months, and that cases have been reported even after several years of treatment.

If you have ever had angioedema on an ACE inhibitor, make sure it is clearly written in your records and that every prescriber and pharmacist knows. The lisinopril label says treatment should be stopped if angioedema occurs.

Other medicines and blood pressure tablets

If you take an ACE inhibitor or ARB, check with your pharmacist before buying anti-inflammatory painkillers such as ibuprofen. The NHS lists painkillers such as ibuprofen, and water tablets (diuretics), among medicines that may not mix well with lisinopril. Our guide can I take ibuprofen with blood pressure medicine? explains the evidence.

Questions to ask your doctor, nurse or pharmacist

Is my medicine an ACE inhibitor?
Could my cough be caused by it, or should I be tested for something else, such as TB?
Would an ARB, such as losartan, suit me instead?
How soon after switching should we recheck my blood pressure, and do I need any blood tests?
Can you record "ACE inhibitor cough" in my notes?

Frequently asked questions

How do I know if my cough is from lisinopril?

A dry cough that brings up no phlegm, in someone taking lisinopril or another ACE inhibitor, is a typical picture. The only way to be sure is to see whether it clears after the medicine is stopped or switched under your prescriber's guidance. If your cough has lasted more than two weeks, ask to be tested for TB, especially if you also have weight loss, night sweats, fever or blood in the phlegm.

Will the cough go away if I keep taking the tablet?

Sometimes. The NHS says the cough sometimes settles on its own with continued treatment. If it carries on, bothers you or disturbs your sleep, ask your doctor about another medicine.

How long after stopping an ACE inhibitor does the cough go away?

Usually within 1 to 4 weeks, according to the American College of Chest Physicians guideline, but it can linger for up to 3 months.

Will switching to a different -pril help?

Usually not. The lisinopril prescribing information says the cough has been reported with all ACE inhibitors, and a 2012 meta-analysis advised against restarting an ACE inhibitor in people who were already intolerant to one.

Do ARBs like losartan cause a cough?

Rarely. In a 2012 meta-analysis of randomised trials in people who could not tolerate ACE inhibitors, ARBs caused cough at a rate similar to placebo.

Is an ACE inhibitor cough dangerous?

The cough itself is not dangerous, but it can disrupt sleep and make people stop their treatment without telling anyone, which is risky. Swelling of the lips, tongue, face or throat is a different and serious side effect called angioedema, and it needs emergency care.

This article is general information and does not replace advice from your own doctor or pharmacist. Please do not stop or change any medicine without speaking to them first.

Sources

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Caldeira D, David C, Sampaio C. Tolerability of angiotensin-receptor blockers in patients with intolerance to angiotensin-converting enzyme inhibitors: a systematic review and meta-analysis. Am J Cardiovasc Drugs. 2012;12(4):263-277.
NHS. Side effects of ramipril, About ramipril and Common questions about ramipril.
NHS. Side effects of lisinopril and Taking lisinopril with other medicines and herbal supplements.
NHS. Symptoms of heart failure.
US prescribing information for lisinopril tablets, via NDC List.
ACE inhibitors: upper respiratory symptoms. BMJ Case Rep. 2014. doi:10.1136/bcr-2014-205462.
Derbyshire Joint Area Prescribing Committee (NHS). Hypertension guideline, based on NICE NG136.
National Institute for Health and Care Excellence. Hypertension in adults (NG136): treatment algorithm.
Seedat YK, Rayner BL. South African Hypertension Guideline 2011. S Afr Med J. 2012;102:57-84.
Sica DA, Black HR. ACE inhibitor-related angioedema: can angiotensin-receptor blockers be safely used? J Clin Hypertens 2002;4(5):375-380.
Médecins Sans Frontières. Tuberculosis guideline: 2.1 Pulmonary tuberculosis.