SUMMARY OF RECOMMENDATIONS
- 1.
In patients presenting with chronic cough, in order to determine that the ACE inhibitor is the cause
1. In patients presenting with chronic cough, in order to determine that the ACE inhibitor is the cause of the cough, therapy with ACE inhibitors should be discontinued regardless of the temporal relation between the onset of cough and the initiation of ACE inhibitor therapy. The diagnosis is confirmed by the resolution of cough, usually within 1 to 4 weeks of the cessation of the offending agent; however, the resolution of cough may be delayed in a subgroup of patients for up to 3 months.
The mechanism of ACE inhibitor-induced cough remains unclear. Possible protussive mediators include bradykinin and substance P, which are degraded by ACE and therefore accumulate in the upper airway or lung when the enzyme is inhibited; and prostaglandins, the production of which may be stimulated by bradykinin.1, 14 Bradykinin-induced sensitization of airway sensory nerves has been proposed as a potential mechanism of ACE inhibitor-induced cough.14 Some evidence has suggested that the
The only uniformly effective intervention for ACE inhibitor-induced cough is the cessation of therapy with the offending agent. Numerous small studies have evaluated various drugs as potential therapies (Table 1). Agents demonstrating the ability to attenuate cough due to ACE inhibitors in randomized, double-blind, placebo-controlled trials include inhaled sodium cromoglycate,19 theophylline,20 sulindac,21 indomethacin,22 the calcium-channel antagonists amlodipine and nifedipine,22 ferrous
2. In patients presenting with chronic ACE inhibitor-induced cough, discontinue therapy with the drug because it is the only uniformly effective treatment. Quality of evidence, low; net benefit, substantial; grade of recommendation, B
3. In patients whose cough resolves after the cessation of therapy with ACE inhibitors, and for whom there is a compelling reason to treat with these agents, a repeat trial of ACE inhibitor therapy may be attempted. Quality of evidence, fair; net benefit,
5. In patients in whom persistent or intolerable ACE inhibitor-induced cough occurs, therapy should be switched, when indicated, to an ARB, with which the incidence of associated cough appears to be similar to that for the control drug, or to an appropriate agent of another drug class. Quality of evidence, good; net benefit, substantial; grade of recommendation, A
SUMMARY OF RECOMMENDATIONS In patients presenting with chronic cough, in order to determine that the ACE inhibitor is the cause
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