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Dr Sarah Jarvis

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ACE inhibitor cough

I went to my GPs surgery for headaches and was prescribed ramipril for hypertension. I have a history of asthma, albeit mild and intermittent, but the GP didn't look at my documents. I returned a week later with a cough and she prescribed another beta-blocker. Since then I have not stopped coughing. It keeps me up at night and stops me sleeping.

I have had a bronchoscopy which showed nothing specific but the hospital did tell me I did NOT have asthma. This was in April 2014. Since then I have had awful nights and in desperation visited a private doctor who informed me I DO have asthma and it was not being managed properly. I have used Ventolin® more frequently since.

It did improve quite a lot but I feel the "cough" coming back. My GPs are at a loss as to what this cough is. Can you help please?

- Jennifer, UK


Contrary to popular belief, headaches are rarely caused by high blood pressure. The only exception is dangerously high blood pressure, and it’s unlikely your doctor would have just given you a tablet and sent you away if your blood pressure was this high. However, if they were examining you and discovered your blood pressure was high, I can understand them wanting to bring your blood pressure down. Raised blood pressure is one of the single biggest risk factors for stroke and a major risk for heart attack.

Your concern seems to be that your doctor gave you a beta-blocker even though you had asthma, and that this caused your symptoms. Let me reassure you that while you shouldn’t use beta-blockers if you have asthma, because they can make asthma worse, ramipril isn’t a beta-blocker. It belongs to a class of blood pressure lowering tablets called ACE inhibitors. The ACE inhibitors are recommended as the first drugs to give to treat high blood pressure if you’re under 55. (For over-55s, the drug of first choice comes from a group of medicines called the calcium-channel blockers, of which the most commonly prescribed is a medicine called amlodipine.)

All medicines can cause side effects in some patients. ACE inhibitors are very well tolerated on the whole, but up to one in 10 men and one in five women develop a dry cough on them. There is no evidence that you are more likely to get this dry cough if you have asthma. The cough doesn’t do any long-term harm or cause any serious underling problem, but it can be very debilitating. The usual alternative treatment for people who develop side effects on ACE inhibitors is a medicine from another class called the ARBs. There are lots of different tablets in this class, but all of them have a name ending in -sartan (losartan, candesartan, valsartan etc). These do not cause the same dry cough.

The evidence suggests that dry cough caused by ramipril settles when you stop taking the tablets. The good news is that a bronchoscopy can usually eliminate a serious underlying cause such as a tumour. Making a diagnosis of asthma is not as easy as you might think – it is usually done not with bronchoscopy but by checking your lung function using a machine called a spirometer. However, sometimes your spirometry could be completely normal if you didn’t have symptoms at the time, so a normal spirometry doesn’t necessarily exclude asthma.

The usual symptoms of asthma are wheeze and shortness of breath but some people do suffer cough as well. If a doctor has told you that you may have asthma, and if you have found ventolin® useful, then other asthma treatments may work for you as well. For instance, an inhaled corticosteroid can reduce inflammation in the lungs and can sometimes be useful for cough caused by over-sensitive airways as well as for ‘traditional’ asthma.

Dr. Sarah Jarvis
Healthcare Professional

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