Cough and angiotensin II receptor antagonists: cause or confounding?

Abstract

Aims Cough is one of the most frequent side effects associated with angiotensin converting enzyme inhibitors (ACEIs) but is not thought to be associated with losartan, an angiotensin II receptor antagonist (ARA). This study compares reports of cough with losartan and three ACEIs used in general practice. Methods Studies have been conducted for losartan, and three ACEIs enalapril, lisinopril and perindopril, using the technique of Prescription-Event Monitoring. Patients were identified using dispensed prescription data. Questionnaires were sent to patients' general practitioners 6 months after the date of first prescription. Cases of cough within the first 60 days of treatment with losartan resulting in withdrawal of the drug were followed up with additional questionnaires. Incidence rates for reports of cough were calculated. In order to reduce the impact of carry-over effects, rate ratios were calculated for first reports of cough between days 8 and 60 using losartan as the index drug. Results The cohort for each drug exceeded 9000 patients. Age and sex distributions and indications for prescribing the four drugs were similar. Cough was the most frequent reason for discontinuation of losartan and the most frequently reported event in the first month of treatment with this drug. When reports of cough between days 1-7 were excluded, rates of cough were significantly higher for the three ACEIs when compared with losartan (rate ratios 1.5, 4.8 and 5.7, all P<0.03). 101 patients had discontinued losartan due to cough. 91% of these had previously been prescribed an ACEI and 86% had previously experienced ACEI cough. Conclusions Carry-over accounted for the observed excess of reports of cough with losartan. Rates of cough between days 8 and 60 were significantly higher for the three ACEIs compared with losartan. Confounding factors associated with comparative observational cohort studies are discussed.

The safety of valsartan: results of a postmarketing surveillance study on 12 881 patients in England

“…15 Cough is a class effect of ACE inhibitors to the nonspecificity of the ACE. One clinical trial has shown that the incidence of cough under valsartan was similar to that observed under diuretic therapy, but significantly lower than that observed under lisinopril.…”

Losartan: a study of pharmacovigilance data on 14 522 patients

“…We have previously shown that carry-over effects from previously administered ACE inhibitors account for many of the cases of cough reported during the early days of treatment with losartan. 9 Dizziness was the most frequently reported ADR and is already noted in the Summary of Product Characteristics for losartan. 2 There were also occasional reports of vertigo, labyrinthitis and tinnitus possibly associated with losartan.…”

Comparison of angiotensin II receptor antagonists

“…This was borne out by one study that compared the emergence of coughing in patients on losartan vs. three ACE inhibitors commonly prescribed in general practice (enalapril, lisinopril, and perindopril). Rates of cough between Day 8 and Day 60 were significantly higher in patients on the ACE inhibitors vs. the AT 1 receptor antagonist [53]. Similarly, in a randomised, double-blind, double-dummy, placebo-controlled study involving 119 hypertensives, those patients taking enalapril 20 mg demonstrated a statistically higher incidence of cough compared to patients on telmisartan 80 mg [54].…”