A 65-year-old overweight woman comes to the physician with 4 weeks of persistent dry, hacking cough that interferes with her sleep. She has minimal sputum production and no associated upper respiratory symptoms, dyspnea, fever, chills, or generalized malaise. She has never had asthma or episodes of wheezing. She does not smoke cigarettes. Her medical problems include newly diagnosed hypertension, hyperlipidemia, and osteoarthritis of the knees. Her blood pressure is currently well controlled with hydrochlorothiazide and lisinopril. In the past, she developed severe lower-extremity swelling and palpitations with amlodipine.
Her blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 14/min. Pulse oximetry shows 95% on room air. Cardiopulmonary examination is unremarkable.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Question

A 65-year-old overweight woman comes to the physician with 4 weeks of persistent dry, hacking cough that interferes with her sleep.  She has minimal sputum production and no associated upper respiratory symptoms, dyspnea, fever, chills, or generalized malaise.  She has never had asthma or episodes of wheezing.  She does not smoke cigarettes.  Her medical problems include newly diagnosed hypertension, hyperlipidemia, and osteoarthritis of the knees.  Her blood pressure is currently well controlled with hydrochlorothiazide and lisinopril.  In the past, she developed severe lower-extremity swelling and palpitations with amlodipine.
Her blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 14/min.  Pulse oximetry shows 95% on room air.  Cardiopulmonary examination is unremarkable.
Laboratory results are as follows:

Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Cough associated with angiotensin-converting enzyme inhibitors (ACEIs) occurs in 5%-20% of patients and is more common in women. The cough usually appears within 1-2 weeks of initiation but may occur up to 6 months later. ACE metabolizes kinins and substance P, and ACEIs will increase these levels to possibly induce bronchial irritation and cough. ACEI cough is not more common in asthmatics, but it may be associated with bronchospasm. Discontinuing the ACEI is the only way to end the cough, which usually stops in 1 week but may take up to 4 weeks to resolve completely (Choice A). Cough tends to recur with an ACEI challenge with either the same or different drug (Choice E). Angiotensin receptor blocking agents have a lower frequency of cough (2%-4%) and are an alternate agent for those with previously good blood pressure control on ACEIs. (Choices B and C) ACEI-induced cough is more likely than pulmonary etiologies in this nonsmoker with a normal cardiopulmonary examination and no history of dyspnea, asthma, or wheezing. If the cough persists despite ACEI cessation, further workup should include checking for potential pulmonary causes. Educational objective: A dry, hacking cough occurs in about 5%-20% of patients taking an angiotensin-converting enzyme inhibitor (ACEI). Discontinuing the ACEI usually stops the cough, which can take 1-4 weeks to resolve completely. Angiotensin receptor blocking agents have a lower frequency of cough (2%-4%) and are an alternate agent for blood pressure control. __________ References: Angiotensin-converting enzyme inhibitor associated cough: deceptive information from the Physicians' Desk Reference. (http://www.ncbi.nlm.nih.gov/pubmed/21035591) Systematic review. Comparative effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for treating essential hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/17984484) Cough and angioneurotic edema associated with angiotensin-converting enzyme inhibitor therapy. a review of the literature and pathophysiology. (http://www.ncbi.nlm.nih.gov/pubmed/1616218)

A 65-Year-Old Overweight Woman Comes to the Physician with 4