7 ACE Inhibitor Side Effects You Should Know About: Cough, Angioedema, and More
Key takeaways:
Side effects of angiotensin-converting enzyme (ACE) inhibitors include dry cough, very low blood pressure, and low potassium levels. In some cases, lowering your ACE inhibitor dose or switching to another medication can help.
ACE inhibitors may also cause more serious side effects, like kidney damage and severe swelling in the face (angioedema). These may require emergency medical care. You may also need to stop taking your medication.
If you’re pregnant or you have hereditary angioedema, avoid taking ACE inhibitors.
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Table of contents
Angiotensin-converting enzyme (ACE) inhibitors are medications that treat high blood pressure (hypertension). Some ACE inhibitors are also approved for use after a heart attack, for heart failure, and for kidney disease from diabetes. Examples of these medications include lisinopril (Zestril), enalapril (Vasotec), and benazepril (Lotensin).
Even though ACE inhibitors help many people, they have potential risks to be aware of. Below, we’ll discuss seven ACE inhibitor side effects and how to manage them.
1. ACE inhibitor cough
An ACE inhibitor-induced cough is one of the most well-known side effects of these medications. It’s typically a dry, persistent cough with a tickling or scratching sensation in the throat. Although it’s not dangerous, it can be bothersome.
Researchers think it may occur because ACE inhibitors raise levels of two proteins called bradykinin and substance P. This can cause your airways to tighten (constrict), leading to a cough. The cough can occur immediately after your first dose or months later.
If you think you’re experiencing an ACE inhibitor-induced cough, talk to your healthcare provider. The cough can improve over time. So if it’s mild, the benefit of taking an ACE inhibitor may outweigh the risk. But if your cough is severe and impacting your daily life, your provider may ask you to stop taking your ACE inhibitor. After stopping it, your cough will usually go away within a few weeks.
If you have to stop taking your ACE inhibitor, you’ll likely need to replace it with another medication. Your provider may switch you to an angiotensin II receptor blocker (ARB) instead. Examples include losartan (Cozaar), valsartan (Diovan), and olmesartan (Benicar). ARBs work as well as ACE inhibitors in most cases, and they aren’t known to cause a cough.
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2. Low blood pressure
ACE inhibitors lower blood pressure — which is often why they’re prescribed. But they can lower blood pressure too much, leading to hypotension. This is more likely if you have certain health conditions, like aortic valve stenosis, or if you take other medications that lower blood pressure, like diuretics (“water pills”). Symptoms of hypotension include dizziness, tiredness, and weakness.
It’s a good idea to check your blood pressure at home regularly if you take an ACE inhibitor. For many people with hypertension, a good blood pressure goal is 130/80. But find out what goal your healthcare provider recommends.
If you have a low blood pressure reading, or if you experience any symptoms of hypotension, let your provider know. They’ll look at your medication regimen and decide what to do. This may include lowering the dose of your ACE inhibitor or other blood pressure medications.
If your symptoms are severe — like cold and sweaty skin, breathing quickly, or a weak pulse — seek emergency care or call 911.
3. Dizziness
Medications that lower your blood pressure, including ACE inhibitors, can also cause dizziness. When you first start taking an ACE inhibitor, your body has to get used to its effects. This can take a little time, and dizziness may happen in the meantime.
In most cases, dizziness is mild and improves as your body gets used to the medication. But it can also be severe or continue to worsen. In these cases, your healthcare provider may recommend a lower dose of your ACE inhibitor. Or they may recommend switching to another blood pressure medication.
If you’re having severe symptoms of dizziness — like trouble speaking or passing out — seek emergency care or call 911.
4. Kidney problems
ACE inhibitors usually help protect your kidneys and improve blood flow to them. This makes them a first-choice medication for people with high blood pressure and chronic kidney disease.
But in rare cases, ACE inhibitors can cause kidney damage. This can occur at any time while you’re taking the medication. It’s more likely in people with heart failure or existing kidney disease and in people who take diuretics or medications that constrict your blood vessels. Examples include nonsteroidal anti-inflammatory medications (NSAIDs) like ibuprofen (Advil, Motrin).
Usually, any changes to your kidney function will be mild and temporary. Your healthcare provider will likely use blood tests to check your kidney function before and during ACE inhibitor treatment. If your blood tests show significant changes, your provider may recommend stopping your ACE inhibitor.
If you have any symptoms of kidney damage, like peeing less or not at all, swelling in the legs, or shortness of breath, contact your provider right away. If your symptoms feel severe, seek emergency care or call 911.
5. High potassium levels
ACE inhibitors can cause high potassium levels in the blood (hyperkalemia). Hyperkalemia from ACE inhibitors is usually mild. But it can be severe and lead to abnormal heart rhythms, which can be life-threatening.
ACE inhibitors are more likely to increase your potassium levels if you have other risk factors for hyperkalemia. These include having diabetes or existing kidney problems, or taking certain medications like beta blockers or potassium supplements.
Before you start an ACE inhibitor, tell your healthcare provider and pharmacist about all the medications you take, including prescription medications and over-the-counter (OTC) products.
Hyperkalemia doesn’t always cause symptoms. But it may cause muscle weakness, tingling, or nausea and vomiting. If you experience these symptoms, let your provider know right away. They’ll let you know if you need to make any changes to your ACE inhibitor dose or stop taking the medication altogether.
6. Angioedema
Angioedema refers to the swelling of deep tissues. It most often occurs in the face, neck, and mouth. It can occur at any time during ACE inhibitor treatment, even after you’ve been taking it for a while. But it’s rare — less than 1% of people taking an ACE inhibitor will experience angioedema.
Angioedema from ACE inhibitors may occur due to a buildup of bradykinin in the body, which can cause swelling. In severe cases, this swelling can block your airways and lead to trouble breathing.
Certain people may have a higher risk of angioedema. This includes women, people older than 65 years of age, and African American adults. Talk to your healthcare provider about whether you’re at higher risk of angioedema. They can help you weigh the pros and cons of starting an ACE inhibitor.
If you experience any swelling while taking an ACE inhibitor, let your provider know right away. They’ll ask you to stop taking it if they think you’re experiencing angioedema. If your swelling is severe or worsening quickly, or you’re having trouble breathing, seek emergency care.
Good to know: If you’ve had angioedema while taking an ACE inhibitor in the past, or you have a specific form of angioedema — called hereditary angioedema — you should avoid ACE inhibitors.
7. Birth defects if used during pregnancy
If you’re pregnant or trying to become pregnant, it’s best to avoid taking ACE inhibitors. ACE inhibitors have a boxed warning (the FDA’s strictest warning for medications) against use during pregnancy. They may cause harm to a fetus. This includes affecting how your baby’s kidneys develop and lowering the amount of amniotic fluid surrounding the baby. This can lead to a miscarriage or birth defects.
If you become pregnant while taking an ACE inhibitor, let your healthcare provider know right away. In many cases, your provider will recommend stopping the ACE inhibitor. But don’t stop taking your medication without talking to your provider first. This could lead to uncontrolled hypertension, which can be dangerous.
When should you contact your healthcare provider about ACE inhibitor side effects?
If you’re experiencing any bothersome side effects after starting an ACE inhibitor, such as coughing, dizziness, or fatigue, talk to your healthcare provider. But keep in mind that some side effects, like coughing, can occur even after you’ve been taking an ACE inhibitor for a long time.
If you experience any symptoms of a severe ACE inhibitor side effect, you should seek emergency care or call 911. This includes vomiting, severe swelling, and trouble breathing.
Certain medications and health conditions can make ACE inhibitor side effects more likely. So give your provider and pharmacist a list of all the prescription medications and OTC products you take. And make sure they’re aware of your full medical history. This will help them decide whether it’s safe for you to take an ACE inhibitor.
The bottom line
Angiotensin-converting enzyme (ACE) inhibitors treat hypertension and other heart-related conditions. These medications have possible side effects, like ACE inhibitor-induced coughing, very low blood pressure, and high potassium levels.
ACE inhibitors also have rare but serious side effects like kidney damage and angioedema.
Before starting an ACE inhibitor, talk to your healthcare provider. They can help you weigh the risks and benefits of these medications. If you experience any severe side effects of ACE inhibitors — like vomiting, trouble breathing, or severe swelling — seek emergency care or call 911.
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References
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Goyal, A., et al. (2023). ACE inhibitors. StatPearls.
National Heart, Lung, and Blood Institute. (2022). Low blood pressure.
National Kidney Foundation. (n.d.). Acute kidney injury (AKI).
Pinto, B., et al. (2020). ACEI-induced cough: A review of current evidence and its practical implications for optimal CV risk reduction. Indian Heart Journal.
Schoolwerth, A. C., et al. (2001). Renal considerations in angiotensin converting enzyme inhibitor therapy: A statement for healthcare professionals from the Council on the Kidney in Cardiovascular Disease and the Council for High Blood Pressure research of the American Heart Association. Circulation.
Whelton, P. K., et al. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension.
Whelton, P. K., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology.
