A 59-year-old man presents to the general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, an albuterol inhaler, and citalopram. His vital signs are stable, with a blood pressure of 126/79 mmHg. Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL. The remainder of his physical exam is unremarkable.

If this patient's cough is due to one of the medications he is taking, what would be the next step in management?

A. Change lisinopril to metoprolol.
B. Change lisinopril to losartan.
C. Change lisinopril to amlodipine.
D. Change atorvastatin to lovastatin.

The patient's cough may be due to his consumption of the ACE inhibitor, lisinopril. Substituting lisinopril with an ARB like losartan, which doesn't inhibit the breakdown of bradykinin, should address the cough. Changing atorvastatin to lovastatin, both statins, wouldn't alleviate the cough issue.

Explanation:

In this case, the patient's cough may be attributed to the ACE inhibitor he is taking, which is lisinopril. Approximately 10% of patients who are on ACE inhibitors develop a notably dry cough. The next step in management would be to change the lisinopril to a different class of antihypertensive medication. Losartan would be the preferred choice here as it's an ARB (Angiotensin II Receptor Blocker) which is less likely to cause a cough compared to ACE inhibitors.

The other medications listed such as metoprolol and amlodipine are antihypertensive drugs as well, but losartan is typically the first choice when a patient on an ACE inhibitor develops a cough. This is because ARBs don't inhibit the breakdown of bradykinin, a substance that can cause coughing, as do ACE inhibitors. Changing atorvastatin to lovastatin, both of which are statins, wouldn't address the cough issue as statins are not generally known to cause cough.

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