Lisinopril-Induced Rhinorrhea: A Case Report

Introduction: A 47-year-old woman presents to our clinic with a chief complaint of rhinorrhea; she had a medical history of chronic hypertension managed with antihypertensive drugs, including Lisinopril. While dry cough is a well-known side effect of ACE inhibitors, this case highlights a common chief complaint yet less recognized side effect of ACE inhibitors. It further emphasizes that overall, angiotensin receptor blockers may be a better drug of choice in hypertension due to their favorable side effect profile. Case Description: We present the case of a 47-year-old woman with chronic hypertension who presented to our clinic with a runny nose for more than a year. The patient denied cough, fever, facial pain, sneezing, polyps, pruritus, headaches, conjunctivitis, or sore throat. She had a sister with chronic hypertension who experienced rhinorrhea after starting Lisinopril and a father who similarly experienced facial flushing. After several office visits, Lisinopril was discontinued, and their symptoms resolved. Her physical exam was unremarkable. Given her strong family history and Losartan's low side effect profile, we substituted Lisinopril. Two weeks later, her rhinorrhea improved and resolved entirely by week four. Discussion: Lisinopril belongs to a class of medications called ACE inhibitors. It works by inhibiting the conversion of angiotensin I to angiotensin II to regulate blood pressure. Lisinopril may result in the accumulation of bradykinin and substance P, which increases vascular permeability and fluid leakage from blood vessels into the surrounding tissues. This later mechanism mediates symptoms like postnasal drainage, rhinitis, and rhinorrhea. URTI is among the three top diagnoses in outpatient settings in the USA, and having a broad differential is crucial in treating patients to avoid unnecessary diagnostic testing. Most clinicians are aware of ACE-I-induced cough but less frequently recognize rhinorrhea as a side effect. Not everyone using an ACE-I will experience rhinorrhea, and some studies suggest a genetic predisposition. With the increasing prevalence of hypertension notwithstanding the benefits of ACE-I use, we favor the use of ARBs over ACE-Is when indicated in the management of hypertension and renal disease, more so in patients who are intolerant to ACE inhibitors, especially since ARBs are reasonably comparable in effectiveness and tolerability.