The People's Perspective on Medicine

ACE Inhibitors Like Lisinopril and Lung Cancer

Tens of millions of people take ACE inhibitors to lower high blood pressure. Is there an association between drugs like lisinopril and lung cancer?
Film chest X-ray PA upright : show pleural effusion at right lung due to lung cancer

Doctors appreciate ACE (angiotensin receptor enzyme) inhibitors for lowering high blood pressure. They have been first-line treatments for hypertension for many years. We used to think drugs such as benazepril, captopril, enalapril, fosinopril and lisinopril were “remarkable.” That was before we heard from hundreds of patients that an ACE inhibitor cough could be devastating. Now, we are also reading about the possibility there is a link between drugs like lisinopril and lung cancer.

Our Historical Perspective on ACE Inhibitors:

In our book, Best Choices from the People’s Pharmacy (2006), we were enthusiastic about ACE inhibitors. Here is how we described such drugs:

An ACE Up Your Sleeve

“One of the most extraordinary advances in pharmaceutical research and blood pressure management evolved out of the jungles of Brazil. A Brazilian scientist noted that when people were bitten by the poisonous jararaca snake, they experienced a dramatic drop in blood pressure. By harnessing the power of the snake venom to lower blood pressure, pharmacologists were able to isolate chemicals that could be used as drugs.

“These venom-derived compounds block an enzyme that converts a naturally occurring chemical called angiotensin I into a powerful vasoconstrictor called angiotensin II, which in turn raises blood pressure. The drugs are called angiotensin-converting enzyme (ACE) inhibitors. The first was captopril (Capoten), and it was followed by a wide range of other chemicals that have revolutionized the treatment of high blood pressure.

“By all accounts, ACE inhibitors are now considered to be the best choices in the treatment of high blood pressure for many patients.”

ACE Inhibitors vs. ARBs (angiotensin receptor blockers):

ARBs have a somewhat similar mechanism of action. They work by impeding the vasoconstrictor activity of angiotensin II. Read more about this intriguing class of medications at this link

Over the last year and a half, ARBs like losartan, valsartan and irbesartan have been under a nitrosamine contamination cloud. There have been so many recalls of these drugs that we long ago lost count. We suspect that many physicians have turned to ACE inhibitors to avoid questions about quality.

A New Concern: ACEIs like Lisinopril and Lung Cancer?

This reader describes the new dilemma:

Q. My mother took lisinopril for years to control her blood pressure. She regularly went to her physician complaining of a chronic cough, but he kept telling her it was allergies and prescribed Zyrtec.

After a year of this, her doctor decided she must have GERD and sent her to a gastroenterologist. The specialist found nothing.

Not once did anyone prescribe a chest X-ray. When she started losing weight and feeling extremely fatigued, I insisted on a chest X-ray. They found advanced lung cancer and she died six months later. Is there a link between lisinopril and lung cancer?

A. Lisinopril is one of the most frequently prescribed medications in the U.S. It is an ACE (angiotensin converting enzyme) inhibitor. More than 20 million Americans take this drug because it is so effective for blood pressure control.

For the most part, lisinopril is considered safe. It can cause a chronic cough, however. That is something your mother’s doctor should have considered. We have been puzzled why so many doctors apparently overlook this classic complication of ACE inhibitors.

Lisinopril and Lung Cancer?

Only a few studies have addressed your question about lisinopril and lung cancer. In 2012, Canadian researchers reviewed the medical records of more than a million individuals (PLOS One, Dec. 12, 2012).  They found that long-term use of ACE inhibitors was linked to a modestly increased risk of lung cancer.

A more recent study also found a slightly higher rate of lung cancer among patients who had taken an ACE inhibitor for at least five years (BMJ, Oct. 24, 2018).

Here is what the authors conclude:

“In this large population based study of nearly one million patients, the use of ACEIs was associated with an overall 14% increased risk of lung cancer. Associations were evident after five years of use and increased with longer durations of use, particularly among patients who used ACEIs for more than 10 years (31% increased risk). Although the magnitudes of the observed associations are modest, ACEIs are one of the most widely prescribed drug classes; in the UK, 70.1 million antihypertensives are dispensed each year, of which approximately 32% are ACEIs. Thus, small relative effects could translate into large absolute numbers of patients at risk for lung cancer.”

The authors call for more research that would involve patients “exposed for longer durations.” The Food and Drug Administration rarely requires such long-term trials. As a result, any connection between lisinopril and lung cancer is not likely to be uncovered for a very long time, if ever.

It’s virtually impossible to determine whether any given case of cancer is the result of exposure to a medication. The FDA does not make this any easier. The agency reports that animal studies did not reveal any signs of a “tumorigenic effect” with lisinopril. But in the adverse events section of the official prescribing information for lisinopril the FDA lists rare, serious, possibly drug-related events reported in uncontrolled studies or marketing experience. Included in this very long list is “malignant lung neoplasms.”  

What NOT to Do About the Question of Lisinopril and Lung Cancer:

We always emphasize that no one should ever stop any medication without discussing all concerns with the prescribing physician. That is especially true for a commonly prescribed drug for hypertension. Print the article from the BMJ and give your provider time to read and consider it. The absolute risk appears small, but given the number of people taking lisinopril and its cousins, the risk may not be trivial.

Readers can learn more about other alternatives for controlling hypertension in our Guide to Blood Pressure Treatment. It is available in the Health eGuides section of www.PeoplesPharmacy.com.

Share your own thoughts about ACE inhibitors in the comment section below.

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    Obvious problem with some studies is that the chances of lung problems do increase as we age. Finding a control group to monitor can be a challenge. Doctors need to listen more to the patients’ concerns and resist making assumptions, even educated guesses based upon medical training. Often the patient can nail the details.

    Now, as to pointing to the cause, that remains part of the medical mystery to be searched out by various tests. In this case switching to a different medication might result in the cough clearing up and, if so, that too is worthy of note. I was included in a discussion that a change in my health could even be psychosomatic when a condition seemed to reappear. This was allowing for all possibilities to be examined as I, the patient, experienced the condition. I expect the medical team to be open to a wide range of explanations, not go one at a time to see if A is the cause or assume the problem will just resolve itself on it’s own. We expect better from an auto mechanic.

    I take Candesartan(Atacand). Had a CT Scan Nov.19, 2019, and the report said there was a nodule on my lung and will have to have possibly a Pet/scan to determine what it is??? They called it a semi-solid airspace opacity within the right upper lobe. Now am I supposed to sweat bullets or just wait till they decide? Scary

    I’ve done extensive research into lisinopril (nearly three years)! I’ve read of how the medicine works in the body & its hidden dangers! I’m a victim of lisinopril. I’ve sustained severe, catastrophic & personal injuries! As of September 2019, 231,346 consumers have reported to the FDA side effects from usage of lisinopril! Lisinopril (since widely prescribed) is the cause of an “unrecognized epidemic” across the USA!

    I’ve been on Enalapril for 10 yrs and I had heard about this risk of lung cancer. I had planned to ask my GP to switch me to an ARB until all the FDA notice came out saying that most of the brands were contaminated with nitrosamines. So I think that I will stick with what I’m on since I have been able to decrease my dose over the years. Hopefully I can get off of them instead.

    I took Lisinopril for three days and had an allergic reaction of angioedema, which the doctors in the Emergency room diagnosed within the first half hour. They said that this kind of reaction from Lisinopril is seen quite often. This is one of the most frightening experiences I’ve ever had. (Throat closing up do to swelling etc.) I was pumped full of steroids & kept over night for observation….doctors were afraid I would have a heart attack! The specialist that examined my noise/throat said he sees this quite often and doesn’t understand why Lisinopril still on the market!

    Lisinopril is a BAD drug and should be removed from the market. It made my mouth and throat swell and gifted me with a horrible cough. I informed my doctor that I wasn’t taking any BP medicine ever again. It’s been 3 years and I feel fine. BP is in the normal range after giving up salt.

    I am a clinical pharmacist. I worked for Merck & launched both enalapril and lisinopril. If a patient is experiencing cough they should, of course, tell their physician, but they should also discuss this with their pharmacist. Pharmacists are trained to spot drug-induced adverse events & are very likely to know this information immediately. Please discuss this information with ALL your healthcare providers. Note, also that ARB’s can induce cough, albeit at a lower percent than ACEI’s.

    Hi Ellen,

    Thanks so much for your input on this. We absolutely agree that people should discuss their drug side effects with everyone on the health care team. What has puzzled us over the years is the number of physicians who do NOT recognize cough as an ACE inhibitor adverse reaction. You would be astonished to learn how many patients get worked up for allergies, lung infections, and all sorts of other conditions when the cause of the symptoms was a drug like lisinopril.

    What happens when a pharmacist tells a physician that the symptoms a patient is complaining about are drug related? You might not be surprised to learn that some doctors get annoyed that a pharmacist is bringing this to their attention…if the pharmacist even gets a call back. Then what should the patient do?

    Surely the risk is dose related. At which low does does the cancer risk approach zero? I take 5 mg enalapril daily, for 25 years. Since I reduced my dose from 10 mg., the cough is not a problem. (Reduction was made possible by CocoaVia)

    I’ve taken ACE inhibitors for over 30 years. I started on enalapril, then prinivil, zestril, and finally lisinopril. I never experienced a chronic cough or any other listed side effects. However, my sister had the cough, and I often wonder if there’s a genetic tendency that may affect me in the future in a more drastic way.

    Although I was very jaundiced while on enalapril and have had a slight yellowing of my clothing on the others, my doctors never connected this to the drugs.

    My mother in law, NEVER sick other than her blood pressure being high at age 76 died in 1996, six months after being diagnosed with cancer. They never knew where it started but found it in her lungs, her breast, her eye, her gums and then her brain.

    She was on Lisinopril for years and always complained of a cough but back in the early 90s doctors may not have been aware of this side effect and never changed her meds.
    It’s very sad that we find out how bad drugs are for us years after the damage is done. It’s very difficult to determine at that point that it was the drug.

    If lisinopril is from snake venom what other meds are from snake venom?

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