Q: I have a specific regarding the drug Enalapril. This drug is very cheap. Since the anti- hypertensive drug needs to be continued for life long, cost factor has to be kept in mind. My brother in law had been prescribed following combinations - Amlopress AT twice and Losacar H twice. Earlier, he was on Normace D (Enalpril-10 mg + HTZ 25 mg) but the consulting physician asked him to discontinue as this drug had adverse effect of dry cough. He asked to switch over to Losacar H twice. The new drug may be more powerful but cost wise there is a lot of difference. Is Losartan superior to Enalapril and if not then why is the latter discouraged on account of dry cough? In terms of efficacy, are both similar?

A:If enalapril has caused cough in the patient, there is no alternative but to discontinue the medicine. The cough, once it appears, just does not go away and can cause extreme distress including loss of sleep. In the absence of adequate details of the patient (age, height, weight, etc.) it is not possible to give a specific reply but following general observations may be helpful: 1. The first line treatment is usually a diuretic (such as hydrochlorothiazide) and losartan or enalapril. If there is cough, the correct therapy is hydrochlorothiazide and losartan. The doctor has correctly prescribed Losacar-H. Generally one tablet a day should be adequate; if not one tablet two times a day is to be given. 2. If the above treatment (i.e. 2 tablets a day) does not bring down the BP to near-normal levels, then and then only, a third drug needs to be added. The third drug can be amlodipine 5mg (Amlodac) or 10mg once a day. It is a long acting medicine and hence need not be given twice. 3. In rare cases, one may have to give a fourth medicine. This can be atenolol (Aten) 50, or at the most, 100mg a day. The patient is taking all the four medicines. Was an attempt made to control BP with two and three medicines? With regard to cost, it is true that there are wide variations and hence it is the prescriber's moral responsibility to choose a correct brand but definitely of a good manufacturer. For example the cost of Amlodac brand of amlodipine 10mg manufactured by Cadila Healthcare (a reputed quality manufacturer) is Rs. 14.41, while the same medicine made by Cipla under the brand name of Amlopres costs Rs. 37.45.