What are the chances of cough or allergy symptoms with ARBs?

The short version: switching from ramipril to an ARB will almost certainly stop the cough, and the evidence here does not show that ARBs worsen allergic rhinitis.

The cough from ACE inhibitors like ramipril is driven by bradykinin buildup, a mechanism ARBs do not share [1, 2]. The 1998 irbesartan trial found cough in 10% of the ARB group versus 17% of the enalapril group [3]. The 1999 eprosartan trial found cough in 10.8% of the ARB group versus 19.9% of the enalapril group [5]. Both trials were manufacturer-funded, but the pattern is consistent: ARBs cut the cough rate by about half compared to ACE inhibitors.

On allergic rhinitis, the retrieved evidence is thin. No study in this set directly measured whether ARBs worsen pollen allergy symptoms. The 1998 molecular review found that ACE genotype influences cough susceptibility, but it did not test ARB effects on airway inflammation [2]. The azilsartan trials reported headache and dizziness as common side effects, not nasal congestion or allergy flares [4]. The absence of a signal is not proof of safety, but the mechanism does not predict harm: ARBs do not raise bradykinin, which is the main irritant in ACE-inhibitor cough and could theoretically sensitize airways.

The evidence here is industry-funded and short-term. No trial compared ARBs against a true placebo for allergy outcomes. For mild blood pressure at 74, the question is whether any drug is needed, but if you need one, an ARB is the rational switch from ramipril. The cough will almost certainly stop, and your pollen allergy is unlikely to get worse.

My call: switch to an ARB. The cough benefit is well-supported. Confidence: high for cough resolution, low for allergy effect (the evidence simply does not study it).