From the Guidelines
Intranasal glucocorticoids should be the initial treatment for this patient with chronic cough and cobblestone nasal mucosa appearance, as they are the most effective medication class for controlling symptoms of allergic rhinitis, including sneezing, itching, rhinorrhea, and nasal congestion. The patient's symptoms, including dry intermittent cough and the need to clear her throat, along with the cobblestone appearance of her nasal mucosa, are suggestive of allergic rhinitis with postnasal drip, a common cause of chronic cough 1. Intranasal corticosteroids, such as fluticasone propionate or mometasone furoate, can reduce inflammation and swelling in the nasal passages, thereby alleviating symptoms.
Some key points to consider when prescribing intranasal glucocorticoids include:
- They should be used at the recommended doses to minimize local side effects, such as nasal irritation and bleeding 1.
- Patients should be instructed to direct sprays away from the nasal septum and to have their nasal septum periodically examined to assure that there are no mucosal erosions 1.
- Intranasal corticosteroids may be considered for initial treatment without a previous trial of antihistamines and/or oral decongestants, and they should always be considered before initiating treatment with systemic corticosteroids for the treatment of rhinitis 1.
In contrast to other options, oral antihistamines like Benadryl may have limited efficacy in treating nonallergic rhinitis syndromes and can cause significant side effects, such as sedation, performance impairment, and anticholinergic effects 1. PPIs are not indicated for the treatment of allergic rhinitis or chronic cough in the absence of gastroesophageal reflux disease (GERD) symptoms. Inhaled glucocorticoids are typically used for the treatment of asthma or chronic obstructive pulmonary disease (COPD), and there is no indication for their use in this patient's case.
Given the patient's medical history, including hypertension and diabetes, it is essential to monitor her blood pressure and blood glucose levels while she is on treatment. However, intranasal glucocorticoids are not generally associated with clinically significant systemic side effects, making them a safe choice for this patient 1.
From the Research
Treatment Options for Chronic Cough and Cobblestone Nasal Mucosa Appearance
The patient presents with a dry intermittent cough for four months and a cobblestone appearance of the nasal mucosa. Given the absence of fevers, chills, allergic symptoms, heartburn, wheezing, or shortness of breath, and considering the patient's history of hypertension and diabetes, the following treatment options can be considered:
- Intranasal Glucocorticoids: Studies have shown that intranasal glucocorticoids are effective in treating upper airway diseases, including allergic rhinitis and non-allergic rhinitis 2, 3, 4. They have strong anti-inflammatory local action with minimal impact on general health, resulting in few and benign side effects. The cobblestone appearance of the nasal mucosa suggests an inflammatory process, making intranasal glucocorticoids a suitable treatment option.
- Inhaled Glucocorticoids: While inhaled glucocorticoids are commonly used to treat respiratory conditions such as asthma, there is no clear indication for their use in this patient's case, given the absence of wheezing or shortness of breath.
- Benadryl: Benadryl is an antihistamine that can be used to treat allergic symptoms. However, since the patient does not exhibit any allergic symptoms, its use may not be justified.
- PPI (Proton Pump Inhibitor): PPIs are used to treat gastroesophageal reflux disease (GERD) and other conditions characterized by excessive acid production. Since the patient does not have heartburn or any other symptoms suggestive of GERD, PPIs may not be necessary.
Recommendation
Based on the patient's symptoms and the absence of any contraindications, Intranasal Glucocorticoids appear to be the most suitable treatment option. They can help reduce inflammation in the nasal mucosa, potentially alleviating the patient's symptoms 2, 3, 4, 5. It is essential to monitor the patient's response to treatment and adjust the therapy as needed.