What is the recommended treatment for cough variant asthma?

Treatment of Cough Variant Asthma

Patients with cough variant asthma should initially be treated with a standard antiasthmatic regimen of inhaled bronchodilators and inhaled corticosteroids as first-line therapy. 1

First-Line Treatment

The recommended treatment approach for cough variant asthma (CVA) follows a stepwise algorithm:

1. Initial therapy: Inhaled corticosteroids (ICS) should be considered first-line treatment 1

   • ICS effectively reduces cough symptoms, improves pulmonary function, and decreases airway inflammation 2
   • Studies show that 90% of patients treated with ICS experience complete cough relief 3
   • ICS also reduces bronchial hyperresponsiveness, potentially preventing progression to classic asthma 4

2. Add short-acting bronchodilator (e.g., albuterol) as needed for symptom relief

   • Can be used in combination with ICS for better symptom control 1

Treatment for Refractory Cases

If response to initial therapy is incomplete:

1. Step-up ICS dose 1

   • Higher doses of ICS may be needed for patients with persistent symptoms

2. Add leukotriene receptor antagonist (LTRA) 1

   • For patients with cough refractory to ICS and bronchodilators
   • LTRAs like zafirlukast have been shown to improve subjective cough scores and inhibit experimentally induced cough 1
   • Should be added before escalating to systemic corticosteroids

3. Short course of systemic corticosteroids (for severe/refractory cases) 1

   • Oral prednisone 30 mg daily for 1-2 weeks
   • Follow with maintenance ICS therapy
   • Diagnostic trial of oral steroids can establish diagnosis and lead to effective long-term control with ICS 5

Monitoring and Follow-up

• Regular assessment of cough symptoms and pulmonary function
• Monitor for development of classic asthma symptoms (wheezing, dyspnea)
• Long-term ICS therapy is recommended as discontinuation can lead to:
  • Return of cough symptoms
  • Worsening of pulmonary function
  • Increased airway inflammation 2
  • Higher risk of progression to classic asthma 4

Important Clinical Considerations

• Duration of therapy: Long-term maintenance therapy is often necessary as studies show stopping anti-inflammatory therapy leads to symptom recurrence 2
• Progression risk: Without proper treatment, a significant proportion of CVA patients may develop classic asthma 6, 4
• Diagnostic confirmation: If cough persists despite adequate therapy, reconsider the diagnosis and evaluate for alternative causes 1
• Treatment resistance: In patients with apparently corticosteroid-resistant cough variant asthma, alternative diagnoses should be considered 1

Special Considerations

• For patients with non-eosinophilic asthma, response to corticosteroids may be limited
• Assessment of airway inflammation (when available) can help identify patients who may benefit from more aggressive anti-inflammatory therapy 1
• Combination therapy with salmeterol/fluticasone provides greater improvements in cough symptoms, pulmonary function, and airway inflammation compared to salmeterol alone 2

The evidence strongly supports that proper treatment with ICS not only relieves cough but also reduces the risk of progression to classic asthma, making early and appropriate intervention crucial for optimal outcomes.