What type of inhaler can be prescribed for a former smoker with a chronic cough?

Treatment of Chronic Cough in a Former Smoker

For a former smoker with chronic cough lasting one year, an inhaled corticosteroid (ICS) such as fluticasone is the most appropriate first-line inhaler treatment, with the addition of a long-acting bronchodilator (LABA) such as salmeterol if response is inadequate. 1

Understanding the Likely Diagnosis

Chronic cough in a former smoker is most commonly due to:

• Chronic bronchitis (cough with sputum production for ≥3 months in 2 consecutive years)
• Cough-variant asthma
• Non-asthmatic eosinophilic bronchitis
• Reactive airway disease related to prior smoking

Treatment Algorithm

First-Line Treatment

• Start with an inhaled corticosteroid (ICS) such as fluticasone at a dose of 88-220 mcg twice daily for 2-4 weeks 1
• ICS is the cornerstone of treatment for airway inflammation in both asthma and chronic bronchitis 1
• Monitor for response after 2-4 weeks

If Partial Response to ICS

• Add a long-acting bronchodilator (LABA) such as salmeterol to the ICS regimen 1
• Combined ICS/LABA (such as fluticasone/salmeterol) has been shown to improve lung function and quality of life in patients with COPD and chronic bronchitis 2, 3

If Inadequate Response to ICS/LABA

• Consider adding a long-acting muscarinic antagonist (LAMA) such as tiotropium 4
• Triple therapy (ICS/LABA/LAMA) may provide additional benefits for patients with persistent symptoms 2

Evidence for Effectiveness

• The American College of Chest Physicians recommends ICS as first-line treatment for chronic cough in patients with suspected airway inflammation 1
• Studies show that the combination of ICS/LABA significantly improves lung function compared to placebo or single agents 2, 3
• For patients with chronic bronchitis, combined regimens of inhaled long-acting β-agonist and inhaled corticosteroid may improve cough 5

Important Considerations

• Smoking cessation is crucial - 90% of patients will have resolution of their cough after smoking cessation 5
• Avoidance of all respiratory irritants is the most effective means to improve or eliminate the cough of chronic bronchitis 5
• Short-acting bronchodilators (like albuterol) should not be used as primary therapy but can be used as rescue medication 1
• Central cough suppressants such as codeine and dextromethorphan can be considered for short-term symptomatic relief only 5

Monitoring and Follow-up

• If significant improvement (>70% reduction in cough severity) is observed with ICS, continue therapy for 2-3 months, then consider gradual dose reduction 1
• If only partial improvement is observed, increase ICS dose or add LABA 1
• Monitor for common side effects of ICS including oral candidiasis, hoarseness, and dysphonia 6
• For LABA therapy, monitor for potential cardiovascular and central nervous system effects 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics for routine treatment of chronic cough unless there is clear evidence of bacterial infection 1
• Do not rely solely on bronchodilators without addressing underlying inflammation 1
• Do not use theophylline during acute exacerbations of chronic bronchitis 1
• Do not neglect to emphasize smoking cessation as the most effective intervention 5

By following this evidence-based approach, you can effectively manage chronic cough in a former smoker while improving their quality of life and reducing the risk of complications.