What medications are used for chronic cough suppression?

Medications for Chronic Cough Suppression

For chronic cough suppression, ipratropium bromide is the first-line recommended medication for patients with chronic bronchitis, while central cough suppressants like codeine and dextromethorphan are recommended for short-term symptomatic relief. 1, 2

First-Line Medications

For Chronic Bronchitis

• Ipratropium bromide (inhaled): The only anticholinergic agent recommended for cough suppression in chronic bronchitis with substantial benefit (Grade A recommendation) 1, 2

For Symptomatic Relief

• Peripheral cough suppressants: Levodropropizine and moguisteine for short-term relief in chronic bronchitis (Grade A recommendation) 1
• Central cough suppressants:
  • Dextromethorphan: Effective for dry cough with fewer side effects than codeine 2, 3
  • Codeine: Effective but with intermediate benefit (Grade B recommendation) 1, 4

For Cough Clearance

• Hypertonic saline solution: Recommended on a short-term basis (Grade A recommendation) 1
• Erdosteine: Recommended on a short-term basis (Grade A recommendation) 1

Second-Line/Alternative Options

• Menthol-based preparations: Provide acute but short-lived cough suppression 2
• Sedating antihistamines: Consider for nocturnal cough when sleep is disrupted 2
• Neuromodulators: For refractory chronic cough:
  • Amitriptyline
  • Pregabalin
  • Gabapentin
  • Morphine 5, 6

Medications for Specific Situations

For Elderly Patients

• Prefer dextromethorphan over codeine due to better safety profile 2, 3
• Use caution with central cough suppressants due to side effect risk 2

For Refractory Chronic Cough

• Consider gabapentin or pregabalin 6
• Speech therapy in combination with pharmacologic treatment 5, 6

Not Recommended

• Agents that alter mucus characteristics: Not recommended for cough suppression in chronic bronchitis (Grade D recommendation) 1
• Zinc preparations: Not recommended (Grade D recommendation) 1
• OTC combination cold medications: Not recommended except for older antihistamine-decongestant combinations (Grade D recommendation) 1
• Albuterol: Not recommended for non-asthmatic cough (Grade D recommendation) 1
• Drugs affecting the efferent limb of cough reflex: Not recommended (Grade D recommendation) 1

Important Considerations and Warnings

• Duration limitations: Limit cough suppressant use to short-term relief (<1 week) 2
• Dextromethorphan warnings: Do not use with MAOIs; contains sodium metabisulfite which may cause allergic reactions 7
• Medical evaluation needed: If cough persists beyond 1-2 weeks, especially with concerning symptoms like hemoptysis, fever, or breathlessness 2
• Codeine considerations: More side effects than dextromethorphan despite similar efficacy in reducing cough frequency 3

Algorithm for Medication Selection

1. Identify underlying cause of chronic cough
2. For chronic bronchitis: Start with ipratropium bromide
3. For short-term symptomatic relief:
   • First choice: Dextromethorphan (20mg) for patients without contraindications
   • Alternative: Codeine (10-20mg) if dextromethorphan is contraindicated
4. If inadequate response: Consider peripheral cough suppressants (levodropropizine, moguisteine)
5. For refractory cases: Consider neuromodulators (gabapentin, pregabalin) with speech therapy

Remember that chronic cough medications should be used for short-term relief while addressing the underlying cause, and medical evaluation is necessary if cough persists despite treatment.