What is the first line treatment for cough?

First-Line Treatment for Cough

For acute cough, the first-line treatment is home remedies such as honey and lemon, followed by over-the-counter cough remedies containing dextromethorphan if needed. 1

Treatment Algorithm Based on Cough Duration

Acute Cough (< 3 weeks)

1. First-line: Home remedies

   • Honey and lemon mixture
   • Adequate hydration
   • Rest

2. Second-line: OTC medications

   • Dextromethorphan-containing products for suppressing cough 1, 2
   • First-generation antihistamine plus decongestant for coughs associated with common cold 1
   • Menthol lozenges or vapor for temporary relief 1
   • Paracetamol for associated fever or pain 1

3. For productive cough:

   • Guaifenesin to help loosen phlegm and thin bronchial secretions 3

Subacute Cough (3-8 weeks)

1. Determine if postinfectious
   • If postinfectious, manage symptomatically as with acute cough
   • If not postinfectious, evaluate and manage as chronic cough 1

Chronic Cough (> 8 weeks)

1. Identify and treat underlying cause:

   • Upper airway cough syndrome: Antihistamine-decongestant combination 1
   • Asthma: Inhaled corticosteroids, bronchodilators, leukotriene receptor antagonists 1
   • Non-asthmatic eosinophilic bronchitis: Inhaled corticosteroids 1
   • GERD: Proton pump inhibitors, diet/lifestyle modifications 1
   • Chronic bronchitis: Ipratropium bromide (first-line) 4

2. For refractory chronic cough:

   • Peripheral cough suppressants (levodropropizine, moguisteine) 4, 5
   • Neuromodulators (gabapentin, pregabalin) for cough hypersensitivity syndrome 4, 6
   • Non-pharmacological cough control therapy 7, 8

Important Considerations

Red Flags Requiring Medical Evaluation

• Coughing up blood
• Breathlessness
• Prolonged fever and feeling unwell
• Underlying medical conditions (COPD, heart disease, diabetes, asthma)
• Recent hospitalization
• Symptoms persisting beyond three weeks 1

Common Pitfalls to Avoid

1. Inappropriate antibiotic use: Most acute coughs are viral and antibiotics won't help, even if producing phlegm 1

2. ACE inhibitor-induced cough: Always consider medication-induced cough in patients taking ACE inhibitors. Cough typically resolves within days to 2 weeks after discontinuation (median 26 days) 1

3. Overlooking smoking: Smoking cessation is crucial for patients with chronic cough, with resolution typically occurring within 4 weeks 1

4. Overuse of codeine: Not recommended due to significant adverse effects and no greater efficacy than dextromethorphan 4

5. Albuterol misuse: Not recommended for non-asthmatic cough 4

Special Populations

Elderly Patients

• Should seek medical evaluation if cough persists beyond 1-2 weeks 4
• Higher risk of medication side effects, particularly with codeine-containing products

Patients with Multiple Causes

• Maintain all partially effective treatments when multiple causes are present 1
• Check compliance with prescribed therapies 1

By following this structured approach to cough management based on duration and underlying cause, most patients can achieve significant symptom relief and improved quality of life.