What is the best medication for a patient with anxiety who also has a dry cough?

Managing Anxiety in a Patient with Dry Cough

For a patient with anxiety who also has a dry cough, lorazepam is recommended as the first-line medication due to its dual benefits of treating anxiety while not exacerbating cough symptoms. 1

Medication Selection Algorithm

1. First-line option: Benzodiazepines

   • Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg in 24 hours)
   • For elderly or debilitated patients: 0.25-0.5 mg (maximum 2 mg in 24 hours)
   • Oral tablets can be used sublingually for faster onset 1

2. Second-line option: Buspirone

   • If dry cough is severe or persistent, buspirone may be preferred as it lacks respiratory side effects
   • Starting dose: 7.5 mg twice daily
   • Titrate up to 15-30 mg/day in divided doses 2
   • Note: Delayed onset of action (1-2 weeks) compared to benzodiazepines 3

3. Avoid medications that may worsen cough:

   • Opioid-based anxiolytics like codeine should be used cautiously as they may cause respiratory depression
   • SSRIs may cause dry mouth which can exacerbate cough symptoms

Managing the Dry Cough Component

If the cough is particularly troublesome and requires specific treatment:

1. Non-pharmacological approaches:

   • Simple non-drug measures such as honey (teaspoon as needed) 1
   • Adequate hydration and humidification

2. Over-the-counter options:

   • Dextromethorphan 10-15 mg three to four times daily 4
   • Glycerol-based cough syrups 1

3. For refractory cough:

   • Consider gabapentin if cough persists despite other treatments 1
   • Multimodality speech pathology therapy for chronic cough 1

Special Considerations

Anxiety-Cough Relationship

Recent evidence shows that anxiety and cough have a bidirectional relationship. Patients with anxiety report more severe cough symptoms 5, and 43% of patients with chronic refractory cough screen positive for anxiety 6. Addressing anxiety may improve cough perception and severity.

Monitoring and Follow-up

• Assess response to benzodiazepines within 24-48 hours
• If using buspirone, explain the delayed onset of action to ensure compliance 3
• Monitor for sedation with benzodiazepines, especially when initiating therapy
• For long-term anxiety management, periodically reassess the need for continued medication 2, 7

Cautions

• Benzodiazepines should be used for short-term management due to risk of dependence
• Buspirone has been safely used for up to one year without withdrawal symptoms upon discontinuation 7
• Avoid codeine-containing preparations when possible due to side effect profile and limited efficacy compared to alternatives 1, 4

By addressing both the anxiety and cough symptoms simultaneously, this approach optimizes treatment outcomes while minimizing adverse effects and potential drug interactions.