What is the recommended cough suppressant for a patient with Coronavirus disease (COVID-19)?

Recommended Cough Suppressant for COVID-19 Patients

For patients with COVID-19 and distressing cough, honey should be used as first-line treatment, followed by codeine linctus or codeine phosphate tablets if necessary, and morphine sulfate oral solution as a second-choice option only if cough remains distressing. 1

First-Line Treatment

Honey

• Start with simple non-drug measures such as honey
• Dosage: One teaspoon of honey as needed
• Benefits: Natural cough suppressant with minimal side effects
• Evidence: Recommended by NICE guidelines as first-choice treatment 1

Second-Line Treatment (if honey is insufficient)

Codeine-Based Options

• Use only if cough is distressing and honey is ineffective
• Options:
  • Codeine linctus (15 mg/5 mL)
  • Codeine phosphate tablets (15 mg, 30 mg)
• Initial dosage: 15-30 mg every 4 hours as required
• Maximum: Up to four doses in 24 hours
• Can increase to 30-60 mg four times daily if necessary (maximum 240 mg in 24 hours) 1

Third-Line Treatment

Morphine Sulfate Oral Solution

• Use only if cough remains distressing despite codeine
• Dosage: 2.5-5 mg every 4 hours as required
• Can increase to 5-10 mg every 4 hours if needed
• For patients already taking regular morphine, increase the regular dose by one-third 1

Important Considerations

Contraindications

• Avoid cough suppressants in patients with chronic bronchitis and bronchiectasis due to risk of sputum retention 1

Monitoring

• Monitor for respiratory depression with opioid-based treatments
• Watch for constipation as a side effect of codeine and morphine
• Ensure adequate hydration to help manage cough symptoms

Special Populations

• For elderly or frail patients: Start with lower doses of codeine (15 mg) or morphine (2.5 mg)
• For patients with renal impairment: Use reduced doses and monitor closely

Additional Supportive Measures

• Maintain adequate hydration
• Rest and monitor vital signs (heart rate, oxygen saturation, respiratory rate, blood pressure) 2
• Position patient upright to reduce cough severity
• Avoid irritants that may exacerbate cough

Bacterial Co-infection Considerations

• Antibiotics should not be routinely administered unless there is clinical suspicion of bacterial infection 2
• If bacterial pneumonia is suspected, follow standard community-acquired pneumonia treatment guidelines 1

Common Pitfalls to Avoid

1. Skipping first-line therapy (honey) and moving directly to opioids
2. Using cough suppressants in patients with productive cough who need to clear secretions
3. Overuse of codeine or morphine leading to respiratory depression
4. Failing to recognize when cough may be a sign of worsening COVID-19 requiring escalation of care

The NICE guidelines provide a clear, stepwise approach to managing cough in COVID-19 patients, prioritizing simple measures first before moving to medications with more potential side effects. This approach balances symptom relief with patient safety while recognizing that distressing cough significantly impacts quality of life in COVID-19 patients.