What can be prescribed for chronic cough if Tessalon (Benzonatate) pearls have not been sufficient?

From the Guidelines

For chronic cough not responding to Tessalon pearls (benzonatate), consider prescribing gabapentin, starting with a dose escalation schedule beginning at 300 mg once a day, with additional doses being added each day as tolerated, up to a maximum tolerable daily dose of 1,800 mg a day in two divided doses, as suggested by the American College of Chest Physicians (CHEST) Cough Expert Panel 1. The choice of medication should address the specific underlying mechanism of the cough, whether it's airway inflammation, hypersensitivity, acid reflux, or postnasal drip.

• If postnasal drip is suspected, add intranasal corticosteroids like fluticasone nasal spray (1-2 sprays per nostril daily).
• For cough due to gastroesophageal reflux, try proton pump inhibitors such as omeprazole (20mg daily before breakfast) 1.
• If asthma is the cause, consider montelukast (10mg daily) or a short course of oral prednisone (20mg daily for 5 days) for severe symptoms. Some key points to consider when treating chronic cough include:
• The importance of identifying and addressing the underlying cause of the cough.
• The potential benefits and risks of different treatment options, such as gabapentin, inhaled corticosteroids, and proton pump inhibitors.
• The need for ongoing evaluation and follow-up to assess the response to treatment and adjust the treatment plan as needed. It's also important to note that the treatment of chronic cough should be individualized and based on the specific needs and circumstances of each patient, as suggested by the American College of Chest Physicians (CHEST) Cough Expert Panel 1.

From the FDA Drug Label

Ask a doctor before use if you have • chronic cough that lasts as occurs with smoking, asthma or emphysema Ask a doctor before use if you have cough that lasts or is chronic such as occurs with smoking, asthma, chronic bronchitis, or emphysema

If Tessalon (Benzonatate) pearls have not been sufficient for chronic cough, other options that can be considered are:

• Dextromethorphan (PO) 2
• Guaifenesin (PO) 3 It is recommended to ask a doctor before use of these medications, especially if the patient has a chronic cough.

From the Research

Alternative Treatments for Chronic Cough

If Tessalon (Benzonatate) pearls have not been sufficient in treating chronic cough, other treatment options can be considered.

• Gabapentin, pregabalin, and/or speech therapy may be prescribed for patients with refractory chronic cough 4.
• Centrally acting opioids such as morphine, codeine, pholcodeine, and dextromethorphan can be used as cough suppressants, but their efficacy may be limited and associated with side effects 5.
• Other centrally acting drugs such as amitriptyline, paroxetine, and carbamezepine have been reported to be successful in treating chronic cough in some cases 5.

Disease-Specific Treatments

Treatment of the underlying cause of chronic cough is essential.

• Upper airway cough syndrome, asthma, and gastroesophageal reflux disease are common causes of chronic cough in adults, and treatment should be targeted at these conditions 4, 6.
• In children, the most common causes of chronic cough are respiratory tract infections, asthma, and gastroesophageal reflux disease, and evaluation and treatment should focus on these etiologies 4, 6.

Further Evaluation and Testing

If the cause of chronic cough is not identified, further testing and referral to a specialist may be necessary.

• Chest radiography can rule out concerning infectious, inflammatory, and malignant thoracic conditions 4, 6.
• High-resolution computed tomography and referral to a pulmonologist may be indicated if the cause of chronic cough is not identified 6.