What are common prescription medications for cough in India, including dosages and treatment options for beginners?

Common Prescription Medications for Cough in India: A Guide for Beginners

For effective management of cough in India, dextromethorphan is the preferred first-line antitussive medication due to its favorable safety profile and effectiveness, while codeine should be reserved as a last resort for unexplained chronic cough when other treatments have failed. 1, 2

Classification of Cough Medications in India

Antitussives (For Dry, Non-productive Cough)

1. Non-opioid Antitussives:

   • Dextromethorphan
     • Dosage: 30 mg every 6-8 hours, not exceeding 120 mg in 24 hours
     • Available as: Syrups, lozenges, tablets
     • Benefits: Effective cough suppression with fewer side effects than opioids
     • Common brands: Benadryl DR, Kofarest, Ascoril D 1, 3

2. Opioid Antitussives:

   • Codeine
     • Dosage: 10-20 mg every 4-6 hours, not exceeding 120 mg daily
     • Available as: Syrups, tablets, often in combinations
     • Note: Should be used only when other treatments fail due to higher side effect profile and potential for dependence
     • Common brands: Codeine-containing combinations like Corex, Phensedyl 1, 4

Expectorants (For Productive, Mucus-producing Cough)

• Guaifenesin

  • Dosage: 200-400 mg every 4 hours, not exceeding 2400 mg daily
  • Action: Helps loosen phlegm and thin bronchial secretions
  • Common brands: Ascoril, Grilinctus 1

• Ambroxol/Bromhexine

  • Dosage: Ambroxol 30 mg three times daily; Bromhexine 8 mg three times daily
  • Action: Mucolytic that breaks down mucus
  • Common brands: Ambrodil, Mucolite, Bronchosolvin 3

Bronchodilators

• Levosalbutamol/Salbutamol
  • Dosage: Levosalbutamol 1-2 mg three times daily; Salbutamol 2-4 mg three times daily
  • Action: Relieves bronchospasm, reduces cough sensitivity
  • Common brands: Asthalin, Levolin 5, 6

Combination Products (Widely Used in India)

• Antihistamine + Decongestant + Antitussive

  • Example: Chlorpheniramine + Phenylephrine + Dextromethorphan
  • Common brands: Cofsils, D'Cold 2, 3

• Bronchodilator + Mucolytic + Expectorant

  • Example: Levosalbutamol + Ambroxol + Guaifenesin
  • Common brands: Levolin-A, Ascoril LS 6

Treatment Algorithm Based on Cough Type

1. Acute Dry Cough (Less than 3 weeks)

• First-line: Dextromethorphan (30 mg every 6-8 hours) 1
• Alternative: Antihistamine-decongestant combinations for cough with rhinitis 2
• For nighttime cough: First-generation antihistamines like chlorpheniramine can be beneficial due to sedating effects 1, 3

2. Productive Cough

• First-line: Guaifenesin (200-400 mg every 4 hours) 1
• Alternative: Ambroxol/Bromhexine for thick, difficult-to-expectorate mucus 3
• Important: Maintain good hydration to help thin secretions 2

3. Cough with Bronchospasm

• First-line: Levosalbutamol-containing formulations 6
• Dosage: Levosalbutamol 1-2 mg three times daily 5

4. Postinfectious Cough (3-8 weeks after respiratory infection)

• First-line: Inhaled ipratropium bromide 7
• Second-line: Inhaled corticosteroids when cough persists despite ipratropium 7
• For severe paroxysms: Short course of oral prednisone (30-40 mg daily) 7

5. Chronic Cough (More than 8 weeks)

• Important: Requires evaluation for underlying causes before symptomatic treatment 7
• Last resort: Codeine-based preparations (10-20 mg every 4-6 hours) when other treatments have failed 2

Special Considerations

When to Refer to a Specialist

• Cough persisting beyond 3 weeks despite treatment
• Cough with blood (hemoptysis)
• Cough with significant breathlessness
• Cough in patients with pre-existing conditions like COPD, heart disease 1

Cautions and Contraindications

• Codeine:

  • Not recommended for children under 12 years
  • Use with caution in elderly patients
  • Risk of dependence with prolonged use 1, 4

• Antihistamines:

  • May cause drowsiness; avoid when driving or operating machinery
  • Use with caution in patients with glaucoma, prostatic hypertrophy 3

• Bronchodilators:

  • May cause tremors, palpitations
  • Use with caution in patients with cardiovascular disease, hypertension 5, 6

Non-Pharmacological Approaches

• Honey and lemon mixtures: Effective for symptomatic relief, especially for nighttime cough 1
• Menthol lozenges or vapor: Provides symptomatic relief 1
• Adequate hydration: Helps thin secretions and ease expectoration 2
• Avoid smoking and secondhand smoke exposure: Reduces cough symptoms 1

Common Pitfalls to Avoid

1. Inappropriate use of antibiotics: Antibiotics are ineffective for viral cough and contribute to antibiotic resistance 1

2. Prolonged use of codeine: Can lead to dependence and should be used only as a last resort 2

3. Treating symptoms without addressing underlying cause: Persistent cough may indicate serious conditions requiring specific treatment 8

4. Overlooking drug interactions: Be cautious when recommending cough medications to patients with pre-existing conditions or those on other medications 8

5. Ignoring red flags: Green or yellow sputum may suggest bacterial infection requiring medical evaluation 8

By following this structured approach to cough management, healthcare providers in India can effectively treat cough symptoms while minimizing risks and complications.