What are the recommended prescription treatments for cough management in a general practice setting?

Prescription Treatments for Cough Management in General Practice

The most effective prescription treatments for cough management in general practice should be selected based on the type of cough (dry vs. productive) and its underlying cause, with antitussives reserved for dry, bothersome cough and expectorants for productive cough with thick mucus. 1

Initial Assessment and Classification

Before prescribing any medication, classify the cough:

• Acute cough: lasting less than 3 weeks (typically viral) 2
• Chronic cough: lasting more than 8 weeks 2
• Post-viral cough: lingering for 3-8 weeks after URTI 2

First-Line Prescription Options

For Dry, Non-Productive Cough:

1. Dextromethorphan

   • Preferred first-line antitussive due to better safety profile 1, 3
   • Dosage: 30 mg every 6-8 hours, not exceeding 120 mg in 24 hours 1
   • Available in extended-release formulations for 12-hour relief 3

2. Codeine-containing preparations

   • Second-line option due to higher side effect profile 1, 4
   • Typically combined with guaifenesin (e.g., 10 mg codeine with 100 mg guaifenesin per 5 mL) 4
   • More effective for severe cough but has addiction potential

For Productive Cough:

1. Guaifenesin
   • First-line expectorant for productive cough 1
   • Dosage: 200-400 mg every 4 hours, not exceeding 2400 mg daily 1
   • Helps loosen phlegm and thin bronchial secretions

Treatment Algorithm Based on Underlying Cause

1. Upper Airway Cough Syndrome (Post-nasal drip)

• First-line: Topical nasal corticosteroids 2
• Add-on: First-generation antihistamines for nighttime cough 1

2. Asthma/Cough Variant Asthma

• First-line: Inhaled corticosteroids 2
• Assessment: Consider bronchial provocation testing if asthma is suspected 2
• Trial: Two-week oral steroid trial may be diagnostic and therapeutic 2

3. Gastroesophageal Reflux Disease (GERD)

• First-line: Proton pump inhibitors with alginates for minimum 3 months 2
• Note: Reflux-associated cough may occur without typical GERD symptoms 2

4. ACE Inhibitor-Induced Cough

• First-line: Discontinue ACE inhibitor regardless of temporal relationship 2
• Alternative: Switch to angiotensin receptor blocker if ACE inhibitor must be continued 2
• Resolution: Cough typically resolves within 1-4 weeks but may take up to 3 months 2

Special Considerations

For Elderly Patients:

• Lower starting doses of medications
• Monitor closely for side effects
• Seek medical evaluation if cough persists beyond 1-2 weeks 1

For Breastfeeding Mothers:

• Dextromethorphan is preferred due to safety profile 1
• Use lowest effective dose for shortest duration 1
• Take medication immediately after breastfeeding to minimize infant exposure 1

Red Flags Requiring Urgent Medical Attention

Advise patients to seek immediate medical care if they experience:

• Hemoptysis (coughing up blood)
• Significant breathlessness
• Prolonged fever
• Pre-existing conditions (COPD, heart disease, diabetes, asthma) with worsening cough 2, 1

Non-Recommended Treatments

• Avoid combination cold medications for specific cough management 1
• Avoid antibiotics for viral cough 1
• Avoid cough suppression when patient expectorates significant amounts of sputum 1
• Avoid mucolytics and bronchodilators for acute lower respiratory tract infections 1

When to Refer to Specialist

Consider referral to a specialist cough clinic when:

• Cough persists despite appropriate treatment trials
• Diagnostic uncertainty remains after initial investigations
• Chest X-ray shows abnormalities
• Patient has concerning symptoms (hemoptysis, weight loss) 2, 1

Monitoring and Follow-up

• Quantify cough severity at baseline and follow-up using visual analog scales 2
• Assess treatment response after appropriate duration (2 weeks for steroid trial, 3 months for GERD) 2
• Consider alternative diagnosis if no response to targeted therapy

By following this evidence-based approach to cough management in general practice, clinicians can provide effective symptomatic relief while addressing underlying causes to improve patient outcomes and quality of life.