What are the current pharmacological treatment options for acute and chronic cough?

Pharmacological Treatment Options for Acute and Chronic Cough

For acute and chronic cough management, central cough suppressants such as codeine and dextromethorphan are recommended for short-term symptomatic relief of chronic bronchitis, while peripheral cough suppressants like levodropropizine and moguisteine are recommended for short-term relief of both acute and chronic bronchitis. 1

Acute Cough Treatment

Upper Respiratory Tract Infections (URIs)

• First-line approach: Supportive care as most cases are self-limiting
• Not recommended for URIs:
  • Central cough suppressants (codeine, dextromethorphan) 1
  • Peripheral cough suppressants 1
  • Zinc preparations 1
  • Over-the-counter combination cold medications 1
  • Albuterol (for non-asthmatic cough) 1

Acute Bronchitis

• Recommended:

  • Hypertonic saline solution and erdosteine (short-term) 1
  • Peripheral cough suppressants (levodropropizine, moguisteine) 1
  • Guaifenesin (200-400 mg every 4 hours, max 2400 mg daily) for productive cough 2

• For acute exacerbation of chronic bronchitis:

  • Short-acting β-agonists or anticholinergic bronchodilators 1
  • Short course (10-15 days) of systemic corticosteroids 1

Chronic Cough Treatment

Chronic Bronchitis

• Recommended:

  • Central cough suppressants (codeine, dextromethorphan) 1
  • Peripheral cough suppressants (levodropropizine, moguisteine) 1
  • Long-acting β-agonist with inhaled corticosteroids (ICS) 1
  • ICS therapy for FEV1 <50% predicted or frequent exacerbations 1
  • Ipratropium bromide 1
  • Benzonatate (acts peripherally by anesthetizing stretch receptors) 3

• Not recommended:

  • Theophylline 1
  • Expectorants (no evidence of effectiveness) 1
  • Long-term oral corticosteroids 1

Non-asthmatic Eosinophilic Bronchitis (NAEB)

• First-line: Inhaled corticosteroids 1, 2
• For occupation-related causes: Allergen/sensitizer avoidance 1

Reflux-Associated Cough

• Recommended: Proton pump inhibitors with alginates for minimum 3 months 2

ACE Inhibitor-Induced Cough

• Recommended: Discontinuation of ACE inhibitor regardless of temporal relationship 2

Special Populations

Cystic Fibrosis

• Recommended:

  • Amiloride to increase cough clearance 1
  • Chest physiotherapy 1

• Not recommended: Recombinant DNase for cough clearance (though it improves spirometry) 1

Neuromuscular Impairment

• Not recommended: Protussive pharmacologic agents 1
• Consider:
  • Manually assisted cough for expiratory muscle weakness 1
  • Expiratory muscle training 1

Treatment Algorithm

1. Identify cough duration:

   • Acute (<3 weeks)
   • Subacute (3-8 weeks)
   • Chronic (>8 weeks)

2. For acute cough:

   • If URI: Supportive care only
   • If bronchitis: Consider peripheral cough suppressants, hypertonic saline, erdosteine

3. For chronic cough:

   • Rule out common causes (asthma, GERD, NAEB, ACE inhibitors)
   • For chronic bronchitis: Central cough suppressants, peripheral cough suppressants, or benzonatate
   • For NAEB: Inhaled corticosteroids
   • For refractory cases: Consider slow-release morphine, amitriptyline, paroxetine, gabapentin 4

Important Caveats

• Central cough suppressants may cause drowsiness and constipation, especially at higher doses 4
• Dextromethorphan at 30mg has shown limited efficacy in clinical trials for URI cough 5
• Chronic cough may represent a disease entity itself (chronic idiopathic cough) when causes cannot be identified, characterized by hypersensitivity of the cough reflex 6
• Quantify cough severity at baseline and follow-up using visual analog scales to assess treatment response 2
• Patients should seek immediate medical care for hemoptysis, significant breathlessness, prolonged fever, or worsening of pre-existing conditions 2