What are the medication options for suppressing chronic cough in patients with Chronic Obstructive Pulmonary Disease (COPD)?

Medication Options for Suppressing Chronic Cough in COPD

For patients with chronic cough due to COPD, central cough suppressants such as codeine or dextromethorphan are recommended for short-term symptomatic relief, while bronchodilator therapy with ipratropium bromide should be used as a first-line treatment for long-term management. 1

First-Line Pharmacological Options

Bronchodilators

• Anticholinergic agents (first choice):

  • Ipratropium bromide significantly reduces cough frequency and severity in patients with chronic bronchitis 2
  • Tiotropium bromide (once-daily long-acting anticholinergic) improves lung function for 24 hours and reduces COPD exacerbations 3
  • Onset of action is slower than β2-agonists (30-90 minutes) but may be more effective for COPD-related cough 2

• β2-agonists:

  • Short-acting β2-agonists (e.g., albuterol) may help control bronchospasm and relieve dyspnea, with some evidence for reducing chronic cough 2
  • Can be used in combination with anticholinergics for additive effect at submaximal doses 2

Central Cough Suppressants (for short-term use)

• Codeine and dextromethorphan:
  • Recommended for short-term symptomatic relief of coughing in chronic bronchitis 2, 1
  • Caution: A carefully conducted study showed no significant effect of codeine over placebo in COPD cough 4
  • Should be used only for short-term relief to avoid masking underlying conditions 1

Second-Line Options

Theophylline

• May be considered to control chronic cough in stable patients with chronic bronchitis 2
• Requires careful monitoring for complications and drug interactions 2
• Not recommended during acute exacerbations of COPD 2

Opiates for Refractory Cough

• Low-dose slow-release morphine (5-10 mg twice daily) may be effective for intractable chronic cough 5
• Should be reserved for when alternative treatments have failed and cough significantly impacts quality of life 2
• Requires reassessment of benefits and risks at 1 week and monthly thereafter 2

Neuromodulators for Refractory Cough

• Gabapentin may be considered for patients with refractory chronic cough 2, 1
• Multimodality speech pathology therapy can be beneficial for persistent cough 2

Management During Acute Exacerbations

1. Bronchodilators:

   • Short-acting β2-agonists or anticholinergic agents should be administered 2
   • If no prompt response, add the other agent at maximal dose 2

2. Antibiotics:

   • Recommended when purulent sputum is present 1
   • Most effective in patients with severe exacerbations and more severe airflow obstruction 2

3. Corticosteroids:

   • Short course of systemic corticosteroids (10-15 days) for acute exacerbations 1

Important Considerations and Caveats

• Avoid ineffective treatments:

  • Postural drainage and chest percussion have not proven clinical benefits in stable patients with chronic bronchitis or during acute exacerbations 2
  • Expectorants and mucokinetic agents lack evidence for effectiveness 1
  • Theophylline should not be used during acute exacerbations 2

• Monitor for side effects:

  • Opiates may cause constipation, drowsiness, and respiratory depression 5
  • Anticholinergics may worsen glaucoma or urinary retention 3

• Combination therapy:

  • Long-acting β-agonist with inhaled corticosteroid may reduce exacerbation rates and cough in patients with stable COPD, particularly those with FEV₁ <50% predicted 1

• Non-pharmacological interventions:

  • Smoking cessation is highest priority for patients who still smoke 1
  • Staying hydrated and avoiding irritants can help manage symptoms 1

For patients with truly refractory cough despite optimal COPD management, consider trials of therapies recommended for unexplained chronic cough, such as gabapentin or speech therapy interventions, or referral to specialized cough clinics.