Is Tessalon Perles (benzonatate) effective for relieving coughs?

Efficacy of Tessalon Perles (Benzonatate) for Cough Relief

Benzonatate (Tessalon Perles) has limited evidence supporting its efficacy for cough relief, with only small case series showing benefit primarily in cancer-related cough, and should be considered a second-line option after other more proven therapies.

Mechanism of Action

Benzonatate acts peripherally by anesthetizing the stretch receptors in the respiratory passages, lungs, and pleura, thereby reducing the cough reflex at its source 1. It begins working within 15-20 minutes, with effects lasting 3-8 hours, and does not inhibit the respiratory center at recommended doses.

Evidence for Efficacy

In Cancer-Related Cough

• Limited evidence from small case series suggests benzonatate may be effective for cough in patients with malignant pulmonary involvement 2
• In one small case series, benzonatate effectively controlled cough in 80% of 21 patients with malignant pulmonary involvement 2
• Another small case series of three patients showed effectiveness for opioid-resistant cough associated with lung cancer 3

In Acute Cough

• A study evaluating benzonatate 200mg alone and in combination with guaifenesin 600mg in acute viral cough found that benzonatate alone did not significantly inhibit cough-reflex sensitivity compared to placebo 4
• However, the combination of benzonatate and guaifenesin suppressed capsaicin-induced cough more effectively than either agent alone 4

Comparison to Other Antitussives

The ACCP evidence-based guidelines indicate several other agents have better evidence for cough suppression:

• Dextromethorphan: Demonstrated efficacy in suppressing acute cough in a meta-analysis 2
• Menthol: Effectively suppresses the cough reflex by inhalation, though effects are acute and short-lived 2
• Sedative antihistamines: Effective for cough suppression but cause drowsiness 2
• Codeine/pholcodine: Not recommended due to significant adverse side effect profiles despite similar efficacy to dextromethorphan 2

Safety Considerations

Benzonatate requires caution in prescribing due to:

• Risk of serious adverse events with overdose, including cardiac arrest 5
• Structural similarity to local anesthetics (tetracaine and procaine) 5
• Limited treatment options in overdose settings 5

Clinical Application Algorithm

1. First-line options (better evidence base):

   • Dextromethorphan (non-sedating, demonstrated efficacy in meta-analyses)
   • Menthol-based products (for short-term relief with minimal systemic effects)

2. Consider benzonatate when:

   • First-line agents have failed
   • Patient has cancer-related cough resistant to opioids
   • Patient cannot tolerate other antitussives

3. Avoid benzonatate in:

   • Patients at risk for overdose or misuse
   • Children (higher risk of serious adverse events)
   • Patients unable to swallow capsules whole (capsules should not be crushed)

Conclusion

While benzonatate is FDA-approved for symptomatic relief of cough 1, the evidence supporting its efficacy is limited primarily to small case series in cancer patients. Other agents like dextromethorphan and menthol have more robust evidence supporting their use for cough suppression. Benzonatate should be considered a second-line option, particularly for cancer-related cough that is resistant to other treatments.