How to manage and prevent daily dry cough in a known asthmatic (Asthma) 20-year-old?

Management of Daily Dry Cough in a 20-Year-Old Asthmatic

Inhaled corticosteroids (ICS) should be considered as first-line treatment for managing chronic dry cough in this known asthmatic patient, with step-up therapy including increased ICS dose and addition of leukotriene inhibitors if response is incomplete. 1

Initial Assessment and Management

Step 1: Confirm Asthma as Cause of Chronic Cough

• Assess if cough is the only symptom (cough variant asthma) or part of broader asthma symptoms
• Consider non-invasive measurement of airway inflammation (blood eosinophil counts, fractional exhaled nitric oxide) to predict corticosteroid response 1
• Rule out other causes of chronic cough:
  • Upper airway cough syndrome (UACS)
  • Non-asthmatic eosinophilic bronchitis (NAEB)
  • Gastroesophageal reflux disease (GERD)

Step 2: First-Line Treatment

• Start with daily low-dose inhaled corticosteroids plus as-needed short-acting beta-agonist (SABA) 2
• Alternative option: low-dose ICS-formoterol as needed 2
• For cough variant asthma specifically, inhaled corticosteroids are strongly recommended as first-line treatment 1

Step-Up Therapy if Initial Response is Incomplete

Step 3: Increase ICS Dose

• If response to initial ICS therapy is incomplete after 4-8 weeks, increase the inhaled corticosteroid dose 1
• Complete resolution of cough may require up to 8 weeks of treatment 1

Step 4: Add Leukotriene Inhibitor

• Consider adding montelukast (leukotriene receptor antagonist) if cough persists despite increased ICS dose 1, 3
• Montelukast blocks substances called leukotrienes, which improves asthma symptoms including cough 3

Step 5: Consider Combination Therapy

• Add long-acting beta-agonists (LABAs) in combination with ICS if symptoms persist 1, 4
• For moderate persistent asthma, low-dose ICS-formoterol therapy is recommended 2, 5

Prevention Strategies

1. Identify and Avoid Triggers:

   • Common inhaled allergens or occupational sensitizers 1
   • Viral infections, exercise, emotional disturbances 1
   • Environmental irritants (cigarette smoke, pollution) 1, 2

2. Medication Adherence:

   • Ensure proper inhaler technique is demonstrated and understood 2
   • Take ICS regularly as prescribed, even when asymptomatic 3
   • Monitor SABA use - using more than twice weekly indicates inadequate control 2

3. Self-Management Plan:

   • Provide written action plan for managing worsening symptoms 2
   • Consider peak flow monitoring in patients 5 years and older 1
   • Document when to seek medical help for worsening symptoms 1, 2

Common Pitfalls to Avoid

• Undertreatment: Inadequate step-up in therapy when control is poor can lead to worsening outcomes 2
• Overreliance on SABAs: Frequent use indicates poor control and need for controller medication 2
• Delayed response expectations: Complete resolution of cough may require up to 8 weeks of treatment 1
• Ignoring comorbidities: Untreated UACS, GERD, or NAEB can contribute to persistent cough 1
• Misdiagnosis: Ensure proper diagnosis of asthma versus cough variant asthma or NAEB, as treatment approaches may differ 1, 6

Special Considerations

• If cough persists despite optimal therapy, consider bronchial challenge testing to confirm airway hyperresponsiveness 1
• In cases of severe, persistent cough despite optimal therapy, a short course of oral corticosteroids (prednisone 40mg/day for 5-10 days) may be considered 1
• For patients with cough variant asthma, monitor for development of classic asthma symptoms, as approximately 30% may progress to typical asthma 6

By following this structured approach to managing chronic dry cough in this young asthmatic patient, you should be able to achieve symptom control and prevent future exacerbations.