What is the recommended treatment approach for a non-productive cough using Tessalon Perles (benzonatate)?

Benzonatate (Tessalon Perles) for Non-Productive Cough

Benzonatate (Tessalon Perles) is recommended as a third-line agent for non-productive cough at a dose of 100-200 mg three times daily, with a maximum daily dose of 600 mg, when first-line demulcents and second-line opioid derivatives have failed to provide relief. 1, 2

Treatment Algorithm for Non-Productive Cough

First-Line Therapy

• Begin with demulcents such as simple linctus (syrup) or glycerol-based linctus where available 1
• These provide soothing effects on the pharyngeal mucosa without significant side effects
• Evaluate response after 2-4 days

Second-Line Therapy (if demulcents fail)

• Opioid derivatives titrated to acceptable side effect profile:
  • Dextromethorphan 10-15 mg three to four times daily (maximum 120 mg/day) 1, 3
  • Codeine 30-60 mg four times daily 1
  • Hydrocodone 5 mg twice daily 1

Third-Line Therapy (if opioids fail or are contraindicated)

• Peripherally-acting antitussives:
  • Benzonatate (Tessalon Perles) 100-200 mg three times daily (maximum 600 mg/day) 1, 2
  • Levodropropizine 75 mg three times daily (where available) 1
  • Sodium cromoglycate 10 mg four times daily (where available) 1

Fourth-Line Therapy (for refractory cases)

• Local anesthetics:
  • Nebulized lidocaine 5 mL of 0.2% solution three times daily 1, 4
  • Nebulized bupivacaine 5 mL of 0.25% solution three times daily 1

Mechanism of Action and Efficacy of Benzonatate

Benzonatate is a non-narcotic antitussive that works peripherally by anesthetizing stretch receptors in the lungs, pleura, and respiratory passages, thereby reducing the cough reflex at its source 5. Unlike centrally-acting opioid antitussives, benzonatate does not cause respiratory depression or sedation when used at recommended doses.

Evidence shows that benzonatate can be effective in controlling cough in patients with lung cancer when opioids have failed 1, 6. Case studies have demonstrated its efficacy in opioid-resistant cough in advanced cancer patients 6.

Important Considerations for Benzonatate Use

Administration

• Capsules must be swallowed whole
• Never break, chew, dissolve, cut, or crush the capsules 2
• Doing so can release the medication too quickly, causing numbness of the mouth and throat that may lead to choking

Contraindications and Precautions

• Assess aspiration risk before prescribing, as local anesthetics can increase aspiration risk in frail patients 1
• Use with caution in elderly patients
• Not recommended for children under 10 years of age 2

Monitoring

• Evaluate response after 3-5 days of therapy
• Discontinue if no improvement is observed
• Limit treatment duration to minimize risk of adverse effects

Safety Concerns

• Rare but serious adverse events include cardiac arrest with overdose 7
• Patient education regarding proper dosing is essential
• Store medication securely away from children

Alternative Approaches for Persistent Cough

If the cough persists despite appropriate pharmacological management, consider:

1. Re-evaluating for underlying causes such as:

   • Post-nasal drip syndrome
   • Gastroesophageal reflux
   • Cough variant asthma 8

2. Addressing environmental triggers:

   • Minimize exposure to irritants (smoke, dust, strong odors)
   • Maintain adequate hydration
   • Use humidification if appropriate

Conclusion

Benzonatate (Tessalon Perles) offers an effective option for non-productive cough, particularly when first-line demulcents and second-line opioid derivatives have failed. Its peripheral mechanism of action makes it particularly useful for patients who cannot tolerate or have not responded to opioid-based antitussives. However, proper administration and patient education are essential to ensure safety and efficacy.