What is the recommended medication for a cough?

Recommended Medication for Cough

Dextromethorphan is the recommended first-line medication for dry, irritating cough in adults, with a recommended dosage of 30 mg every 6-8 hours (not exceeding 120 mg in 24 hours). 1

Types of Cough and Appropriate Treatments

For Dry, Non-Productive Cough:

• Dextromethorphan (first choice):
  • Dosage: 30 mg every 6-8 hours, maximum 120 mg/24 hours 1
  • Particularly effective for cough that prevents sleep
  • Lower abuse potential than opioid-based alternatives 1
  • Safety: Generally safe for patients with asthma and hypertension 1

For Productive Cough (with mucus):

• Guaifenesin (expectorant): Helps facilitate mucus elimination 1
• Avoid cough suppressants like dextromethorphan, codeine, or benzonatate as they may prevent necessary clearance of secretions 1

For Chronic Bronchitis:

• Ipratropium bromide: 2 inhalations (36 mcg) 3-4 times daily 1
• Alternative: Combination of long-acting β-agonist with inhaled corticosteroids 1
• Hypertonic saline solution: For short-term use to increase cough clearance 1

Important Contraindications and Precautions

• Do not use dextromethorphan if:

  • Taking monoamine oxidase inhibitors (MAOIs) or within 2 weeks of stopping MAOIs 2
  • Cough is productive with phlegm/mucus 2
  • Patient has chronic cough associated with smoking, asthma, or emphysema (consult doctor first) 2

• Stop use and consult doctor if:

  • Cough persists beyond 7 days
  • Cough returns or occurs with fever, rash, or persistent headache 2
  • Green or yellow sputum is present (suggests bacterial infection) 3

Special Population Considerations

Children:

• Under 4 years: FDA warns against OTC cough medications due to limited benefit and potential risks 1
• Over 1 year: Honey is more effective than placebo or diphenhydramine and comparable to dextromethorphan 1
• Pediatric dosing: Studies suggest 0.5 mg/kg of dextromethorphan may balance symptom relief with avoiding adverse events 4

Elderly:

• Seek medical evaluation if cough persists beyond 1-2 weeks or is accompanied by concerning symptoms (hemoptysis, breathlessness, prolonged fever) 1

Pregnant or Breastfeeding Women:

• Consult healthcare provider before use 2
• For breastfeeding: Use lowest effective dose for shortest duration and take immediately after breastfeeding 1

Evidence Quality and Clinical Pearls

• Multiple systematic reviews have found limited evidence supporting OTC cough medications 5, 6
• Codeine has not been shown to effectively treat cough caused by the common cold 7
• If cough persists beyond 3 weeks, further evaluation is recommended to rule out underlying conditions 1
• When recommending cough medications, consider pre-existing conditions like hypertension, stomach problems, or asthma 3
• Monitor for red flags requiring further investigation: hemoptysis, systemic illness, suspicion of inhaled foreign body, or suspicion of lung cancer 1

Algorithm for Cough Treatment

1. Determine cough type:

   • Dry/irritating → Dextromethorphan
   • Productive → Guaifenesin
   • Chronic bronchitis → Ipratropium bromide

2. Consider patient factors:

   • Age (avoid dextromethorphan in young children)
   • Comorbidities (asthma, hypertension, etc.)
   • Medication interactions (especially MAOIs)

3. Evaluate duration:

   • <3 weeks: Likely acute, treat symptomatically
   • 3-8 weeks: Subacute, consider further evaluation

   • 8 weeks: Chronic, requires medical assessment

4. Monitor response:

   • Improvement within 7 days → Continue treatment
   • No improvement or worsening → Seek medical evaluation