What is the recommended medication for cough in asthma patients?

Recommended Medication for Cough in Asthma Patients

Inhaled corticosteroids (ICS) are the first-line medication for treating cough in asthma patients, with leukotriene receptor antagonists (LTRAs) as a second-line option when response to ICS is incomplete. 1

First-Line Treatment: Inhaled Corticosteroids

Initial Approach

• For patients with cough due to asthma, start with a standard antiasthmatic regimen of inhaled corticosteroids 1
• ICS are the cornerstone of therapy as they:
  • Suppress airway inflammation, which is the underlying cause of asthma symptoms including cough
  • Inhibit almost every aspect of the inflammatory process in asthma 2
  • Are effective regardless of age or asthma severity

Dosing Considerations

• Begin with standard daily doses (equivalent to 200-250 μg of fluticasone propionate) which achieve 80-90% of maximum therapeutic benefit 3
• For cough variant asthma (CVA), ICS should be considered as first-line treatment 1
• Follow national asthma guidelines for dosing, though cough-specific studies in asthma are limited 1

Treatment Algorithm for Cough in Asthma

Step 1: Initial Assessment and Treatment

• Confirm asthma diagnosis (consider methacholine challenge if spirometry is non-diagnostic) 4
• Start inhaled corticosteroids at standard dose
• Consider measurement of airway inflammation (FeNO, sputum eosinophils) to predict corticosteroid response 1

Step 2: If Response is Incomplete

• Increase the inhaled corticosteroid dose 1
• Reassess for alternative causes of cough
• Consider adding a leukotriene receptor antagonist (LTRA) 1

Step 3: For Severe or Refractory Cough

• Add a leukotriene receptor antagonist before escalating to systemic corticosteroids 1
• For severe cases, administer a short course (1-2 weeks) of systemic oral corticosteroids followed by maintenance with inhaled corticosteroids 1

Evidence for Combination Therapy

• Beta-agonists can be considered in combination with ICS 1
• Fixed-dose combination inhalers containing both ICS and fast-acting beta-agonists (FABA) may:
  • Reduce exacerbations requiring systemic steroids compared to FABA alone 5
  • Reduce hospital admissions or emergency department visits 5
  • Improve adherence by simplifying the regimen 6

Common Pitfalls and Caveats

1. Misdiagnosis: Ensure proper diagnosis of asthma-related cough versus other causes like non-asthmatic eosinophilic bronchitis (NAEB) or gastroesophageal reflux disease (GERD) 1

2. Inadequate Assessment: Failure to assess airway inflammation may lead to inappropriate treatment. When available, measure airway inflammation to identify patients who may benefit from more aggressive anti-inflammatory therapy 1

3. Overreliance on Bronchodilators: Using only bronchodilators without addressing underlying inflammation will not adequately control asthma cough 1

4. Medication Adherence: Poor adherence to regular therapy is common and increases risk of exacerbations 5

5. Corticosteroid Resistance: A small proportion of patients may be resistant to the anti-inflammatory effects of corticosteroids 2

6. Inappropriate Dose Escalation: The dose-response curve to inhaled corticosteroids is relatively flat; adding another class of therapy may be preferable to increasing ICS dose in moderate-to-severe asthma 2

By following this evidence-based approach to managing cough in asthma patients, clinicians can effectively control symptoms, improve quality of life, and reduce the risk of exacerbations.