What medications can be given for acute cough in the Emergency Department (ED)?

Medications for Acute Cough in the Emergency Department

For acute cough in the Emergency Department, dextromethorphan is the recommended first-line antitussive agent due to its superior safety profile compared to opioid alternatives, with dosing of 60 mg providing optimal cough suppression. 1

First-Line Treatment Options

Non-Pharmacological Options

• Simple home remedies like honey and lemon may be as effective as pharmacological treatments and should be considered first for benign viral cough 1
• Central modulation through voluntary cough suppression may be sufficient to reduce cough frequency in some patients 1

Pharmacological Options

Dextromethorphan

• Non-sedating opiate that centrally suppresses the cough reflex 2
• Dosing considerations:
  • Standard over-the-counter dosing is often subtherapeutic 1
  • Maximum cough reflex suppression occurs at 60 mg and can be prolonged 1, 2
  • Available in extended-release formulations providing 12-hour relief 3
• Caution with higher doses as some combined preparations contain other ingredients like paracetamol 1

Menthol

• Suppresses cough reflex when administered by inhalation 1
• Provides acute but short-lived cough suppression 1
• Can be prescribed as menthol crystals or proprietary capsules 1

First-Generation Antihistamines

• Sedative antihistamines can suppress cough but cause drowsiness 1
• May be particularly suitable for nocturnal cough 1
• Not more effective than placebo in some studies 4, 5

Second-Line Options

Expectorants (Guaifenesin)

• Evidence for efficacy is mixed 4
• One study showed 75% of participants reported guaifenesin as helpful compared to 31% in the control group 4
• Available in sugar-free and alcohol-free formulations 6

Codeine/Pholcodine

• Not recommended due to adverse side effect profile 1
• No greater efficacy than dextromethorphan 1, 7

Special Considerations

Postinfectious Cough

• For severe paroxysms of postinfectious cough, consider prednisone 30-40 mg daily for a short period 1
• Inhaled ipratropium may be tried before central antitussives 1
• Central acting antitussives like dextromethorphan should be considered only when other measures fail 1, 2

Pertussis (Whooping Cough)

• If pertussis is suspected (paroxysms of coughing, post-tussive vomiting, inspiratory whooping sound for ≥2 weeks), macrolide antibiotics are indicated 1
• Isolation for 5 days from the start of treatment is recommended 1

Practical Approach to Cough in ED

1. Assess for serious underlying causes requiring specific treatment

2. For benign viral cough:

   • Start with non-pharmacological approaches (honey and lemon) 1
   • If additional relief needed, use dextromethorphan at appropriate doses (30-60 mg) 1, 2
   • For nocturnal cough, consider first-generation antihistamines 1
   • For short-term relief of severe symptoms, menthol inhalation can provide quick but brief relief 1

3. For postinfectious cough:

   • Consider inhaled ipratropium first 1
   • Use dextromethorphan when other measures fail 1, 2
   • For severe paroxysms, short-course prednisone may be beneficial 1

Cautions and Limitations

• Evidence for OTC cough medications is mixed with many studies showing conflicting results 4, 5
• Dextromethorphan should not be used for productive cough where clearance of secretions is beneficial 2
• Pediatric dosing differs significantly - follow age-appropriate guidelines 3
• Avoid codeine-containing preparations due to adverse effect profile despite similar efficacy to dextromethorphan 1, 8