What is the recommended dose of Amitriptyline (Amitriptyline) for treating neurogenic cough?

Amitriptyline Dosing for Neurogenic Cough

For neurogenic cough treatment, amitriptyline should be initiated at 10 mg at bedtime and titrated upward as needed to a maximum of 75 mg daily, with most patients responding at doses between 10-50 mg daily. 1

Medication Selection and Dosing Algorithm

• Amitriptyline is an effective first-line neuromodulator for neurogenic cough, with approximately 78% of patients experiencing significant symptom relief 1
• Initial dosing should start low at 10 mg once daily at bedtime to minimize sedation and other side effects 2, 1
• Dose can be titrated upward every 1-2 weeks based on response and tolerability 1
• Most patients achieve adequate symptom control with doses between 10-50 mg daily 1
• Maximum recommended dose is 75 mg daily for neurogenic cough 1

Efficacy and Expected Outcomes

• Amitriptyline provides an average of 77% symptom reduction in responsive patients 1
• Response is typically seen within 2-4 weeks of reaching an effective dose 1
• Treatment should be continued for at least 6 months before considering discontinuation 3
• If inadequate response after 4-6 weeks at maximum tolerated dose, consider switching to alternative neuromodulator 1

Side Effect Management

• Common side effects include dry mouth, sedation, and dizziness 2
• To minimize sedation, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy if needed 2
• Monitor for more serious side effects including urinary retention, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 2
• Consider dose reduction if side effects are problematic but cough control is adequate 1

Alternative Neuromodulators

• If amitriptyline is ineffective or poorly tolerated, gabapentin is a recommended alternative 3, 1
• Gabapentin should be initiated at 300 mg daily and titrated up to 1800 mg daily in divided doses 3
• Desipramine is another alternative with similar efficacy (73% symptom reduction) but potentially different side effect profile 1

Patient Selection Considerations

• Best candidates for amitriptyline therapy have cough persisting >8 weeks despite treatment for common causes (GERD, asthma, postnasal drip) 4
• Patients with vocal fold motion asymmetry on laryngoscopy may be particularly responsive to neuromodulator therapy 5
• Consider trigger reduction strategies (nasal irrigation, dietary modifications) before initiating amitriptyline 6

Treatment Monitoring

• Reassess cough severity and medication side effects every 2-4 weeks during dose titration 1
• Use validated cough questionnaires (Leicester Cough Questionnaire or Cough Severity Index) to objectively track improvement 4, 7
• Perform risk-benefit reassessment at 6 months of therapy 3
• Consider gradual dose reduction after 6-12 months of stable symptom control 1

Common Pitfalls to Avoid

• Failure to rule out other treatable causes of chronic cough before diagnosing neurogenic cough 3, 4
• Starting with too high a dose, leading to side effects and medication discontinuation 2
• Inadequate duration of therapy before declaring treatment failure 1
• Not considering combination therapy with other treatment modalities for refractory cases 4