What are the recommended medications for a non-productive cough?

Recommended Medications for Non-Productive Cough

For non-productive cough, dextromethorphan is the recommended first-line medication due to its superior safety profile compared to opioid alternatives, with optimal dosing of 60 mg providing maximum cough suppression. 1

First-Line Treatment Options

• Simple home remedies like honey and lemon may be as effective as pharmacological treatments and should be considered first for benign viral cough 2, 1
• Dextromethorphan is FDA-approved as a cough suppressant and is the preferred pharmacological option due to its better safety profile 3, 1
• Standard over-the-counter dosing of dextromethorphan is often subtherapeutic; maximum cough reflex suppression occurs at 60 mg and can be prolonged 2, 1
• Menthol by inhalation provides acute but short-lived cough suppression and can be prescribed as menthol crystals or proprietary capsules 2, 4
• First-generation sedative antihistamines can suppress cough but cause drowsiness, making them particularly suitable for nocturnal cough 2, 1

Second-Line Options and Considerations

• Codeine and pholcodine have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile (drowsiness, nausea, constipation, physical dependence) and are not recommended 2, 5
• Extended-release formulations of dextromethorphan (like Delsym) can provide up to 12 hours of cough relief 3
• 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 for postinfectious cough 1

Special Considerations

• Caution with higher doses of dextromethorphan as some combined preparations contain other ingredients like paracetamol 2
• Dextromethorphan should not be used for productive cough where clearance of secretions is beneficial 6
• Some dextromethorphan preparations contain sodium metabisulfite, which may cause allergic-type reactions in susceptible individuals 3
• Central modulation through voluntary cough suppression may be sufficient to reduce cough frequency in some patients 2

Practical Algorithm for Non-Productive Cough Management

1. Start with non-pharmacological approaches:

   • Honey and lemon mixtures 2, 1
   • Voluntary cough suppression techniques 2

2. If additional relief is needed, use:

   • Dextromethorphan at appropriate doses (30-60 mg) 2, 1
   • Consider extended-release formulations for longer relief 3

3. For nighttime cough disrupting sleep:

   • First-generation antihistamines with sedative properties 2, 4

4. For quick but temporary relief:

   • Menthol inhalation 2, 4

5. Avoid codeine-containing products due to poor benefit-to-risk ratio 2, 7

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan that may not provide adequate relief 2, 1
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects 2, 5
• Failing to recognize that over-the-counter combinations may contain additional active ingredients that could cause side effects or interactions 8
• Using antitussives for productive cough where suppression may be counterproductive 6
• Overlooking that the evidence for many over-the-counter cough medications is limited, with some studies showing no benefit over placebo 8, 9