What is a suitable cough medicine for a patient with hypertension?

Suitable Cough Medicines for Patients with Hypertension

For patients with hypertension, dextromethorphan or menthol-based cough preparations are the most suitable options for cough relief, while avoiding preparations containing sympathomimetic decongestants which can elevate blood pressure. 1, 2

Understanding the Risks of Cough Medicines in Hypertension

• Sympathomimetic decongestants (phenylephrine, phenylpropanolamine, ephedrine, pseudoephedrine) commonly found in cold and cough preparations can elevate blood pressure and should be avoided in hypertensive patients 2
• Many over-the-counter cough medications contain combinations of ingredients, so careful label reading is essential to avoid those with decongestants 2
• ACE inhibitors, commonly used for hypertension treatment, can themselves cause a dry, persistent cough in 5-35% of patients, which could complicate diagnosis of the underlying cause of cough 1

Recommended Cough Medicines for Hypertensive Patients

First-line options:

• Dextromethorphan-based preparations (without decongestants):

  • Non-sedating opiate derivative that suppresses the cough reflex 1
  • Effective dose for maximum cough suppression is 60 mg, though many OTC preparations contain lower doses 1
  • Caution with high doses as some combined preparations may contain other ingredients 1

• Menthol preparations:

  • Suppresses cough reflex when inhaled 1
  • Available as menthol crystals or proprietary capsules 1
  • Provides acute but short-lived cough suppression 1

• Guaifenesin (for productive cough):

  • Acts by loosening mucus in airways, making coughs more productive 3
  • Safe expectorant for treatment of mucus-related symptoms 3
  • Available in immediate-release and extended-release formulations 3

Second-line options:

• First-generation antihistamines (for nighttime cough):
  • Sedative antihistamines can suppress cough but cause drowsiness 1
  • May be particularly useful for nocturnal cough 1, 4
  • Examples include chlorpheniramine 4

Medications to Avoid in Hypertensive Patients

• Codeine or pholcodine:

  • No greater efficacy than dextromethorphan but have greater adverse side effect profiles 1
  • Not recommended due to safety concerns 1

• Any cough/cold preparations containing:

  • Phenylephrine (alpha-adrenergic stimulant) 2
  • Phenylpropanolamine (alpha-adrenergic stimulant) 2
  • Ephedrine (alpha and beta receptor stimulant) 2
  • Pseudoephedrine (alpha and beta receptor stimulant) 2

Special Considerations for Patients on ACE Inhibitors

• If a patient on an ACE inhibitor develops a persistent dry cough, consider that the medication itself may be the cause 1, 5
• ACE inhibitor-induced cough typically resolves within 1-4 weeks after discontinuation of the medication 1, 5
• For patients who must remain on antihypertensive therapy, switching to an angiotensin receptor blocker (ARB) is recommended as ARBs rarely cause cough 1, 5
• In rare cases where an ARB is not suitable, a calcium channel blocker like amlodipine may be considered 5

General Approach to Cough Treatment in Hypertensive Patients

• For acute viral cough (most common):

  • Simple home remedies like honey and lemon may be sufficient 1
  • If medication is needed, choose dextromethorphan or menthol-based preparations without decongestants 1
  • Avoid combination products unless all ingredients are safe for hypertensive patients 2

• For persistent cough:

  • Rule out ACE inhibitor as a cause if patient is taking one 1
  • Consider underlying conditions requiring specific treatment 1
  • Choose cough suppressants based on whether the cough is productive (guaifenesin) or non-productive (dextromethorphan) 3, 4