What are the recommended medications and management strategies for cough and cold symptoms?

Management of Cough and Cold Symptoms

For most cough and cold symptoms, non-pharmacological approaches should be tried first, followed by targeted medications for specific symptoms only when necessary. 1, 2

First-Line Approach: Non-Pharmacological Management

• Simple home remedies like honey and lemon mixtures are recommended as first-line treatment for benign viral cough and are often as effective as pharmacological treatments 1, 2, 3
• Voluntary cough suppression through central modulation may be sufficient to reduce cough frequency in some patients 4, 3
• Adequate hydration helps thin mucus secretions and may ease cough symptoms 5
• Hand hygiene is important to reduce the spread of viruses that cause cold illnesses 6

Pharmacological Management Based on Symptom Type

For Dry, Non-Productive Cough:

• Dextromethorphan is the recommended first-line antitussive agent due to its superior safety profile compared to opioid alternatives 1, 2, 7
• Maximum cough reflex suppression occurs at 60 mg of dextromethorphan, which is higher than typical over-the-counter dosing 2, 4
• Dextromethorphan should be used with caution as some combination preparations contain additional ingredients like pain relievers 2, 4
• Menthol by inhalation can provide acute but short-lived cough suppression and can be prescribed as menthol crystals or proprietary capsules 2, 3
• First-generation antihistamines with sedative properties may suppress cough and are particularly useful for nocturnal cough 2, 4

For Productive Cough:

• Hypertonic saline solution and erdosteine are recommended on a short-term basis to increase cough clearance in patients with bronchitis 1
• Ipratropium bromide is the only inhaled anticholinergic agent recommended for cough suppression in patients with URI or chronic bronchitis 1
• Expectorants may help loosen phlegm and thin bronchial secretions to make cough more productive 8, 5

Not Recommended:

• Codeine and other central cough suppressants have limited efficacy for cough due to upper respiratory infections and are not recommended 1
• Over-the-counter combination cold medications, with the exception of older antihistamine-decongestant combinations, are not recommended until randomized controlled trials prove they are effective cough suppressants 1
• Albuterol is not recommended for acute or chronic cough not due to asthma 1
• Zinc preparations are not recommended for acute cough due to the common cold 1

Special Considerations

• For nocturnal cough disrupting sleep, first-generation antihistamines with sedative properties may be beneficial 2, 4
• Patients should be educated about reading package labeling for appropriate dosing and administration of OTC medications 9
• For severe paroxysms of postinfectious cough, short-course prednisone may be considered 4

When to Seek Medical Attention

• Cough with increasing breathlessness (possible asthma or anaphylaxis) 3
• Cough with fever, malaise, purulent sputum (possible serious lung infection) 3
• Coughing up blood 1
• Prolonged fever and feeling unwell 1
• Pre-existing medical conditions like chronic bronchitis (COPD), heart disease, diabetes, asthma 1, 5
• Recent hospitalization 1
• Symptoms persisting for more than three weeks 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan that may not provide adequate relief 2, 4
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects 2, 4
• Overlooking potential drug interactions in patients with pre-existing medical conditions 5
• Potential for overdosage when patients take multiple remedies simultaneously (especially with paracetamol, aspirin, or ibuprofen) 5
• Using cough suppressants for productive coughs where clearance of secretions is beneficial 4, 5