What are the treatment options for chronic dry cough?

Treatment of Chronic Dry Cough

The most effective approach to treating chronic dry cough requires identifying and addressing the underlying cause, with gastroesophageal reflux disease (GERD), upper airway cough syndrome, and asthma being the most common etiologies. 1

Diagnostic Approach

Before initiating treatment, determine the likely cause of chronic dry cough:

• Rule out common causes through targeted history focusing on:

  • Heartburn or regurgitation symptoms (suggesting GERD) 1
  • Upper airway symptoms (suggesting rhinosinusitis) 1
  • Wheezing or shortness of breath (suggesting asthma) 1
  • Medication review, particularly ACE inhibitors 1
  • Smoking history 1

• Consider chest radiography to rule out concerning infectious, inflammatory, and malignant conditions 2

Treatment Algorithm Based on Etiology

1. GERD-Related Chronic Cough

If clinical profile suggests GERD (even without typical GI symptoms):

• First-line approach (1-3 month trial): 1

  • Dietary and lifestyle modifications:
    • Limit fat intake to <45g/day
    • Avoid coffee, tea, soda, chocolate, mints, citrus products, tomatoes, alcohol
    • Smoking cessation
    • Limit vigorous exercise that increases intra-abdominal pressure
  • Acid suppression therapy with proton pump inhibitors (PPIs)
  • Consider adding prokinetic therapy either initially or if no response to the above

• For refractory cases: 1

  • Intensify medical therapy with maximum acid suppression and prokinetic therapy
  • Consider objective testing with 24-hour esophageal pH monitoring
  • Antireflux surgery may be considered in carefully selected cases after failed maximal medical therapy for at least 3 months

2. Upper Airway Cough Syndrome

If prominent upper airway symptoms are present:

• First-line therapy: Trial of first-generation antihistamine-decongestant combination 1
• For persistent symptoms: Trial of topical nasal corticosteroids 1

3. Asthma and Non-asthmatic Eosinophilic Bronchitis

• Diagnostic approach: Consider bronchial provocation testing in patients with normal spirometry 1
• Treatment: Trial of inhaled corticosteroids for 2 weeks 1
• Note: A negative response to a 2-week oral steroid trial makes eosinophilic airway inflammation unlikely 1

4. Unexplained Chronic Cough

When standard treatments fail and cough remains unexplained after thorough investigation:

• Consider multimodality speech pathology therapy 1

• Neuromodulatory medications: 1, 3

  • Gabapentin
  • Pregabalin

• Avoid inhaled corticosteroids in patients with negative tests for bronchial hyperresponsiveness and eosinophilia 1

5. Symptomatic Relief Options

• Over-the-counter options: 1, 4

  • Dextromethorphan-containing cough remedies
  • Menthol lozenges or vapor
  • Honey and lemon (as home remedy)

• Prescription options: 5, 4

  • Benzonatate for symptomatic relief
  • First-generation antihistamines (e.g., chlorpheniramine)
  • Codeine or other opioid derivatives (caution: sedation and addiction potential) 6

Important Considerations

• Chronic cough should be considered unexplained only after thorough assessment according to best-practice guidelines 1

• Empiric treatment trials should be given adequate time (1-3 months for GERD therapy) 1

• Smoking cessation is essential for any smoker with chronic cough 1

• Failure of empiric therapy does not rule out the targeted condition; more intensive therapy or objective testing may be needed 1

• Referral to a specialist cough clinic should be considered for refractory cases 1

• Cough may have multiple contributing causes requiring simultaneous treatment approaches 1