What is the best course of action for managing a cancer-related cough?

Management of Cancer-Related Cough

For cancer-related cough, a step-up approach is recommended starting with demulcents, followed by opioid derivatives, peripherally-acting antitussives, and local anesthetics as needed, with cough suppression exercises as a valuable non-pharmacological option. 1

Initial Assessment

• Begin with a comprehensive evaluation to identify treatable causes of cough, as cancer-related cough can stem from multiple factors including direct tumor effects, pleural effusion, infections, GERD, or treatment-induced causes 1
• Differentiate between productive and nonproductive cough, as management strategies differ (suppression for nonproductive vs. mucolytics for productive cough) 1
• Assess cough severity and impact on quality of life, as cough significantly affects psychological, social, and physical domains 2

Step-Up Management Approach

Step 1: Non-Pharmacological Interventions

• Cough suppression exercises are recommended as first-line or adjunctive therapy and include:
  • Education about cough triggers
  • Pursed lip breathing techniques
  • Swallowing or sipping water when cough urge occurs
  • Laryngeal hygiene and hydration
  • Diaphragmatic breathing exercises 1

Step 2: Initial Pharmacological Management

• Demulcents (syrups) should be tried first when pharmacological treatment is required:
  • Butamirate linctus
  • Simple linctus
  • Glycerin-based linctus 1

Step 3: Opioid Derivatives

• If demulcents fail, progress to opioid derivatives titrated to an acceptable side-effect profile:
  • Codeine (10 mg three times daily)
  • Dihydrocodeine (10 mg three times daily)
  • Hydrocodone (5 mg twice daily) 1, 3
• Monitor for common side effects including constipation and sedation 3

Step 4: Peripherally-Acting Antitussives

• For opioid-resistant cough, try peripherally-acting antitussives:
  • Levodropropizine (75 mg three times daily)
  • Moguisteine (100-200 mg three times daily)
  • Levocloperastine (20 mg three times daily)
  • Sodium cromoglycate (10 mg four times daily) 1

Step 5: Local Anesthetics

• When peripheral antitussives fail, consider local anesthetics:
  • Nebulized lidocaine (5 mL of 0.2% solution three times daily)
  • Nebulized bupivacaine (5 mL of 0.25% solution three times daily)
  • Benzonatate (100-200 mg four times daily) 1
• Caution: First dose of nebulized anesthetics should be administered in a clinical setting due to risk of bronchospasm 1

Step 6: Refractory Cases

• For intractable cough unresponsive to standard approaches, consider N-of-1 trials with:
  • Gabapentin
  • Diazepam
  • Carbamazepine
  • Baclofen
  • Amitriptyline
  • Thalidomide 1

Special Considerations

• Endobronchial brachytherapy should be considered for localized endobronchial disease when surgery, chemotherapy, or external beam radiation are not indicated 1

• Clinical associations to consider:

  • Female patients may experience more severe cough 4
  • Patients with comorbid asthma or GERD often have worse cough symptoms 4
  • Poor performance status correlates with higher cough severity and impact 4

Pitfalls to Avoid

• Don't assume cough is solely due to cancer; multiple causes often coexist and require specific management 1
• Avoid prolonged ineffective treatments; if a treatment approach doesn't show improvement after a short trial, move to the next step 1
• Don't overlook the psychological impact of cough, which can cause social embarrassment and reduced quality of life 2
• Remember that cancer stage and histology don't necessarily correlate with cough severity, so all patients deserve aggressive symptom management regardless of disease status 4