What is the first line treatment for acute cough?

First-Line Treatment for Acute Cough

For acute viral cough, start with simple home remedies like honey and lemon, which are as effective as many pharmacological treatments and represent the simplest, cheapest first-line approach. 1, 2, 3

Initial Non-Pharmacological Management

• Acute viral cough is almost invariably benign and prescribed treatment can be regarded as unnecessary 1
• Home remedies such as honey and lemon should be offered first 1, 2, 3
• Voluntary cough suppression through central modulation of the cough reflex may be sufficient to reduce cough frequency in many patients 1, 2
• Simple drinks and linctuses may work through this central modulation mechanism 1

Pharmacological Options When Additional Relief Needed

First-Generation Antihistamine/Decongestant Combinations

• The American College of Chest Physicians (ACCP) strongly recommends first-generation antihistamine/decongestant combinations as first-line pharmacological treatment for acute cough from the common cold 1
• These should be used unless contraindications exist (glaucoma, benign prostatic hypertrophy, hypertension, renal failure, gastrointestinal bleeding, congestive heart failure) 1
• Antihistamine-decongestant combinations were significantly more effective than placebo in adult studies (p < 0.01) 4

Dextromethorphan

• Dextromethorphan is the preferred antitussive agent due to superior safety profile compared to codeine-based alternatives 2, 3, 5
• Standard over-the-counter dosing is often subtherapeutic; maximum cough reflex suppression occurs at 60 mg 1, 2, 3
• The generally recommended dosage provides a dose-response effect, with prolonged suppression at higher doses 1
• Exercise caution with higher doses as some combined preparations contain additional ingredients like paracetamol 1, 2
• Dextromethorphan has been shown to suppress acute cough in meta-analysis 1

Menthol

• Menthol by inhalation suppresses the cough reflex and provides acute but short-lived relief 1, 2, 3
• Can be prescribed as menthol crystals BPC or proprietary capsules 1, 2

Sedative Antihistamines

• First-generation antihistamines with sedative properties suppress cough but cause drowsiness 1, 2, 3
• Particularly suitable for nocturnal cough when sleep disruption is the primary concern 1, 2, 3

What NOT to Use

Codeine and Pholcodine

• Opiate antitussives (codeine, pholcodine) have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile and are NOT recommended 1, 2, 3
• These agents cause drowsiness, nausea, constipation, and physical dependence 3

Newer-Generation Antihistamines

• Newer-generation, nonsedating antihistamines should NOT be used because they are ineffective for acute cough 1

Over-the-Counter Combination Products

• Most OTC combination cold medications are not recommended except those containing older antihistamine/decongestant ingredients 1

Red Flags Requiring Different Management

• Acute cough with increasing breathlessness should be assessed for asthma or anaphylaxis 1, 2
• Acute cough with fever, malaise, purulent sputum, or recent infection history requires assessment for serious acute lung infection 1
• Significant hemoptysis or possible foreign body inhalation mandates specialist referral for bronchoscopy 1, 2
• Biphasic course (worsening after initial improvement) or failure to improve after first week suggests bacterial sinusitis or pertussis requiring antibiotics 1

Practical Algorithm

1. Start with honey and lemon for all patients with uncomplicated acute viral cough 1, 2, 3
2. Add first-generation antihistamine/decongestant combination if additional relief needed and no contraindications 1
3. Consider dextromethorphan 30-60 mg as alternative antitussive if antihistamine/decongestant contraindicated or for additional relief 2, 3, 5
4. Use sedative antihistamines specifically for nighttime cough disrupting sleep 1, 2, 3
5. Menthol inhalation for quick but temporary relief as needed 1, 2, 3

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan that provide inadequate relief 2, 3
• Prescribing codeine-based antitussives which offer no efficacy advantage but increased side effects 1, 2, 3
• Using antibiotics for uncomplicated acute viral cough, which are ineffective and promote resistance 1, 6
• Prescribing newer nonsedating antihistamines, which lack efficacy for cough 1