What is the appropriate dosage of hydrocodone (opioid cough suppressant) for cough management?

Hydrocodone Dosing for Cough Suppression

For cough management in adults, hydrocodone should be initiated at 5 mg twice daily (10 mg total daily dose), which represents the evidence-based starting dose that achieves effective cough suppression in most patients. 1, 2

Initial Dosing Strategy

• Start with 5 mg twice daily as the standard initial dose for opioid-naïve patients requiring hydrocodone for cough suppression 1, 2
• This starting dose aligns with CDC guidance recommending the lowest effective opioid dose, typically 5-10 MME per single dose or 20-30 MME daily for opioid-naïve patients 1
• In a phase II dose-titration study of 25 patients with advanced cancer and cough, 5 mg twice daily achieved a median 70% improvement in cough frequency, with most patients responding at a median total daily dose of 10 mg (range 5-30 mg/day) 1, 2

Dose Titration Protocol

• If inadequate response after 24 hours, increase the daily dose incrementally until achieving ≥50% improvement in cough frequency 2
• The effective dose range is typically 5-30 mg per day in divided doses, with most patients responding to 10 mg daily 1, 2
• Titrate by the smallest practical amount to minimize overdose risk, which increases with each dose escalation 1
• Most patients who respond will improve within one day of reaching their effective dose 2

Critical Safety Thresholds

• Before exceeding 50 MME/day total opioid dose (from all sources), pause and reassess the risk-benefit ratio, as overdose risk increases substantially above this threshold without proportional pain or cough control benefit 1
• For patients ≥65 years or those with renal/hepatic insufficiency, consider lower starting doses (e.g., 2.5 mg formulations) due to narrower therapeutic windows 1
• Implement increased monitoring frequency and offer naloxone with overdose prevention education if total daily opioid dose reaches or exceeds 50 MME/day 1

Important Clinical Caveats

• Hydrocodone is contraindicated in patients under 18 years due to unfavorable benefit-risk profile, including respiratory depression risk and lack of efficacy data in pediatric populations 3
• The 2017 CHEST guidelines specifically list hydrocodone 5 mg twice daily in their dosing table for antitussives, supporting this as the standard approach 1
• Hydrocodone demonstrates effectiveness and safety for cough in advanced cancer with tolerable side effects (dry mouth, nausea, mild drowsiness) at recommended doses 4, 2
• Consider alternative peripherally-acting antitussives (levodropropizine, benzonatate) if opioid side effects are problematic, though availability varies by country 1, 5