What are the recommended treatments for a cough?

Recommended Treatments for Cough

For acute cough from the common cold in adults, start with simple home remedies like honey and lemon, and if pharmacological treatment is needed, use dextromethorphan 60 mg (not the subtherapeutic over-the-counter doses) or a first-generation antihistamine/decongestant combination; avoid codeine-based products entirely as they offer no efficacy advantage but carry significant adverse effects. 1, 2, 3

Initial Assessment and Approach

Before treating any cough, first rule out life-threatening causes such as congestive heart failure, pneumonia, or pulmonary embolism 4. For acute cough, determine whether nasal symptoms are present—if so, this indicates a common cold rather than acute bronchitis, which is frequently overdiagnosed and leads to unnecessary antibiotic prescriptions 4.

Key point: Antibiotics are rarely effective for acute cough and should NOT be used for common cold, acute bronchitis, asthma, or mild chronic bronchitis exacerbations 4. Reserve antibiotics only for pneumonia, bacterial sinusitis, pertussis (if caught early), or severe chronic bronchitis with significant airflow obstruction 4.

First-Line Treatment Options

Non-Pharmacological Approaches

• Honey and lemon mixtures are the simplest, cheapest, and often as effective as pharmacological treatments for benign viral cough 1, 2, 5
• Voluntary cough suppression through central modulation may be sufficient to reduce cough frequency in some patients 1, 2

Pharmacological Options for Dry/Non-Productive Cough

Dextromethorphan (Preferred Antitussive)

• Dextromethorphan is a non-sedating opiate that effectively suppresses the cough reflex centrally 1, 3
• Critical dosing error to avoid: Standard over-the-counter doses are subtherapeutic; maximum cough suppression occurs at 60 mg, not the typical 15-30 mg found in most OTC preparations 1, 2, 5
• Meta-analysis has demonstrated efficacy for acute cough 1, 5
• Superior safety profile compared to codeine or pholcodine 1, 2, 5
• Caution: Some combination preparations contain additional ingredients like paracetamol/acetaminophen—check labels carefully when using higher doses 1, 2

First-Generation Antihistamine/Decongestant Combinations

• Strongly recommended by guidelines for acute cough from common cold unless contraindications exist (glaucoma, benign prostatic hypertrophy, hypertension, renal failure, GI bleeding, heart failure) 4
• Particularly useful for nocturnal cough due to sedative effects 1, 2, 5
• More effective than newer non-sedating antihistamines, which should NOT be used as they are ineffective 4

Alternative Options

• Naproxen (NSAID): Strongly recommended as an alternative unless contraindicated 4
• Menthol inhalation: Provides acute but short-lived cough suppression; can be prescribed as menthol crystals or proprietary capsules 1, 2, 5

For Productive/Wet Cough

• Guaifenesin (expectorant): FDA-approved to loosen phlegm and thin bronchial secretions 6, though evidence is mixed—one large study showed 75% found it helpful versus 31% placebo, but another showed no difference 7
• Hypertonic saline and erdosteine: Recommended short-term to increase cough clearance in bronchitis 5, 8
• Ipratropium bromide inhaled: The only inhaled anticholinergic recommended for cough suppression in upper respiratory infections or chronic bronchitis 5, 8

What NOT to Use

Codeine and Pholcodine

• Do NOT use: These have no greater efficacy than dextromethorphan but carry significantly worse adverse effect profiles including drowsiness, nausea, constipation, physical dependence, and respiratory suppression 1, 2, 5
• Particularly dangerous in children under 12 years and those 12-18 years with respiratory conditions due to risks of respiratory suppression and opioid toxicity 9, 10
• Despite being prescribed in 65-80% of acute bronchitis cases, they are not indicated 4

Newer Non-Sedating Antihistamines

• Should NOT be used as they are ineffective for cough 4

Over-the-Counter Combination Cold Medications

• Not recommended unless they contain older antihistamine/decongestant ingredients 4

Special Situations

Postinfectious Cough

• Try inhaled ipratropium before central antitussives 2
• For severe paroxysms, consider prednisone 30-40 mg daily for a short period 2
• Central acting antitussives like dextromethorphan should be considered only when other measures fail 2

Suspected Pertussis

• Macrolide antibiotics are indicated 2
• Isolation for 5 days from start of treatment 2

Chronic Cough (≥4 weeks)

• Encourage smoking cessation—leads to significant symptom remission 1
• Consider GERD as a cause (may occur without GI symptoms)—requires intensive acid suppression with proton pump inhibitors for at least 3 months 1
• For cough with upper airway symptoms, trial topical corticosteroid 1
• Perform bronchial provocation testing if spirometry normal and no obvious cause 1

Red Flags Requiring Medical Attention

• Cough with increasing breathlessness (assess for asthma or anaphylaxis) 1
• Cough with fever, malaise, purulent sputum (possible serious lung infection) 1
• Significant hemoptysis 1
• Possible foreign body inhalation 1
• Coughing up blood, prolonged fever, feeling unwell 5

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (15-30 mg instead of 60 mg) 1, 2
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects 1, 2
• Overdiagnosing acute bronchitis when it's actually a common cold, leading to unnecessary antibiotic prescriptions 4
• Failing to consider GERD as a cause for persistent cough 1
• Not recognizing that reflux-associated cough may occur without gastrointestinal symptoms 1