What are the options for cough suppressant medications?

Cough Suppressant Options

For chronic or acute bronchitis, use dextromethorphan 60 mg (not the standard 15-30 mg OTC dose) or peripheral cough suppressants like levodropropizine; for URI-related cough, avoid central suppressants and use ipratropium bromide instead; codeine offers no advantage over dextromethorphan and should be avoided due to its worse side effect profile. 1, 2

Treatment Algorithm by Cough Type

For Chronic or Acute Bronchitis

First-line options:

• Dextromethorphan at 60 mg provides maximum cough reflex suppression (standard OTC doses of 15-30 mg are subtherapeutic) 2, 3
• Peripheral cough suppressants (levodropropizine, moguisteine) are recommended for short-term symptomatic relief with substantial benefit 1
• Ipratropium bromide (inhaled anticholinergic) is the only inhaled agent recommended for cough suppression 1

Second-line options:

• Codeine can be used but offers no efficacy advantage over dextromethorphan while causing more drowsiness, nausea, constipation, and physical dependence 2, 3, 4
• First-generation sedating antihistamines (like chlorpheniramine or promethazine) are particularly suitable for nocturnal cough due to sedative properties 2, 3

For Upper Respiratory Infection (URI/Common Cold)

Recommended:

• Simple home remedies like honey and lemon may be as effective as pharmacological treatments and should be tried first 2, 3
• Ipratropium bromide (inhaled) is the only recommended agent 1
• Older antihistamine-decongestant combinations may provide benefit 1

NOT recommended:

• Central cough suppressants (dextromethorphan, codeine) have limited efficacy for URI-related cough 1
• Peripheral cough suppressants have limited efficacy for URI 1
• Zinc preparations are not recommended 1
• Most OTC combination cold medications lack proven efficacy 1

For Postinfectious Cough

Treatment sequence:

• Try inhaled ipratropium first before central antitussives 2, 3
• For severe paroxysms, consider prednisone 30-40 mg daily for a short period 2, 3
• Central acting antitussives like dextromethorphan should only be considered when other measures fail 2, 3

Specific Agent Details

Dextromethorphan

• Optimal dosing is 60 mg for maximum cough suppression (higher than typical OTC recommendations) 2, 3
• Has superior safety profile compared to opioid alternatives 2, 3
• FDA-approved as a cough suppressant 5
• Should not be used for productive cough where secretion clearance is beneficial 2, 3
• Caution: Some combined preparations contain other ingredients like acetaminophen at higher doses 2

Codeine

• FDA-approved for cough due to minor throat and bronchial irritation 6
• Not recommended as first-line due to adverse effects without superior efficacy 1, 2
• Causes drowsiness, nausea, constipation, and risk of physical dependence 2

Ipratropium Bromide

• The only inhaled anticholinergic recommended for cough suppression in URI or chronic bronchitis 1
• Should be tried before central antitussives in postinfectious cough 2, 3

Menthol

• Provides acute but short-lived cough suppression when inhaled 2, 3
• Can be prescribed as menthol crystals or proprietary capsules 2

Agents NOT Recommended

• Albuterol for acute or chronic cough not due to asthma 1
• Mucolytics (agents altering mucus characteristics) for chronic bronchitis cough suppression 1
• Drugs affecting the efferent limb of the cough reflex 1
• Protussive pharmacologic agents in neuromuscular impairment 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (15-30 mg instead of 60 mg) that provide inadequate relief 2, 3
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects 2, 3
• Using central cough suppressants for URI-related cough where they have limited efficacy 1
• Applying cough suppressants to productive cough where secretion clearance is needed 2, 3
• Overlooking simple non-pharmacological approaches like honey and lemon for benign viral cough 2, 3