What alternative treatments are available when cough medicine with Tesslon (dextromethorphan) pearls is ineffective?

When Benzonatate (Tesslon Perles) Fails for Cough

If benzonatate is ineffective, switch to a stepwise approach starting with higher-dose dextromethorphan (60 mg, not the subtherapeutic over-the-counter dose), followed by opioid antitussives like hydrocodone or morphine if needed, and finally consider gabapentin or speech pathology therapy for truly refractory cases. 1, 2

Clarification: Benzonatate vs. Dextromethorphan

First, benzonatate (Tesslon Perles) is NOT the same as dextromethorphan - benzonatate is a peripherally-acting local anesthetic that numbs stretch receptors in the lungs, while dextromethorphan is a centrally-acting cough suppressant. 2, 3 The question appears to conflate these two different medications.

Immediate Next Steps

Step 1: Optimize Dextromethorphan Dosing

• Use 60 mg of dextromethorphan for maximum cough reflex suppression, not the typical subtherapeutic over-the-counter doses (15-30 mg). 1, 2
• This higher dose provides prolonged relief and is often more effective than standard dosing. 1
• Caution: Verify that combination products don't contain excessive paracetamol (acetaminophen) at this higher dose. 1

Step 2: Consider Simple Remedies First

• Try honey and lemon mixtures before escalating to stronger medications, particularly for benign viral cough. 1, 2
• Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived cough suppression. 1, 2

Escalation Algorithm for Persistent Cough

For General Chronic Cough (Non-Cancer)

Second-Line: Opioid Antitussives

• Hydrocodone is preferred - start at 5 mg twice daily, with median effective doses around 10 mg/day. 4
• Hydrocodone liquid formulation allows flexible dose titration, which is critical since effective doses vary significantly between patients. 4
• Avoid codeine and pholcodine - they have no greater efficacy than dextromethorphan but significantly more side effects (drowsiness, nausea, constipation, physical dependence). 1, 2

Third-Line: Neuromodulators

• Gabapentin is recommended for refractory chronic cough when standard treatments fail. 1, 5
• Pregabalin is an alternative neuromodulator option. 5
• Low-dose morphine (preferred over other opioids for refractory cases) can be considered when other options fail. 5

Fourth-Line: Speech Pathology

• Multimodality speech pathology therapy (cough suppression exercises) can be effective as an alternative or adjunct to pharmacological therapy. 1

For Cancer-Related Cough (Specific Algorithm)

The CHEST guidelines provide a clear stepwise approach: 1

1. Demulcents first: Butamirate linctus, simple linctus, or glycerol-based syrups. 1

2. Opioid derivatives second: Pholcodine or hydrocodone (preferred), dihydrocodeine, or morphine - titrate to acceptable side-effect profile. 1

3. Peripherally-acting antitussives third (for opioid-resistant cough): Levodropropizine, moguisteine, levocloperastine, or sodium cromoglycate. 1

4. Local anesthetics fourth: Nebulized lidocaine/bupivacaine or benzonatate for opioid-resistant cough that doesn't respond to peripheral antitussives. 1

5. Experimental agents last: Consider N-of-1 trials with diazepam, gabapentin, carbamazepine, baclofen, amitriptyline, or thalidomide for intractable cough. 1

Critical Timing Considerations

• If cough persists beyond 3 weeks, stop antitussive therapy and reassess for underlying causes rather than continuing symptomatic treatment. 2
• Beyond 8 weeks (chronic cough), investigate for asthma, GERD, post-nasal drip, or other treatable causes before continuing antitussive therapy. 2, 5
• Do not prescribe benzonatate or any antitussive for extended periods without reassessing the underlying cause. 2

Common Pitfalls to Avoid

• Don't use subtherapeutic doses of dextromethorphan - most over-the-counter preparations contain inadequate amounts. 1, 2
• Don't prescribe codeine - it has the worst side effect profile among opioid antitussives despite being most researched. 1
• Don't continue antitussives indefinitely - if cough persists beyond 3 weeks, the priority shifts to diagnosis rather than symptom suppression. 2
• Don't use first-generation antihistamines during daytime - they cause significant drowsiness and are only suitable for nocturnal cough. 1, 2

Special Populations

Diabetic Patients

• Monitor blood glucose more frequently when starting any new cough medication. 2
• Avoid combination products with pseudoephedrine in diabetic patients with comorbid hypertension. 2
• Benzonatate is actually preferred in diabetics because it has no effect on blood glucose levels. 2

Interstitial Lung Disease

• Follow the unexplained chronic cough guideline with gabapentin and speech pathology therapy as primary options. 1
• Opiates are suggested for palliative symptom control when alternative treatments fail and cough adversely affects quality of life, with reassessment at 1 week then monthly. 1