What is the recommended treatment for acute cough?

Treatment of Acute Cough

For acute cough, start with simple home remedies like honey and lemon as first-line treatment; if pharmacological intervention is needed, use dextromethorphan at 60 mg (not the standard OTC dose of 30 mg) as it provides superior cough suppression with a better safety profile than codeine-based alternatives. 1, 2

First-Line Non-Pharmacological Approach

• Honey and lemon mixtures are the simplest, cheapest, and often effective first-line treatment for acute viral cough, which is typically benign and self-limiting, lasting 1-3 weeks 1, 3
• Voluntary cough suppression techniques may reduce cough frequency through central modulation of the cough reflex and can be sufficient for some patients 1, 2
• Most acute cough from viral upper respiratory tract infections does not require prescribed medication 1

Pharmacological Options When Needed

Dextromethorphan (Preferred Agent)

• Dextromethorphan is the recommended first-line antitussive due to its superior safety profile compared to opioid alternatives 2, 3, 4
• The drug acts as a non-sedating opiate that centrally suppresses the cough reflex 1, 3
• Critical dosing consideration: Standard OTC dosing (30 mg) is often subtherapeutic; maximum cough suppression occurs at 60 mg 2, 3
• Meta-analysis has demonstrated effectiveness for acute cough, with a clear dose-response relationship 1, 3
• Exercise caution with combination preparations as some contain additional ingredients like paracetamol that could lead to inadvertent overdose at higher doses 1, 2

Alternative Pharmacological Options

• Menthol inhalation (as crystals or proprietary capsules) suppresses cough reflex acutely but provides only short-lived relief 1, 2
• First-generation antihistamines with sedative properties can suppress cough and are particularly useful for nocturnal cough disrupting sleep, though they cause drowsiness 1, 2, 3
• Guaifenesin (expectorant) helps loosen phlegm and thin bronchial secretions for productive coughs 5

What NOT to Use

• Codeine and pholcodine have no greater efficacy than dextromethorphan but carry significantly worse adverse effect profiles (drowsiness, nausea, constipation, physical dependence) and are not recommended 1, 2, 3
• Research shows codeine is no more effective than placebo in reducing cough symptoms 6, 7

Practical Treatment Algorithm

1. Start with honey and lemon for all patients with benign viral acute cough 1, 3
2. Add dextromethorphan 30-60 mg if additional relief needed during daytime 2, 3
3. Consider first-generation antihistamines specifically for nighttime cough disrupting sleep 2, 3
4. Use menthol inhalation for quick but temporary relief of severe cough paroxysms 2
5. Avoid codeine-containing products entirely due to poor benefit-to-risk ratio 2

Red Flags Requiring Further Evaluation

• Cough with increasing breathlessness (assess for asthma or anaphylaxis) 1
• Cough with fever, malaise, and purulent sputum (may indicate serious lung infection) 1
• Significant hemoptysis or possible foreign body inhalation (requires specialist referral) 1
• Coughing up blood, prolonged fever, and feeling unwell (require medical attention) 3

Common Pitfalls to Avoid

• Using subtherapeutic 30 mg doses of dextromethorphan when 60 mg provides optimal suppression 2
• Prescribing codeine-based antitussives which offer no efficacy advantage but increased side effects 2
• Not recognizing that most acute viral cough is self-limiting and reassuring patients appropriately 1
• Failing to adjust chronic disease medications (asthma, COPD, cardiac failure, diabetes) during acute respiratory infections 1