Recommended Non-Controlled Cough Medications
For chronic or acute bronchitis, prescribe dextromethorphan 60 mg for optimal cough suppression, or alternatively ipratropium bromide inhaler for both bronchitis and upper respiratory infections. 1, 2
Primary Non-Controlled Options by Clinical Context
For Chronic or Acute Bronchitis
Dextromethorphan 60 mg is the preferred first-line non-controlled antitussive, as this dose provides maximum cough reflex suppression compared to the subtherapeutic standard OTC doses of 15-30 mg. 1, 2
Peripheral cough suppressants (levodropropizine or moguisteine) are Grade A recommendations for short-term symptomatic relief in bronchitis patients, with good evidence and substantial benefit. 3
Ipratropium bromide inhaler is the only recommended inhaled anticholinergic agent for cough suppression in chronic bronchitis, with Grade A evidence. 3
For Upper Respiratory Infections (URI/Common Cold)
Ipratropium bromide is the ONLY pharmacologic agent recommended for URI-related cough, as central suppressants like dextromethorphan have limited efficacy in this context (Grade D recommendation). 3, 2
Simple home remedies like honey and lemon should be tried first for benign viral cough, as they may be as effective as pharmacological treatments. 1, 2
An older antihistamine-decongestant combination may be considered as the sole OTC combination medication with any supporting evidence for acute cough due to common cold. 3
Important Clinical Distinctions
When to Use vs. Avoid Cough Suppressants
For non-productive (dry) cough: Dextromethorphan is appropriate as a first-line antitussive agent. 1
For productive cough: Avoid antitussive agents entirely, as they interfere with beneficial secretion clearance; instead consider hypertonic saline or erdosteine for short-term use to increase cough clearance. 3, 4
For nocturnal cough specifically: First-generation sedating antihistamines like promethazine can be added to dextromethorphan due to their sedative properties. 1
Dosing Considerations
Standard OTC dextromethorphan dosing (15-30 mg) is often subtherapeutic for optimal cough suppression; the evidence supports 60 mg for maximum effect. 1, 2
Treatment duration should be limited to short-term use, typically less than 7 days. 1, 2
Medications to Avoid
Codeine is NOT recommended as first-line despite being non-controlled in some formulations, as it has no greater efficacy than dextromethorphan but carries a worse adverse effect profile including drowsiness, nausea, constipation, and risk of physical dependence. 2, 5
Albuterol is not recommended for acute or chronic cough not due to asthma (Grade D). 3
Mucolytics are not recommended for chronic bronchitis cough suppression. 3, 2
Zinc preparations are not recommended for acute cough due to common cold (Grade D). 3
Most OTC combination cold medications are not recommended until randomized controlled trials prove efficacy, with the exception of older antihistamine-decongestant combinations. 3
Common Pitfalls to Avoid
Using subtherapeutic doses of dextromethorphan (15-30 mg instead of 60 mg) that fail to provide adequate cough suppression. 1, 2
Prescribing central cough suppressants for URI-related cough, where they have limited efficacy and Grade D recommendations. 3, 2
Using cough suppressants for productive cough, which prevents beneficial mucus clearance. 4, 2
Overlooking ipratropium bromide as the sole recommended inhaled agent for both URI and bronchitis-related cough. 3, 2