What syrup is recommended for dry and wet coughs?

Syrup Recommendations for Dry and Wet Cough

For both dry and wet cough, start with simple honey and lemon mixtures as first-line treatment, then escalate to dextromethorphan 30-60 mg (not the subtherapeutic over-the-counter doses) if symptoms persist, while avoiding codeine-based syrups due to their poor benefit-to-risk ratio. 1, 2

First-Line Treatment: Non-Pharmacological Approach

• Honey and lemon mixtures are the simplest, cheapest, and often as effective as pharmacological treatments for both dry and wet cough 1, 2
• Simple voluntary cough suppression techniques may be sufficient to reduce cough frequency in many cases 1, 2
• Adequate hydration helps thin secretions and makes wet coughs more productive 1

Second-Line: Dextromethorphan-Based Syrups

Critical dosing consideration: Standard over-the-counter dextromethorphan dosing is often subtherapeutic and ineffective 1, 2

• Dextromethorphan is the recommended antitussive due to superior safety profile compared to codeine 3, 1, 2
• Optimal dosing: Maximum cough reflex suppression occurs at 60 mg, which is higher than typical OTC recommendations 1, 2
• FDA-approved dosing for adults: 10 mL every 12 hours for extended-release formulations, not to exceed 20 mL in 24 hours 4
• Caution: Some combination preparations contain other ingredients like paracetamol/acetaminophen; be careful with higher doses 1, 2

Available Dextromethorphan Syrups

Common over-the-counter options include 3:

• Benylin Dry Coughs
• Robitussin for dry coughs
• Delsym (extended-release formulation) 4
• Various combination cold medications

Third-Line: Antihistamine-Containing Syrups

• First-generation sedating antihistamines (like chlorpheniramine) can suppress cough but cause drowsiness 1, 2, 5
• Particularly suitable for nocturnal cough where sedation is beneficial 1, 2, 5
• Combination products containing chlorpheniramine with dextromethorphan are available 5

Additional Symptomatic Options

• Menthol inhalation provides acute but short-lived cough suppression through cold/menthol receptors 1, 2
• Can be used as menthol crystals, proprietary capsules, or lozenges 1
• Useful for quick temporary relief 2

What to AVOID

Codeine-based syrups are NOT recommended despite widespread historical use 3, 1, 2:

• Codeine has no greater efficacy than dextromethorphan 1, 2
• Much greater adverse effect profile including drowsiness, nausea, constipation, and physical dependence 1, 2
• FDA dosing for codeine: 2 teaspoons (10 mL) every 4 hours for adults, but this is not recommended as first-line 6
• Pholcodine similarly not recommended for same reasons 1, 2

Special Considerations for Wet vs. Dry Cough

For wet/productive cough specifically:

• Antibiotics are NOT helpful even when bringing up phlegm, as most cases are viral 3, 1
• Focus should be on adequate hydration to thin secretions 1
• Cough suppression may be counterproductive if clearance of secretions is needed 2

For dry cough specifically:

• Antitussives like dextromethorphan are more appropriate 3, 5
• Demulcents (simple linctus, glycerol-based syrups) can be tried initially 3

When to Seek Medical Attention

Stop self-treatment and see a doctor if 3, 1:

• Coughing up blood
• Breathlessness present
• Prolonged fever and feeling unwell
• Underlying conditions (COPD, heart disease, diabetes, asthma)
• Recently hospitalized
• Symptoms persist for more than 3 weeks

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (standard OTC doses may not provide adequate relief) 1, 2
• Prescribing codeine-based products which have no efficacy advantage but increased side effects 1, 2
• Using antibiotics for viral cough with phlegm production 3, 1
• Ignoring the effectiveness of simple remedies like honey and lemon before escalating to medications 1, 2

Practical Algorithm

1. Start: Honey and lemon mixture + adequate hydration 1, 2
2. If insufficient relief: Dextromethorphan 30-60 mg (higher than typical OTC dosing) 1, 2
3. For nighttime cough: Consider first-generation antihistamine-containing syrup 1, 2
4. For quick temporary relief: Add menthol inhalation 1, 2
5. Avoid: Codeine or pholcodine-based syrups 1, 2