What is the recommended dosage of Tessalon (benzonatate) for cough relief?

Recommended Dosage of Tessalon (Benzonatate) for Cough Relief

The FDA-approved dosage of benzonatate is 100-200 mg three times daily as needed for cough, with a maximum daily dose of 600 mg in three divided doses. 1

Standard Dosing Protocol

• Usual dose: One 100 mg or 200 mg capsule three times daily (tid) as needed for cough 1
• Maximum dose: Up to 600 mg daily in three divided doses if necessary to control cough 1
• Administration: Capsules must be swallowed whole and should NOT be broken, chewed, dissolved, cut, or crushed 1

Clinical Context and Positioning

Benzonatate is a peripherally-acting local anesthetic antitussive that occupies a specific niche in cough management:

• Primary indication: Benzonatate is reserved for opioid-resistant cough or when opioids are contraindicated 2
• Guideline-recommended sequence: The American College of Chest Physicians recommends benzonatate as a later-line option after demulcents and opioid derivatives have failed in cancer-related cough 2
• Alternative dosing in guidelines: Clinical practice guidelines cite 100-200 mg four times daily (qid) as an alternative dosing schedule 2

When to Use Benzonatate

Step-wise approach based on guidelines:

1. First-line: Simple demulcents (honey, lemon, glycerol-based syrups) 2, 3
2. Second-line: Dextromethorphan (preferred non-opioid) or opioid derivatives if needed 2, 3
3. Third-line: Benzonatate for opioid-resistant cough 2

• Benzonatate has demonstrated effectiveness specifically in cancer patients with opioid-resistant cough 2, 4
• Case reports show benzonatate achieving symptomatic relief when codeine and other opioids failed 4

Critical Safety Warnings

Aspiration risk: As a local anesthetic, benzonatate increases aspiration risk, particularly in frail patients with cancer; assess aspiration risk before prescribing 2

Overdose danger: Benzonatate overdose can cause rapid-onset life-threatening cardiac arrest, even in adults, with limited treatment options available 5

Capsule integrity: The requirement to swallow capsules whole is critical—chewing or dissolving releases the local anesthetic, causing oral numbness and potential choking hazard 1

Practical Prescribing Considerations

• Benzonatate is most appropriate when central cough suppressants (opioids, dextromethorphan) have failed or are contraindicated 2
• Patient education about swallowing capsules whole is mandatory to prevent local anesthetic complications 1
• Monitor for effectiveness within the first few doses; if ineffective after a short trial, discontinue and try alternative approaches 2
• The drug's peripheral mechanism of action (anesthetizing stretch receptors in respiratory passages) differs from central suppressants, explaining its utility in opioid-resistant cases 6, 4