Medications for Dry Cough
Start with dextromethorphan 60 mg three to four times daily as your first-line antitussive agent for dry cough, as this dose provides maximum cough reflex suppression with a superior safety profile compared to codeine-based alternatives. 1, 2
First-Line Treatment Approach
Dextromethorphan at 60 mg is the optimal dose for maximum cough suppression, though standard over-the-counter preparations typically contain subtherapeutic doses of only 15-30 mg. 1, 2
The maximum daily dose is 120 mg, typically divided into 10-30 mg doses three to four times daily, though higher individual doses (up to 60 mg) are more effective. 3
Dextromethorphan has a superior safety profile compared to opioid alternatives like codeine, with fewer adverse effects including less drowsiness, nausea, constipation, and no risk of physical dependence. 1, 2
When Dextromethorphan Alone Is Insufficient
For nocturnal cough disrupting sleep, add a first-generation sedating antihistamine like promethazine, which provides both cough suppression and sedation specifically beneficial for nighttime symptoms. 1
For postinfectious cough, try inhaled ipratropium bromide before escalating to central antitussives, as it is the only inhaled agent recommended for cough suppression with substantial benefit. 3, 1, 2
Second-Line Options
If dextromethorphan fails, consider these alternatives in order:
Codeine 30-60 mg four times daily (maximum 240 mg/24 hours), though this is less preferred due to greater side effects without superior efficacy. 3
Peripheral cough suppressants such as levodropropizine (75 mg three times daily), moguisteine (100-200 mg three times daily), or levocloperastine (20 mg three times daily) where available. 3
For severe paroxysms of postinfectious cough, consider a short course of prednisone 30-40 mg daily. 1
Non-Pharmacologic Options to Consider First
Honey (one teaspoon) may be as effective as pharmacological treatments for benign viral cough and should be tried first for simple cases. 3, 1
Menthol inhalation provides acute but short-lived cough suppression and can be used as an adjunct. 1
Critical Pitfalls to Avoid
Do not use subtherapeutic doses of dextromethorphan (15-30 mg) when 60 mg provides optimal suppression. 1, 2
Avoid codeine as first-line despite its historical use—it has no greater efficacy than dextromethorphan but significantly worse adverse effects including drowsiness, nausea, constipation, and risk of physical dependence. 1, 2
Do not use cough suppressants for productive cough where clearance of secretions is beneficial. 1, 2
Albuterol is not recommended for cough not due to asthma. 3, 2
Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) lack evidence of efficacy and should not be recommended. 3