What medications can I give for a cough?

Medications for Cough Management

Direct Recommendation

For acute cough due to upper respiratory infection, start with honey and lemon as first-line treatment; if pharmacological therapy is needed, use dextromethorphan 60 mg (not the standard OTC dose of 30 mg) for optimal cough suppression, particularly for nocturnal symptoms. 1

Treatment Algorithm Based on Cough Type and Duration

For Acute Viral Cough (URI/Common Cold)

First-Line Non-Pharmacological:

• Simple home remedies like honey and lemon are the simplest, cheapest, and often as effective as medications 1, 2
• Voluntary cough suppression techniques may reduce cough frequency through central modulation 1

Pharmacological Options When Needed:

• Dextromethorphan 60 mg is the preferred antitussive due to superior safety profile compared to opioid alternatives 1, 2
• Standard OTC dosing (30 mg) is often subtherapeutic; maximum cough reflex suppression occurs at 60 mg 1, 2
• Important caveat: Some dextromethorphan preparations contain additional ingredients like paracetamol, so caution with higher doses 1
• First-generation sedating antihistamines can suppress cough and are particularly useful for nocturnal cough due to sedative effects 1, 2
• Menthol inhalation provides acute but short-lived relief when inhaled 1, 2

What NOT to Use for Acute URI Cough:

• Codeine and central cough suppressants have limited efficacy for URI and are NOT recommended 3, 1
• Codeine and pholcodine have no greater efficacy than dextromethorphan but significantly worse side effect profiles (drowsiness, nausea, constipation, physical dependence) 1, 2
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective 3
• Zinc preparations are not recommended 3
• Albuterol is not recommended for cough not due to asthma 3

For Chronic or Acute Bronchitis

Recommended Agents:

• Peripheral cough suppressants (levodropropizine, moguisteine) are recommended for short-term symptomatic relief 3
• Central cough suppressants (codeine, dextromethorphan) are recommended for short-term symptomatic relief in chronic bronchitis specifically 3
• Ipratropium bromide (inhaled anticholinergic) is the only inhaled agent recommended for cough suppression in URI or chronic bronchitis 3
• Hypertonic saline and erdosteine are recommended short-term to increase cough clearance 3

For Postinfectious Cough

Stepwise Approach:

• Try inhaled ipratropium before central antitussives 2
• Consider dextromethorphan as central acting antitussive only when other measures fail 2
• For severe paroxysms, consider prednisone 30-40 mg daily for a short period 2
• If pertussis suspected, macrolide antibiotics are indicated with 5-day isolation 2

Critical Clinical Considerations

Red Flags Requiring Different Management:

• Cough with increasing breathlessness: assess for asthma or anaphylaxis 1
• Cough with fever, malaise, purulent sputum: may indicate serious lung infection 1
• Significant hemoptysis or possible foreign body: requires specialist referral 1
• Do NOT use dextromethorphan in patients requiring pneumonia assessment (tachycardia, tachypnea, fever, abnormal chest exam) until pneumonia is ruled out 1
• Cough lasting more than 3 weeks requires full diagnostic workup rather than continued antitussive therapy 2

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (30 mg instead of 60 mg) that may not provide adequate relief 1, 2
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects 1, 2
• Not considering underlying causes like GERD (requires intensive PPI therapy for at least 3 months) or upper airway symptoms (trial of topical corticosteroid) for persistent cough 1
• Failing to recognize that reflux-associated cough may occur without gastrointestinal symptoms 1
• Encouraging smoking cessation, as it leads to significant remission in cough symptoms 1

Special Population Considerations

In Children:

• Honey may modestly decrease frequency and severity of cough 4
• Antihistamines, decongestants, dextromethorphan, or combinations do not relieve cough better than placebo in children 4
• Antitussives were no more effective than placebo 3