What is the best cough medicine?

Best Cough Medicine

For acute cough in adults, dextromethorphan at 60 mg is the recommended first-line pharmacological treatment, though simple home remedies like honey and lemon should be tried first for benign viral cough. 1

Treatment Algorithm for Acute Cough

First-Line Approach: Non-Pharmacological

• Start with honey and lemon mixtures, which may be as effective as pharmacological treatments for benign viral cough 1, 2
• Consider voluntary cough suppression techniques, as central modulation may be sufficient to reduce cough frequency 1

Second-Line: Pharmacological Treatment

Dextromethorphan (Preferred Agent)

• Dextromethorphan is the recommended first-line antitussive due to its superior safety profile compared to opioid alternatives 1, 2, 3
• The optimal dose is 60 mg for maximum cough reflex suppression, which is higher than standard over-the-counter preparations 1, 2, 3
• Standard OTC dosing (15-30 mg) is often subtherapeutic and may not provide adequate relief 1, 2
• Can be dosed at 10-15 mg three to four times daily, with maximum daily dose of 120 mg 1
• Important caveat: Check combination products carefully to avoid excessive amounts of other ingredients like acetaminophen when using higher doses 1

Alternative Options for Specific Situations

• For nocturnal cough disrupting sleep: First-generation sedative antihistamines (like promethazine) can be added due to their sedative properties 1, 2
• For quick but temporary relief: Menthol inhalation provides acute but short-lived cough suppression 1, 2
• For postinfectious cough: Try inhaled ipratropium before central antitussives like dextromethorphan 1, 2, 3
• For severe paroxysms of postinfectious cough: Consider prednisone 30-40 mg daily for a short course 1, 2

What NOT to Use

Codeine-Based Products (Avoid)

• Codeine is NOT recommended despite being widely used historically 1, 3
• Has no greater efficacy than dextromethorphan but carries a much worse adverse effect profile including drowsiness, nausea, constipation, and risk of physical dependence 1, 3

Guaifenesin

• While FDA-approved as an expectorant to loosen phlegm 4, it is not recommended for cough suppression in guidelines 3

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (15-30 mg) when 60 mg provides optimal suppression 1, 2
• Prescribing codeine-based antitussives which have no efficacy advantage but increased side effects 1, 3
• Using antitussives for productive cough where clearance of secretions is beneficial 1, 2, 3
• Continuing antitussive therapy beyond short-term use (typically less than 7 days) 2
• Failing to consider that cough lasting more than 3 weeks requires full diagnostic workup rather than continued antitussive therapy 1

Evidence Quality Considerations

The evidence supporting dextromethorphan is mixed in research studies. One study found minimal benefit of 30 mg dextromethorphan over placebo in acute upper respiratory infections 5, while another found it comparable to codeine at 20 mg doses 6. However, the key insight from guidelines is that standard OTC doses are subtherapeutic 1, 2, explaining the inconsistent research findings. The American College of Chest Physicians and other guideline bodies consistently recommend 60 mg dosing for optimal effect 1, 3.