What is the treatment for an intractable cough?

From the Guidelines

Intractable cough should be treated with opioids, such as morphine or hydrocodone, as they have the most evidence for managing cough in patients with lung cancer.

Treatment Options

• Opioids: Morphine, hydrocodone, and dihydrocodeine are effective for cough suppression in patients with lung cancer, with morphine being the most commonly used 1.
• Demulcents: Simple linctus, dextromethorphan, and glycerol-based cough syrups may be tried initially, although they may be less effective for patients with profound cough 1.
• Peripherally acting antitussives: Levodropropizine, sodium cromoglycate, and benzonatate have shown some efficacy in managing cough, but the evidence is limited 1.
• Local anesthetics: Nebulized lidocaine may be tried when other pharmacologic approaches have failed to manage cough, but aspiration risk should be assessed prior to use 1.

Dosing

• Morphine: 5 mg (single-dose trial of Oramorph; if effective 5-10 mg slow-release morphine bid) 1.
• Hydrocodone: 5 mg bid 1.
• Dihydrocodeine: 10 mg tid 1.

Considerations

• Palliative care: Opioids may be considered for patients with intractable cough in the palliative care setting, with low doses used for symptomatic relief 1.
• Quality of life: Treatment should aim to improve quality of life, with a focus on reducing cough frequency and improving sleep 1.

From the Research

Treatment Options for Intractable Cough

• Treatment of the underlying disease is often sufficient to improve or resolve cough symptoms 2
• If chronic cough persists even after treatment of the underlying disease, or if the chronic cough is not attributable to any cause, then a symptomatic approach with neuromodulators may be considered, with gabapentin as the first choice, and opioids or macrolides as alternatives 2
• Speech pathology treatment and/or neuromodulators should be discussed with patients and alternative options carefully considered, taking into account risk/benefit 2
• Centrally acting opioids such as morphine, codeine, and dextromethorphan, as well as peripherally acting antitussives like moguisteine and levodropropizine, are currently available cough suppressants 3
• Slow-release morphine has been reported to be useful in controlling intractable cough with good tolerance to constipation and drowsiness 3
• Novel promising drugs, such as P2×3 inhibitors, are under investigation, but additional studies are needed in this field 2, 4, 5, 6
• Low-dose morphine is highly effective in a subset of patients with cough resistant to other treatments, and gabapentin and pregabalin are also advocated, but may be limited by adverse events 6
• Cough suppression therapy, when performed by competent practitioners, can be highly effective 6

Non-Pharmacologic Treatment

• Speech pathology can be combined with a neuromodulator to give an enhanced treatment response of longer duration, suggesting that non-pharmacologic treatment may play a key role in the management of chronic refractory cough 2
• Speech pathology therapy should be considered in patients with troublesome chronic cough due to unknown causes or persisting even after adequate avoidance of triggers, and/or treatment of the underlying disease(s) 5