Treatment Pattern for Asthma Cough
Start with inhaled corticosteroids (ICS) combined with inhaled bronchodilators as first-line therapy for asthma-related cough, escalating in a stepwise manner only if the initial response is inadequate. 1
First-Line Treatment Approach
Initiate combination therapy with inhaled corticosteroids plus inhaled bronchodilators immediately for any patient with chronic cough due to asthma, whether cough is the sole symptom (cough variant asthma) or accompanies other asthma symptoms. 1
Beta-agonists should be used in combination with ICS rather than as monotherapy, as LABA monotherapy increases the risk of serious asthma-related events. 1, 2
The CHEST guidelines provide Grade 1B evidence (very strong) supporting this stepwise treatment approach, reflecting robust evidence from general asthma management that applies to cough-specific presentations. 1
Stepwise Escalation for Incomplete Response
If cough persists after initial ICS plus bronchodilator therapy, follow this sequential escalation:
Step 1: Increase the inhaled corticosteroid dose before adding additional agents. 1
Step 2: Add a leukotriene receptor antagonist (such as zafirlukast or montelukast) to the existing ICS and bronchodilator regimen after reconsidering alternative causes of cough. 1
Leukotriene inhibitors have demonstrated efficacy in suppressing cough that was previously resistant to bronchodilators and inhaled steroids, likely by modulating the inflammatory environment around sensory cough receptors. 1
Step 3: Only after the above steps fail, consider a short course (1-2 weeks) of oral corticosteroids followed by transition back to inhaled corticosteroids. 1
Diagnostic Confirmation
When physical examination and spirometry are non-diagnostic, perform bronchial challenge testing (methacholine inhalation test) to confirm airway hyperresponsiveness consistent with asthma. 1
If bronchial challenge testing is unavailable, proceed with empiric antiasthma therapy, but recognize that response to steroids alone will not exclude non-asthmatic eosinophilic bronchitis (NAEB) as a cause. 1
Non-invasive measurement of airway inflammation (sputum eosinophils, blood eosinophils, or fractional exhaled nitric oxide) has clinical utility, as eosinophilic airway inflammation predicts more favorable response to corticosteroids. 1
Critical Pitfalls to Avoid
Never use newer non-sedating antihistamines for asthma cough management—they are completely ineffective and should not be prescribed. 1
Do not jump directly to systemic corticosteroids without trying inhaled therapy first, as this exposes patients to unnecessary systemic side effects when inhaled medications are highly effective. 1, 3
Assess for persistent airway eosinophilia in patients whose cough is refractory to ICS, as this identifies those who may benefit from more aggressive anti-inflammatory therapy rather than simply increasing doses. 1
Always reconsider alternative causes of cough (upper airway cough syndrome, gastroesophageal reflux disease) before escalating asthma therapy, as chronic cough often has multiple contributing factors requiring sequential and additive treatment. 1
Duration and Monitoring
Oral corticosteroids, when necessary, should be given for 1-2 weeks (40-60 mg daily in adults, 1-2 mg/kg/day in children for 3-10 days), with no tapering required for short courses. 1
The diagnosis of cough variant asthma is established only after resolution of cough with specific antiasthma therapy, not merely by positive bronchial challenge testing. 1
Monitor for common ICS side effects including oral candidiasis (advise rinsing mouth after inhalation), dysphonia, and potential adrenal suppression with high-dose or prolonged use. 2