What prescription cough medicine does not increase blood pressure?

Prescription Cough Medicines That Do Not Increase Blood Pressure

For prescription cough suppression without blood pressure concerns, benzonatate is the optimal choice as it acts peripherally without cardiovascular effects, while dextromethorphan (though often available over-the-counter) can be prescribed at therapeutic doses of 30-60 mg and also does not affect blood pressure. 1, 2, 3

Primary Recommendation: Benzonatate

Benzonatate is a peripherally-acting antitussive that anesthetizes stretch receptors in the respiratory passages without any cardiovascular effects, making it ideal for patients with hypertension or blood pressure concerns. 3

• Acts within 15-20 minutes with effects lasting 3-8 hours 3
• Has no inhibitory effect on the respiratory center at recommended dosages 3
• Offers an alternative mechanism to central-acting agents with a different adverse effect profile 2
• Particularly useful when opioids are contraindicated 2

Alternative: Prescription-Strength Dextromethorphan

Dextromethorphan is recommended as the first-line antitussive due to its superior safety profile and lack of cardiovascular effects, though standard over-the-counter dosing is often subtherapeutic. 1, 2

Optimal Dosing Strategy

• Maximum cough reflex suppression occurs at 60 mg, which is higher than typical OTC preparations 1, 2
• Standard prescription dosing: 10-15 mg three to four times daily, with maximum daily dose of 120 mg 2
• For severe cough, a single 60 mg dose can provide prolonged suppression 1, 2

Important Caution

• Check combination products carefully to avoid excessive amounts of acetaminophen or other ingredients when prescribing higher doses 2

Agents to AVOID Due to Blood Pressure Concerns

Decongestant-Containing Combinations

Many over-the-counter cough preparations contain pseudoephedrine or phenylephrine, which can elevate blood pressure and should be avoided. 4

• Oral decongestants like pseudoephedrine can cause blood pressure elevation, particularly in patients with uncontrolled hypertension 4
• Should be used with extreme caution in patients with cardiovascular disease, cerebrovascular disease, or hyperthyroidism 4
• Patients receiving oral decongestants should be monitored for blood pressure changes 4

Opioid-Based Antitussives: Not Recommended

Codeine and hydrocodone are NOT recommended as they offer no efficacy advantage over dextromethorphan but have significantly greater adverse effects, and lack robust evidence in modern trials. 1, 5, 2

• Codeine has no greater efficacy than dextromethorphan but carries risks of drowsiness, nausea, constipation, and physical dependence 1, 2
• The FDA recently restricted hydrocodone-containing cough medications to adults ≥18 years due to safety concerns 4, 6
• Limited efficacy for URI-related cough despite being effective in chronic bronchitis 5

Clinical Algorithm for Prescription Cough Medicine Selection

Step 1: Assess Patient Cardiovascular Status

• If hypertension or cardiovascular disease present: Avoid all decongestant-containing preparations 4
• Verify patient is not taking stimulant medications (e.g., ADHD medications) that could interact 4

Step 2: Choose Appropriate Agent

• First choice: Benzonatate for peripheral action without systemic effects 3
• Alternative: Prescription-strength dextromethorphan at therapeutic doses (30-60 mg) 1, 2

Step 3: Consider Adjunctive Therapy for Nocturnal Cough

• First-generation antihistamines with sedative properties (e.g., diphenhydramine) can suppress cough and are particularly useful for nighttime cough 1, 2
• These do not affect blood pressure but cause drowsiness, making them suitable for bedtime use 1

Step 4: Non-Pharmacologic Approaches

• Simple home remedies like honey and lemon may be as effective as pharmacological treatments for benign viral cough 1, 2
• Menthol inhalation provides acute but short-lived suppression without cardiovascular effects 1, 2

Common Pitfalls to Avoid

1. Prescribing combination cough/cold products without checking for decongestant content - Many contain pseudoephedrine or phenylephrine that elevate blood pressure 4

2. Using subtherapeutic doses of dextromethorphan - Standard OTC dosing (15-30 mg) is often insufficient; therapeutic doses are 30-60 mg 1, 2

3. Defaulting to codeine-based products - These have no efficacy advantage over dextromethorphan but significantly more adverse effects 1, 5, 2

4. Overlooking benzonatate as a prescription option - This peripherally-acting agent is ideal for patients with cardiovascular concerns 3

5. Continuing antitussive therapy beyond 3 weeks - Cough persisting beyond this timeframe requires diagnostic workup rather than continued suppression 2