What is the recommended treatment for a cough?

Treatment for Cough

For acute viral cough, start with simple home remedies like honey and lemon, and if pharmacological treatment is needed, use dextromethorphan at 60 mg for maximum cough suppression, as it has superior efficacy and safety compared to codeine-based alternatives. 1, 2

Initial Assessment and Red Flags

Before treating cough symptomatically, identify patients requiring immediate evaluation:

• Seek medical attention immediately if coughing up blood, experiencing breathlessness, having prolonged fever with feeling unwell, or if symptoms persist beyond three weeks 3
• Patients with chronic conditions (COPD, heart disease, diabetes, asthma) or recent hospitalization require physician evaluation before symptomatic treatment 3
• Rule out pneumonia first in patients with tachycardia, tachypnea, fever, or abnormal chest examination findings before using antitussives 1

First-Line Treatment Approach

Non-Pharmacological Management

• Honey and lemon mixtures are recommended as the simplest, cheapest, and often effective first-line treatment for benign viral cough 1, 2
• Most short-term coughs are due to viral infections and do not require antibiotics, even if producing phlegm 3
• Voluntary cough suppression through central modulation may be sufficient to reduce cough frequency in some patients 1, 2
• Smoking cessation is essential as it significantly improves cough symptoms 1

Pharmacological Options When Needed

Dextromethorphan (Preferred Agent)

• Dextromethorphan is the recommended first-line antitussive due to superior safety profile compared to opioid alternatives 1, 2, 4
• Optimal dosing is 60 mg for maximum cough reflex suppression, which is higher than standard over-the-counter preparations 1, 2
• Standard OTC dosing (10-15 mg three to four times daily) is often subtherapeutic 2
• A clear dose-response relationship exists, with maximum suppression at 60 mg 1, 2
• Caution: Check combination products carefully to avoid excessive amounts of other ingredients like acetaminophen when using higher doses 2

Alternative Pharmacological Options

• Menthol inhalation (as crystals or proprietary capsules) provides acute but short-lived cough suppression 1, 2
• First-generation antihistamines with sedative properties (e.g., diphenhydramine) can suppress cough and are particularly useful for nocturnal cough disrupting sleep 1, 2
• Inhaled ipratropium bromide should be tried before central antitussives for postinfectious cough 2

What NOT to Use

• Codeine and pholcodine have no greater efficacy than dextromethorphan but carry significant adverse side effect profiles including drowsiness, nausea, constipation, and physical dependence 1, 2, 5
• Central cough suppressants including dextromethorphan have limited efficacy for acute cough due to upper respiratory infection and are not routinely recommended for this indication 1
• Antibiotics are not helpful for viral cough, even with phlegm production 3

Treatment Algorithm by Clinical Scenario

Acute Viral Cough (Most Common)

1. Start with honey and lemon mixture 1, 2
2. If additional relief needed, add dextromethorphan 30-60 mg 2
3. For nighttime cough disrupting sleep, consider first-generation antihistamine 2
4. For quick but temporary relief, use menthol inhalation 2

Postinfectious Cough

1. Try inhaled ipratropium first 2
2. If ipratropium fails, consider dextromethorphan as central acting antitussive 2
3. For severe paroxysms not responding to above, consider short-course prednisone 30-40 mg daily 2

Chronic Cough (>3 weeks)

• Requires full diagnostic workup rather than continued antitussive therapy to evaluate for underlying causes 2
• Consider gastroesophageal reflux disease (GORD), which may require intensive acid suppression with proton pump inhibitors for at least 3 months 1
• For cough with upper airway symptoms, trial topical corticosteroid 1
• Perform bronchial provocation testing in patients with normal spirometry without obvious cause 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (less than 60 mg may be inadequate for severe cough) 2, 5
• Prescribing codeine-containing products which offer no advantage over dextromethorphan and have more adverse effects 1, 2, 5
• Failing to recognize that GORD-associated cough may occur without gastrointestinal symptoms 1
• Not considering smoking cessation as a primary intervention in smokers 1
• Continuing symptomatic treatment beyond 3 weeks without diagnostic evaluation 2

Special Populations and Considerations

• For patients with suspected pertussis, macrolide antibiotics are indicated with 5-day isolation from start of treatment 2
• In patients requiring assessment for pneumonia, dextromethorphan should not be used until pneumonia is ruled out 1
• Treatment success is considerably higher for patients managed in specialist cough clinics than in general respiratory settings for refractory cases 3