Oral Corticosteroids for Post-Infectious Cough
A Medrol (methylprednisolone) dose pack can be used for severe post-infectious cough, but only after ruling out other common causes and when first-line treatments have failed or when cough severely impacts quality of life. 1, 2
Treatment Algorithm
Step 1: Confirm the Diagnosis
- Post-infectious cough is defined as cough persisting 3-8 weeks following an acute respiratory infection 1, 2
- If cough has lasted >8 weeks, this is chronic cough requiring different evaluation 1, 2
- Critical pitfall: You must rule out upper airway cough syndrome (present in 33% of cases), asthma (16% of cases), and gastroesophageal reflux disease before considering oral steroids 1, 3
Step 2: First-Line Treatment (Try These First)
- Inhaled ipratropium bromide is the recommended first-line therapy as it has demonstrated efficacy in controlled trials 1, 2, 4
- Antibiotics have absolutely no role unless there is confirmed bacterial infection 1, 2, 3
- Honey (for patients >1 year old) and adequate hydration provide symptomatic relief 4
Step 3: Second-Line Treatment
- Inhaled corticosteroids should be tried next when cough adversely affects quality of life and persists despite ipratropium 1, 2
- However, evidence for inhaled corticosteroids is mixed, with some studies showing benefit and others showing no effect 5, 6, 7
Step 4: When to Use Oral Corticosteroids (Medrol Dose Pack)
Use oral prednisone/methylprednisolone (30-40 mg daily) for a short, finite period only when: 1, 2
- The patient has severe paroxysms of cough that significantly impair quality of life
- Other common causes (upper airway cough syndrome, asthma, GERD) have been specifically ruled out
- First-line treatments (ipratropium) have been tried
The evidence grade for this recommendation is low (Grade C), meaning it's based on limited data but represents expert consensus 1
Important Caveats
Why the Caution?
- The evidence for oral corticosteroids in post-infectious cough is limited—no high-quality RCTs have been completed specifically for this indication 8, 5
- Most evidence comes from cough-variant asthma studies, which is a different condition 9
- A 2013 systematic review found insufficient evidence to recommend routine use of corticosteroids for acute respiratory tract infection-related cough 5
What Must Be Excluded First
- Bacterial sinusitis (would need antibiotics, not steroids alone) 1
- Pertussis (look for cough ≥2 weeks with paroxysms, post-tussive vomiting, or whooping sound—needs macrolide antibiotics) 2, 3
- Asthma or cough-variant asthma (would benefit from inhaled corticosteroids long-term, not just a short course) 3, 9
- Upper airway cough syndrome (needs different treatment approach) 1, 3
Practical Dosing
- Use 30-40 mg prednisone (or methylprednisolone equivalent) daily 1, 2
- Keep the course short and finite (typically 5-7 days) 8
- Monitor for typical steroid adverse effects 6