From the Guidelines
For patients with persistent cough after standard interventions, a therapeutic trial of gabapentin is recommended, starting with a dose of 300 mg once a day and escalating up to a maximum tolerable daily dose of 1,800 mg a day in two divided doses, as it has been associated with improvement in quality of life 1. When managing persistent cough, it's essential to first reassess the underlying cause and consider a step-up approach.
- A thorough evaluation for bronchial hyperresponsiveness and eosinophilic bronchitis should be conducted, and if negative, inhaled corticosteroids may not be necessary 1.
- For patients with unexplained chronic cough, a therapeutic trial of multimodality speech pathology therapy may be beneficial 1.
- Gabapentin has been shown to improve quality of life in patients with unexplained chronic cough, and its potential benefits outweigh the potential side effects, making it a viable treatment option 1.
- It's crucial to discuss the potential side effects and risk-benefit profile with patients before initiating gabapentin therapy and to reassess this profile at 6 months before continuing the drug 1.
- Proton pump inhibitor therapy is not recommended for patients with unexplained chronic cough and a negative workup for acid gastroesophageal reflux disease 1.
From the Research
Treatment Approaches for Persistent Cough
- The treatment of persistent cough after standard interventions involves a multifaceted approach, considering various causes and potentiators 2.
- Identifying and treating underlying diseases or triggers is crucial, such as asthma, chronic bronchitis, gastroesophageal reflux disease, and upper airway cough syndrome 3, 4.
- 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), a symptomatic approach with neuromodulators and/or speech pathology therapy should be considered 3.
- Neuromodulatory agents, such as gabapentin and pregabalin, may be effective in treating refractory chronic cough 4.
- Inhaled corticosteroids, such as fluticasone propionate, have been shown to reduce cough in otherwise healthy adults who do not smoke 5 and are effective in treating cough-variant asthma 6.
Evaluation and Management
- Evaluation of chronic cough should include clinical assessment, spirometry, and chest radiography to rule out concerning infectious, inflammatory, and malignant thoracic conditions 4.
- Empiric treatment should be initiated based on the suspected underlying cause, and patients with refractory chronic cough may warrant referral to a pulmonologist or otolaryngologist 4.
- A practical approach to treatment and management of cough emphasizes the importance of identifying and treating all contributing factors simultaneously 2.