What are the management options for a dry cough and itchy throat?

Management of Dry Cough and Itchy Throat

For acute dry cough and itchy throat, start with dextromethorphan 60 mg as the first-line treatment, as it provides superior cough suppression with better tolerability than codeine-based alternatives. 1

Initial Management Approach

First-Line Treatments

• Dextromethorphan is the preferred antitussive for dry cough due to its superior efficacy and better side effect profile compared to codeine and other opioids 1
• Maximum cough reflex suppression occurs at 60 mg doses with prolonged effect, which is higher than typical over-the-counter preparations 1
• Be cautious with higher doses as some preparations contain other ingredients like paracetamol 1

Simple Home Remedies

• Honey and lemon mixtures should be considered before prescription medications as they provide symptomatic relief and are the simplest, cheapest approach 2, 1
• Adequate hydration helps manage symptoms and should be encouraged in all patients 1

Adjunctive Therapies

• Menthol lozenges or vapor provide acute, short-lived cough suppression through cold and menthol-sensitive receptors and can be used as adjunct therapy 2, 1, 3
• Paracetamol can be taken for associated discomfort 2

Second-Line Options

For Nocturnal Symptoms

• First-generation sedating antihistamines (like chlorpheniramine) can be particularly helpful when cough disrupts sleep 1, 4
• The sedating effect is valuable specifically for nighttime cough control 4

For GERD-Related Cough

• If gastroesophageal reflux is suspected, implement an intensive treatment regimen including antireflux diet, proton pump inhibitors, and prokinetic therapy 1

What NOT to Use

• Codeine or pholcodine have no greater efficacy than dextromethorphan but carry a much greater adverse side effect profile and are not recommended 2, 5
• Antibiotics are not helpful for viral-induced cough, even if you are bringing up phlegm 2
• Newer nonsedating antihistamines are ineffective against cough 6

Red Flags Requiring Medical Evaluation

Seek immediate medical attention if you experience: 2, 1

• Coughing up blood (hemoptysis)
• Breathlessness or progressive dyspnea
• Prolonged fever with systemic symptoms
• Underlying medical conditions (COPD, heart disease, diabetes, asthma)
• Recent hospitalization
• Symptoms persisting beyond three weeks despite treatment

Refractory Cough Management

If symptoms persist despite first and second-line treatments:

• Gabapentin may be considered for refractory chronic cough based on recommendations for unexplained chronic cough 1
• Opioids should be considered for intractable cough, particularly in palliative settings, with morphine showing efficacy and significant quality of life improvement 1, 7
• Multimodality speech pathology therapy including cough suppression techniques, vocal hygiene, and psychoeducational counseling can be beneficial 1

Important Caveats

• Most short-term coughs are due to viral infection and will resolve without specific treatment 2
• Stop smoking as it worsens cough and respiratory symptoms 2
• Practice proper cough hygiene (use handkerchief, wash hands) to prevent spreading infection 2
• When prescribing opioids for symptom control, reassess benefits and risks at 1 week and then monthly before continuing 1