What are some non-narcotic prescription cough syrup options?

Non-Narcotic Prescription Cough Syrup Options

For non-narcotic prescription cough suppression, dextromethorphan at 30-60 mg is the first-line agent, with benzonatate 100-200 mg three to four times daily as an alternative when dextromethorphan is contraindicated or ineffective. 1, 2

First-Line Non-Narcotic Options

Dextromethorphan (Prescription Strength)

• Optimal dosing is 30-60 mg for effective cough suppression, significantly higher than typical over-the-counter preparations which are often subtherapeutic 1, 3
• Maximum daily dose is 120 mg 4, 1
• Standard dosing of 10-15 mg three to four times daily can be used for mild to moderate cough 4
• Superior safety profile compared to codeine-based antitussives with no physical dependence risk 1, 3
• Acts centrally to suppress the cough reflex 1
• Should only be used for non-productive cough; avoid in productive cough where secretion clearance is beneficial 3, 5

Important caveat: When prescribing higher doses (60 mg), check combination products carefully to avoid excessive amounts of acetaminophen or other ingredients 1

Benzonatate (Tessalon Perles)

• Dosing: 100-200 mg orally three to four times daily 4, 2
• Non-narcotic oral antitussive with a different mechanism than dextromethorphan 2
• Particularly useful when opioids are contraindicated 1
• Critical safety warning: Capsules must be swallowed whole; chewing or dissolving can cause local anesthesia of the oral mucosa and risk of choking 2

Second-Line Non-Narcotic Options

Peripherally-Acting Antitussives (Limited Availability)

For opioid-resistant cough, the following may be considered where available:

• Levodropropizine 75 mg three times daily 4
• Moguisteine 100-200 mg three times daily 4
• Levocloperastine 20 mg three times daily 4
• Sodium cromoglycate (inhaled) 10 mg four times daily 4

These agents are not available in many countries but offer alternatives when standard treatments fail 4

Nebulized Local Anesthetics (For Refractory Cases)

Reserved for intractable cough unresponsive to other approaches:

• Nebulized lidocaine 5 mL of 0.2% three times daily 4
• Nebulized bupivacaine 5 mL of 0.25% three times daily 4
• Critical safety consideration: Assess aspiration risk before use, as local anesthetics increase aspiration risk 4
• First dose should be given as inpatient to monitor for reflex bronchospasm 4
• Avoid food and drink for at least 1 hour after administration 4

Adjunctive Non-Narcotic Options

Sedating Antihistamines (For Nocturnal Cough)

• First-generation antihistamines can be added specifically for nighttime cough due to sedative properties 1, 3
• Particularly suitable when cough disrupts sleep 1, 3
• Cause drowsiness, which is therapeutic for nocturnal symptoms but limits daytime use 1, 3

Inhaled Ipratropium

• Should be tried before central antitussives for postinfectious cough 1, 3
• Addresses the bronchospastic component that may contribute to cough 1

Short-Course Corticosteroids

• Prednisone 30-40 mg daily for severe paroxysms of postinfectious cough 1, 3
• Reserved for cases that have failed initial treatment with ipratropium and dextromethorphan 1
• Use only for short periods (typically 2 weeks) 4

Practical Treatment Algorithm

1. Start with dextromethorphan 30-60 mg for non-productive cough 1, 3
2. Add sedating antihistamine if nocturnal cough is prominent 1, 3
3. Switch to benzonatate 100-200 mg three to four times daily if dextromethorphan is ineffective or contraindicated 4, 2
4. For postinfectious cough, try inhaled ipratropium first before central antitussives 1, 3
5. Consider peripherally-acting antitussives (levodropropizine, moguisteine) if available and standard treatments fail 4
6. Reserve nebulized local anesthetics for truly refractory cases with appropriate safety monitoring 4

Critical Pitfalls to Avoid

• Do not use subtherapeutic doses of dextromethorphan (15-30 mg is often insufficient); use 30-60 mg for optimal effect 1, 3
• Never prescribe codeine-containing products as they have no greater efficacy than dextromethorphan but significantly more adverse effects including drowsiness, constipation, nausea, and physical dependence 1, 3
• Avoid antitussives for productive cough where secretion clearance is beneficial 3, 5
• Discontinue treatment if no improvement after 2-4 weeks and reassess for underlying causes 4
• Check for drug interactions with MAOIs before prescribing dextromethorphan 6
• Ensure benzonatate capsules are swallowed whole, never chewed or dissolved 2

Duration of Treatment

• Limit treatment to short-term use (typically less than 7 days for acute cough) 3
• If cough persists beyond 3 weeks, perform full diagnostic workup rather than continuing antitussive therapy 1
• Discontinue if no improvement after a short trial and try alternative approaches 4