What is the initial treatment for upper airway cough syndrome?

Initial Treatment for Upper Airway Cough Syndrome

Start with a first-generation antihistamine/decongestant combination (such as dexbrompheniramine plus sustained-release pseudoephedrine or azatadine plus sustained-release pseudoephedrine) as empiric first-line therapy for upper airway cough syndrome. 1, 2

Treatment Algorithm

Step 1: Empiric First-Line Therapy

• Begin with a first-generation antihistamine/decongestant combination before extensive diagnostic workup 1, 2
• Specific effective combinations include:
  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 2, 3
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 2, 3
• First-generation antihistamines are superior to newer non-sedating antihistamines due to their anticholinergic properties, which are critical for treating the cough component 4, 2
• Newer-generation antihistamines are ineffective for non-allergic UACS and should not be used 2, 3

Step 2: Dosing Strategy to Minimize Side Effects

• Start with once-daily dosing at bedtime for a few days to minimize sedation, then increase to twice-daily therapy 2, 3
• Monitor for common side effects: dry mouth and transient dizziness 2, 3
• Watch for serious side effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 2, 3
• Monitor blood pressure after initiating decongestants as they can worsen hypertension 4

Step 3: Expected Response Timeline

• Most patients improve within days to 2 weeks of initiating therapy 2, 3
• If no response after 1-2 weeks with the antihistamine-decongestant combination, proceed to sinus imaging 1

Step 4: Add Intranasal Corticosteroids (When Indicated)

• Do not use intranasal corticosteroids as initial monotherapy for UACS 4
• Add intranasal corticosteroids (fluticasone 100-200 mcg daily) for a 1-month trial if the antihistamine-decongestant combination is insufficient after 1-2 weeks 4, 3
• For allergic rhinitis specifically, intranasal corticosteroids can be started immediately alongside antihistamines as first-line therapy 4, 2
• Once cough resolves, continue intranasal corticosteroids for 3 months to maintain symptom control and prevent recurrence 4

Step 5: Alternative Options for Non-Responders

• Ipratropium bromide nasal spray is an alternative for patients who don't respond to antihistamine/decongestant combinations or have contraindications (such as uncontrolled hypertension) 2, 3
• For chronic sinusitis: minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae, plus 3 weeks of oral antihistamine/decongestant, plus 5 days of nasal decongestant, followed by 3 months of intranasal corticosteroids 3

Critical Pitfalls to Avoid

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 2, 3
• Do not discontinue intranasal corticosteroids prematurely—the 3-month continuation after cough resolution is critical for preventing recurrence 4
• Recognize "silent" UACS: approximately 20% of patients have no obvious postnasal drip symptoms yet still respond to treatment 2, 3
• The diagnosis is confirmed by response to specific therapy, not by symptoms or physical findings alone 1, 5

When to Suspect Other Causes

• If symptoms persist despite adequate upper airway treatment for 2 weeks, proceed with sequential evaluation for asthma and gastroesophageal reflux disease 4
• Consider sinus imaging if no response to empiric antihistamine/decongestant therapy 1
• UACS accounts for only 14% of chronic cough as a sole cause; most patients have multiple contributing factors 6