What are the recommended medications for a dry cough?

Recommended Medications for Dry Cough

First-Line Treatment

For dry cough, dextromethorphan at 60 mg is the recommended first-line treatment due to its superior safety profile and proven efficacy, while codeine should be avoided despite being commonly prescribed. 1, 2

Dextromethorphan Dosing

• The optimal dose is 60 mg for maximum cough reflex suppression, not the standard over-the-counter doses of 15-30 mg which are subtherapeutic. 1, 2
• Dextromethorphan is specifically recommended for chronic or acute bronchitis with substantial benefit (Grade A recommendation). 3, 1
• It has a superior safety profile compared to opioid alternatives, with fewer adverse effects including less drowsiness, nausea, constipation, and no risk of physical dependence. 1, 2
• Duration should be limited to short-term use, typically less than 7 days. 2

Alternative First-Line Options

Peripheral Cough Suppressants

• Levodropropizine and moguisteine are recommended for short-term symptomatic relief in patients with chronic or acute bronchitis (Grade A recommendation). 3, 1
• These peripheral agents work by anesthetizing stretch receptors in the respiratory passages rather than acting centrally. 4

Benzonatate

• Benzonatate is FDA-approved for symptomatic relief of cough, acting peripherally by anesthetizing stretch receptors in the respiratory passages, lungs, and pleura. 4
• It begins to act within 15-20 minutes with effects lasting 3-8 hours, and has no inhibitory effect on the respiratory center at recommended dosages. 4

Second-Line Treatment

Ipratropium Bromide

• Ipratropium bromide is the only inhaled agent recommended for cough suppression with substantial benefit (Grade A recommendation). 3, 1
• It should be tried before central antitussives in postinfectious cough. 1, 2
• This is particularly useful for URI-related cough where central suppressants have limited efficacy. 3, 1

First-Generation Antihistamines

• Promethazine or other first-generation sedating antihistamines can be added specifically for nocturnal cough due to their sedative properties. 2
• These are particularly suitable when cough interferes with sleep, though caution is warranted in elderly patients due to increased fall risk. 5

Non-Pharmacologic Options

• Simple home remedies like honey and lemon may be as effective as pharmacological treatments for benign viral cough and should be tried first. 1, 2
• Menthol inhalation provides acute but short-lived cough suppression and can be used as an adjunct. 2

What NOT to Use

Codeine and Other Opioids

• Codeine is NOT recommended as first-line despite being commonly prescribed, as it has no greater efficacy than dextromethorphan but significantly worse adverse effects including drowsiness, nausea, constipation, and risk of physical dependence. 1, 2, 5
• For chronic bronchitis, codeine may be considered only if dextromethorphan fails (Grade B recommendation), but this is a lower grade than dextromethorphan's Grade A. 3

Other Ineffective Agents

• Albuterol is not recommended for cough not due to asthma (Grade D recommendation). 3, 1
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) lack evidence of efficacy and are not recommended. 3, 5
• Central cough suppressants have limited efficacy for URI-related cough and are not recommended for this indication (Grade D recommendation). 3, 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (15-30 mg instead of 60 mg) is the most common error. 1, 2
• Prescribing codeine-based antitussives despite lack of efficacy advantage and increased side effects. 1, 5
• Using central cough suppressants for URI-related cough where they have limited efficacy. 3, 1
• Applying cough suppressants to productive cough where secretion clearance is beneficial—antitussives should be avoided in these cases. 2