What medication is recommended for a patient with a recurrent cough in the winter months, worsened by snoring and improved with warmer temperatures?

Recommended Treatment for Recurrent Winter Cough Worsened by Snoring

For this patient with recurrent winter cough worsened by snoring and improved with warmer temperatures, prescribe a first-generation antihistamine combined with a decongestant (such as brompheniramine with sustained-release pseudoephedrine) as empiric therapy for upper airway cough syndrome (UACS). 1

Clinical Reasoning

Most Likely Diagnosis: Upper Airway Cough Syndrome (UACS)

The clinical presentation strongly suggests UACS (formerly called postnasal drip syndrome):

• Seasonal pattern (winter months) indicates likely allergic or non-allergic rhinitis exacerbated by cold, dry air 1
• Snoring worsening symptoms suggests upper airway inflammation and increased postnasal drainage, as snoring is significantly associated with nocturnal cough (OR 3.68) 2
• Temperature-dependent improvement points to environmental/upper airway etiology rather than lower airway disease 1

First-Line Empiric Treatment

The ACCP guidelines explicitly recommend empiric therapy for UACS with a first-generation antihistamine/decongestant (A/D) preparation before extensive diagnostic workup. 1

Specific regimen:

• Brompheniramine with sustained-release pseudoephedrine (dexbrompheniramine 6 mg twice daily plus pseudoephedrine 120 mg twice daily has been shown efficacious in randomized controlled trials) 3
• Alternative: Chlorpheniramine 4 mg at bedtime or diphenhydramine 25-50 mg at bedtime if nocturnal symptoms predominate 3

Why First-Generation Antihistamines Work

• Anticholinergic properties (not just histamine blockade) reduce mucus secretion and postnasal drainage 3
• Sedative effects are therapeutic for nocturnal cough, making them particularly suitable when snoring worsens symptoms 1, 3
• Newer-generation antihistamines (loratadine, desloratadine, terfenadine) are explicitly ineffective for cough because they lack anticholinergic properties 1, 3

Important Safety Screening Required

Before prescribing first-generation antihistamines with decongestants, screen for contraindications:

Antihistamine Component Concerns:

• Benign prostatic hypertrophy (difficulty urinating is primary concern in older men) 3
• Glaucoma (increased intraocular pressure risk) 3
• Urinary retention 3

Decongestant Component Concerns:

• Hypertension (pseudoephedrine can worsen blood pressure) 3
• Cardiac arrhythmias (can cause tachycardia/palpitations) 3
• Insomnia (stimulant effects) 3
• Difficulty with urination 3

Alternative Options if Contraindications Exist

If Antihistamine/Decongestant Contraindicated:

1. Intranasal corticosteroids (first-line for allergic rhinitis component) 3
2. Dextromethorphan 30-60 mg (not standard OTC doses which are subtherapeutic; maximum suppression at 60 mg) 1, 4, 5
3. Menthol inhalation (provides acute but short-lived relief) 1, 4
4. Simple remedies like honey and lemon (may be as effective as pharmacological treatments for benign cough) 1, 4

If Productive Cough Develops:

• Avoid cough suppressants entirely as they interfere with beneficial secretion clearance 3
• Focus on treating underlying UACS rather than suppressing cough 3

Expected Response and Follow-Up

• Improvement should occur within 1-2 weeks of starting first-generation A/D therapy 1
• If no response after empiric trial, proceed to sinus imaging to evaluate for chronic sinusitis (which can be clinically silent) 1
• Consider asthma if cough persists despite UACS treatment, as asthma commonly presents with seasonal cough and is significantly associated with snoring (OR 2.03) 1, 2

Common Pitfalls to Avoid

• Do not prescribe newer-generation antihistamines (loratadine, desloratadine, cetirizine) for cough—they are ineffective 1, 3
• Do not use codeine or pholcodine—they have no greater efficacy than dextromethorphan but significantly more adverse effects 1, 4
• Do not ignore screening for contraindications in elderly males, particularly prostatic hypertrophy and glaucoma 3
• Do not use subtherapeutic doses of dextromethorphan if chosen (standard OTC doses often inadequate; 60 mg provides maximum suppression) 1, 4