What cough medication should I give to someone with a cough?

What Cough Medication Should I Give?

Start with honey (a teaspoon) as first-line treatment for distressing cough, and if pharmacological therapy is needed, use dextromethorphan 30-60 mg (maximum 120 mg daily), avoiding codeine entirely due to its lack of superior efficacy and worse side effect profile. 1, 2

First-Line Non-Pharmacological Approach

• Honey is the recommended initial treatment for benign viral cough, as it may be as effective as pharmacological options and avoids medication side effects 1, 2
• A teaspoon of honey can be given as needed 3
• Honey works through central modulation of the cough reflex and provides a demulcent coating effect on irritated pharyngeal mucosa 1
• Voluntary cough suppression techniques may also reduce cough frequency without medication 1, 2

Pharmacological Treatment When Needed

Dextromethorphan: The Preferred Antitussive

If simple measures fail and the cough is distressing enough to warrant medication, dextromethorphan is the clear first choice. 1, 2

Optimal Dosing Strategy

• Standard dosing is 10-15 mg three to four times daily, with maximum daily dose of 120 mg 1
• For maximum cough suppression, 60 mg provides optimal effect - this is higher than most over-the-counter preparations 1, 2
• Standard OTC dosing is often subtherapeutic 1

Important Safety Considerations

• Check combination products carefully - some contain acetaminophen or other ingredients that could lead to overdose at higher dextromethorphan doses 1
• Do not use if taking MAOIs or within 2 weeks of stopping MAOI therapy 4
• Contains sodium metabisulfite which may cause allergic reactions in susceptible individuals 4
• Stop use if cough lasts more than 7 days, returns, or is accompanied by fever, rash, or persistent headache 4

Alternative Options for Specific Situations

For Nocturnal Cough

• First-generation sedating antihistamines (like chlorpheniramine) can suppress cough and are particularly useful when cough disrupts sleep due to their sedative properties 1, 2

For Quick Temporary Relief

• Menthol inhalation provides acute but short-lived cough suppression when administered by inhalation 1, 2
• Can be prescribed as menthol crystals or proprietary capsules 1, 2

What NOT to Use

Codeine and Other Opioids

Codeine is explicitly not recommended - it has no greater efficacy than dextromethorphan but carries significantly more adverse effects including drowsiness, nausea, constipation, and physical dependence 1, 2

• If codeine is prescribed in your region, dosing would be 15-30 mg every 4 hours as needed (maximum 240 mg/24 hours), but only if cough is distressing and first-line options have failed 3
• Morphine sulfate 2.5-5 mg every 4 hours would be second-choice only for distressing cough 3

Ineffective Options

• Guaifenesin (an expectorant) is not effective for cough suppression 1
• Standard antihistamine-decongestant combinations do not provide greater relief than placebo 5

Critical Clinical Algorithm

1. Assess cough characteristics first:

   • Dry vs. productive cough 2
   • Duration (acute vs. chronic) 2
   • Associated symptoms (fever, breathlessness, hemoptysis) 2

2. Rule out serious conditions requiring different management:

   • Increasing breathlessness → assess for asthma or anaphylaxis 2
   • Fever, malaise, purulent sputum → possible pneumonia requiring antibiotics, not antitussives 2
   • Significant hemoptysis or foreign body → specialist referral 2

3. For benign acute viral cough:

   • Start with honey 1, 2
   • Add dextromethorphan 30-60 mg if needed 1, 2
   • Consider sedating antihistamine for nighttime cough 1, 2

4. For postinfectious cough (persisting after URI but <8 weeks):

   • Try inhaled ipratropium first 1, 2
   • Consider dextromethorphan only if ipratropium fails 1, 2
   • For severe paroxysms, short-course prednisone 30-40 mg daily may be indicated 1

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan - most OTC preparations contain insufficient amounts for optimal effect 1
• Prescribing codeine - it offers no advantage and has worse side effects 1, 2
• Suppressing productive cough - avoid cough suppressants in chronic bronchitis and bronchiectasis where sputum clearance is needed 3
• Continuing antitussive therapy beyond 7 days without reassessment - persistent cough requires evaluation for underlying causes 4
• Missing underlying treatable causes - chronic cough (>3 weeks) requires diagnostic workup for asthma, GERD, post-nasal drip, or other conditions rather than continued symptomatic treatment 1, 2