What can a healthcare provider prescribe for a cough?

What Healthcare Providers Can Prescribe for Cough

For distressing cough, start with honey (a teaspoon as needed), and if pharmacological treatment is necessary, prescribe dextromethorphan 30-60 mg every 4 hours (maximum 120 mg daily) as the first-line antitussive agent, avoiding codeine due to its equivalent efficacy but significantly worse side effect profile. 1, 2

First-Line Non-Pharmacological Approach

• Simple home remedies like honey and lemon should be tried first for benign viral cough, as they may be as effective as pharmacological treatments 1, 2, 3
• Honey acts through central modulation of the cough reflex and provides a demulcent coating effect on the pharynx 2
• Voluntary cough suppression techniques can reduce cough frequency in some patients 2, 3

First-Line Pharmacological Treatment

Dextromethorphan (Preferred Agent)

• Dextromethorphan is the recommended first-line antitussive due to its superior safety profile compared to opioid alternatives 2
• Dosing: 30-60 mg provides optimal cough suppression, with maximum cough reflex suppression occurring at 60 mg 2, 3
• Standard over-the-counter dosing (10-15 mg) is often subtherapeutic 2
• Maximum daily dose is 120 mg 2
• Important caveat: Check combination products carefully to avoid excessive acetaminophen or other ingredients when prescribing higher doses 2, 4
• Dextromethorphan is contraindicated with MAOIs or within 2 weeks of stopping MAOIs 4

Alternative First-Line Options for Specific Situations

• For nocturnal cough disrupting sleep: First-generation sedating antihistamines can suppress cough but cause drowsiness 1, 2, 3
• For quick but temporary relief: Menthol inhalation (prescribed as menthol crystals or proprietary capsules) provides acute but short-lived cough suppression 2, 3

Second-Line Options

For Postinfectious Cough (Persisting After Acute Infection)

• Try inhaled ipratropium bromide first before central antitussives 1, 2, 3
• For severe paroxysms: Prednisone 30-40 mg daily for a short period after ruling out other causes 2, 3
• Central acting antitussives like dextromethorphan should only be considered when other measures fail 2, 3

For Chronic Bronchitis

• Peripheral cough suppressants (levodropropizine, moguisteine) are recommended for short-term symptomatic relief 1
• Central cough suppressants (codeine, dextromethorphan) can be used for short-term relief, though evidence is stronger for peripheral agents 1

What NOT to Prescribe

• Codeine is NOT recommended despite being traditionally used - it has no greater efficacy than dextromethorphan but significantly more adverse effects (drowsiness, nausea, constipation, physical dependence, respiratory depression) 1, 2, 3, 5
• For acute cough due to upper respiratory infection: Central cough suppressants have limited efficacy and are not recommended 1, 2
• Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective 1
• Albuterol is not recommended for acute or chronic cough not due to asthma 1

Critical Safety Considerations and Pitfalls

When to Avoid Cough Suppressants Entirely

• Avoid cough suppressants in chronic bronchitis and bronchiectasis because they can cause sputum retention 1
• Do not use for productive cough where clearance of secretions is beneficial 2
• If cough persists beyond 3 weeks, discontinue antitussives and perform full diagnostic workup rather than continuing symptomatic treatment 2

Red Flags Requiring Different Management

• Cough with increasing breathlessness (assess for asthma or anaphylaxis) 3
• Cough with fever, malaise, purulent sputum (may indicate serious lung infection requiring antibiotics, not antitussives) 3
• Significant hemoptysis or possible foreign body inhalation (requires specialist referral) 3
• Symptoms suggesting pneumonia (tachycardia, tachypnea, fever, abnormal chest examination) must be ruled out first 3

Special Populations

• If pertussis is suspected: Macrolide antibiotics are indicated, not antitussives, with isolation for 5 days from start of treatment 2
• Smoking cessation should be encouraged as it leads to significant remission in cough symptoms 3

Practical Prescribing Algorithm

1. Start with honey (a teaspoon as needed) for all patients with distressing cough 1
2. If pharmacological treatment needed: Dextromethorphan 30-60 mg every 4 hours (maximum 120 mg daily) 2
3. For nighttime cough: Add first-generation antihistamine 2
4. If postinfectious cough: Try inhaled ipratropium before dextromethorphan 2, 3
5. If severe paroxysms in postinfectious cough: Short course prednisone 30-40 mg daily 2, 3
6. Never prescribe codeine - it offers no advantage over dextromethorphan 1, 2, 3