What is the most effective antitussive (cough suppressant) for inpatients on the ward?

From the Guidelines

For inpatients on the ward, opioids such as codeine or morphine are often the most effective cough suppressants when the cough is non-productive and causing significant discomfort or disrupting rest, as suggested by the most recent and highest quality study 1.

Key Considerations

• Before administering any cough suppressant, ensure the cough is not productive or serving a protective function, as suppressing a productive cough can lead to sputum retention and respiratory complications.
• Consider underlying causes of the cough that may require specific treatment, such as asthma, GERD, or ACE inhibitor use.
• Cough suppressants work by acting on the cough center in the medulla oblongata of the brain, reducing the cough reflex sensitivity.
• For patients with renal or hepatic impairment, dose adjustments may be necessary, and monitoring for side effects such as constipation, drowsiness, and respiratory depression is important, especially with opioid-based suppressants.

Recommended Doses

• Codeine: 30-60 mg qid
• Morphine: 5 mg (single-dose trial of Oramorph; if effective 5-10 mg slow-release morphine bid)

Alternatives

• Dextromethorphan (10-15 mg tid or qid) is a good alternative for patients who cannot tolerate opioids or when there are concerns about opioid dependence.
• Levodropropizine (75 mg tid) may be considered as an alternative, although its availability may vary by country.

Important Notes

• The choice of treatment may be dictated primarily by availability rather than pharmacologic parameters.
• Local anesthetics, such as nebulized lidocaine, may be considered when other pharmacologic approaches have failed to manage cough.
• Aspiration risk should be assessed prior to the use of local anesthetics for cough treatment. As supported by 1 and 1, opioids are the most effective cough suppressants for inpatients on the ward, with codeine and morphine being the most commonly used options. However, it's essential to consider the patient's individual needs, potential side effects, and underlying causes of the cough before selecting a treatment option.

From the FDA Drug Label

Purpose Cough suppressant

Drug Facts Active Ingredients Purpose (in each teaspoonful (5 mL)) Codeine Phosphate USP 10 mg ................... Antitussive

Package/Label Principal Display Panel Compare to Delsym® active ingredient Dextromethorphan Polistirex Extended-Release Oral Suspension Cough Suppressant

The best cough suppressant for inpatients on the ward is dextromethorphan (PO) or codeine (PO), as both are labeled as cough suppressants or antitussives 2, 3, 2.

• Dextromethorphan is available in different formulations, including extended-release oral suspension 2.
• Codeine is available in combination with an expectorant, guaifenesin 3. However, the choice between dextromethorphan and codeine should be based on individual patient needs and clinical judgment.

From the Research

Cough Suppressants for Inpatients

• Codeine is a commonly used antitussive for the symptomatic relief of dry or nonproductive cough in clinical practice 4.
• Codeine has been shown to have a greater antitussive action than placebo in healthy subjects, and its efficacy is comparable to dextromethorphan 30 mg 5.
• However, the use of codeine should be limited to only when and as long as it is clinically necessary, particularly in children, due to its potential for adverse effects 4, 6.

Comparison with Other Opioids

• Codeine, dihydrocodeine, and tramadol are considered "weak" opioid analgesics, but they can have the same dose-dependent adverse effects as morphine, including respiratory depression 6.
• The potency of codeine and tramadol is influenced by the cytochrome P450 isoenzyme CYP2D6 genotype, which can lead to overdosing or underdosing in some individuals 6, 7.
• There is no evidence that "weak" opioids are less risky than morphine at its lowest effective dose, and they may require more vigilance due to their variable efficacy and potential for serious overdose 6.

Pharmacologic Therapy for Acute Pain

• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain, but opioids may be necessary for severe or refractory acute pain 8.
• Opioids should be used with caution and attention to minimizing risk, including in patients on medication-assisted therapy for opioid use disorder 8.