What is the first line treatment for managing asthmatic cough?

First-Line Treatment for Asthmatic Cough

Inhaled corticosteroids (ICS) are the definitive first-line treatment for managing chronic cough due to asthma, whether cough is the sole presenting symptom (cough variant asthma) or accompanies other asthma manifestations. 1

Initial Treatment Strategy

Start with inhaled corticosteroids immediately upon diagnosis, as they are the only therapy that directly suppresses the eosinophilic airway inflammation driving asthmatic cough. 1

• Begin with low to medium doses (equivalent to beclomethasone 200-800 μg daily or budesonide 400 μg twice daily) using twice-daily dosing with proper inhaler technique. 2, 3
• Use large volume spacers with metered-dose inhalers to optimize drug delivery, or consider dry powder inhalers for ease of use. 3
• Beta-agonists can be added in combination with ICS but should never be used as monotherapy, as LABA monotherapy increases the risk of serious asthma-related events. 1, 2

The evidence supporting ICS as first-line therapy is graded 1B (strong recommendation, moderate quality evidence) by the American College of Chest Physicians, reflecting the robust evidence base for stepwise asthma treatment in general, though cough-specific studies remain limited. 1

Stepwise Escalation Algorithm for Incomplete Response

If cough persists after 4-8 weeks of initial ICS therapy, follow this sequential approach:

Step 1: Increase the ICS dose up to a daily equivalent of 2000 μg beclomethasone before adding other agents. 1, 2, 3

Step 2: Add a leukotriene receptor antagonist (such as montelukast) to the existing ICS regimen after reconsidering alternative causes of cough. 1, 2, 3

• Leukotriene inhibitors have demonstrated efficacy in suppressing cough previously resistant to bronchodilators and ICS by modulating inflammatory environments around sensory cough receptors. 2

Step 3: Consider short-course oral corticosteroids (prednisolone 30-40 mg daily for 1-2 weeks) only after the above steps fail, followed by transition back to inhaled therapy. 2, 3

• No tapering is required for short courses of 1-2 weeks. 2

Diagnostic Confirmation Before Treatment

• Perform bronchial challenge testing (methacholine inhalation test) to confirm airway hyperresponsiveness when physical examination and spirometry are non-diagnostic. 2, 3
• Consider non-invasive measurement of airway inflammation (sputum eosinophil counts or fractional exhaled nitric oxide) to predict corticosteroid responsiveness, as eosinophilic inflammation is associated with more favorable treatment response. 1, 3

The presence of eosinophilic airway inflammation makes corticosteroid response more likely (Grade 2B recommendation), though the evidence specifically for cough is limited compared to broader asthma populations. 1

Critical Pitfalls to Avoid

Never use non-sedating antihistamines for asthmatic cough management—they are completely ineffective and should not be prescribed. 2

Do not jump directly to systemic corticosteroids without trying inhaled therapy first, as this exposes patients to unnecessary systemic side effects when inhaled medications are highly effective. 2

Do not use long-acting beta-agonists as monotherapy at any stage, as there is no evidence supporting their use alone and they increase serious asthma-related event risk. 2

Always reconsider alternative causes of cough before escalating therapy, particularly gastroesophageal reflux disease (which commonly coexists), ACE inhibitor use, and smoking. 3

Monitoring and Duration

• Monitor for common ICS side effects including oral candidiasis, dysphonia, and potential adrenal suppression with high-dose or prolonged use. 2, 4
• Expect cough control within 1-2 weeks if due to eosinophilic airway inflammation; if no response occurs after appropriate ICS trial, reconsider the diagnosis. 3
• Use cough visual analogue scores or cough-specific quality of life questionnaires to formally quantify treatment effects. 3

The dose-response curve for ICS is relatively flat, making combination therapy with other agents preferable to simply increasing ICS doses in moderate-to-severe disease. 5, 6, 7