When should steroids be started in a patient with cough?

When to Start Steroids in Cough

Start inhaled corticosteroids immediately as first-line therapy for any patient with chronic cough suspected to be asthma-related, combined with an inhaled bronchodilator; reserve systemic (oral) corticosteroids only for severe or refractory cases that fail to respond after 2-4 weeks of inhaled therapy. 1, 2, 3

Initial Treatment: Inhaled Corticosteroids First

Begin with inhaled corticosteroids plus inhaled bronchodilators as the foundation of treatment for asthmatic cough. 1, 3 This approach is recommended by the American College of Chest Physicians with Grade A evidence for patients with cough due to asthma, whether cough is the sole symptom or accompanies other asthma manifestations. 1

Specific Dosing for Inhaled Therapy

• Start budesonide inhalation suspension at 0.5 mg once daily or 0.25 mg twice daily for patients previously on bronchodilators alone or inhaled corticosteroids. 4
• For patients transitioning from oral corticosteroids, initiate budesonide at 0.5 mg twice daily. 4
• If once-daily treatment fails to provide adequate control after 2 weeks, increase the total daily dose or administer as divided doses. 4

Why Inhaled Steroids Work

• Inhaled corticosteroids reduce cough severity and decrease sputum eosinophilic cationic protein levels in patients with chronic cough. 5
• In cough-variant asthma specifically, inhaled corticosteroids relieve cough in 90% of patients and decrease bronchial hyperresponsiveness, reducing the risk of progression to classic asthma. 6, 7

When to Escalate to Systemic Corticosteroids

Reserve oral corticosteroids for severe and/or refractory cough that persists despite adequate trials of inhaled therapy. 1, 2, 3

Stepwise Escalation Algorithm Before Systemic Steroids

1. First, increase the inhaled corticosteroid dose if initial therapy is inadequate. 3
2. Second, add a leukotriene receptor antagonist to the existing inhaled corticosteroid and bronchodilator regimen after excluding poor compliance or alternative diagnoses. 1, 3
3. Third, consider assessing airway inflammation (sputum eosinophilia) if available, as persistent eosinophilia identifies patients who benefit from more aggressive anti-inflammatory therapy. 1
4. Only after these steps fail, proceed to systemic corticosteroids. 1, 3

Systemic Corticosteroid Protocol

• When systemic steroids are indicated, prescribe a short course of 1-2 weeks of oral corticosteroids (40-60 mg daily in adults, 1-2 mg/kg/day in children for 3-10 days), followed by transition back to inhaled corticosteroids. 1, 3
• No tapering is required for short courses of 1-2 weeks. 3
• This approach carries Grade B recommendation from the American College of Chest Physicians. 1

Critical Diagnostic Considerations

Always consider asthma as a potential cause of chronic cough, as it is commonly associated with this symptom. 1

Confirming Asthma as the Cause

• Perform methacholine challenge testing to confirm airway hyperresponsiveness when physical examination and spirometry are non-diagnostic. 1, 3
• A diagnosis of cough-variant asthma is established only after resolution of cough with specific antiasthmatic therapy. 1
• Non-invasive measurement of airway inflammation (sputum eosinophilia) predicts more favorable response to corticosteroids. 3

When Inhaled Steroids Don't Work

• Inhaled corticosteroids are ineffective for chronic cough NOT associated with sputum eosinophilia. 8 Patients without eosinophilic inflammation show no response to budesonide treatment, even at high doses for 4 weeks. 8
• This highlights the importance of confirming asthma or eosinophilic bronchitis before committing to prolonged inhaled steroid therapy. 8

Common Pitfalls to Avoid

• Never 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, 3, 9
• Do not use newer non-sedating antihistamines for asthma cough management, as they are completely ineffective. 1, 2, 3, 9
• Avoid using inhaled corticosteroids for acute bronchospasm or status asthmaticus, as they are not indicated for relief of acute episodes. 4
• Do not assume treatment failure after only a few days; allow 2-4 weeks for inhaled corticosteroids to demonstrate efficacy. 5, 6

Monitoring and Side Effects

• Monitor for oral candidiasis and dysphonia with inhaled corticosteroid use; advise patients to rinse mouth after inhalation. 3, 4
• Watch for paradoxical bronchospasm; if it occurs, discontinue budesonide and institute alternative therapy. 4
• Monitor growth in pediatric patients receiving long-term inhaled corticosteroids. 4
• Systemic corticosteroids carry risks of adrenal suppression, bone mineral density reduction, and immunosuppression, reinforcing the importance of reserving them for refractory cases only. 4

Special Populations

• For patients transitioning from chronic oral corticosteroids to inhaled therapy, taper systemic steroids slowly to avoid adrenal insufficiency. 4
• In children 12 months to 8 years with asthmatic cough, start with 0.25 mg once daily if symptomatic and not responding to non-steroidal therapy. 4