What is the best treatment approach for an adult patient with no underlying medical conditions experiencing a cough?

Best Treatment for Cough in Adults Without Underlying Medical Conditions

For an otherwise healthy adult with acute cough, start with honey and lemon as a home remedy, and if pharmacological treatment is needed, prescribe dextromethorphan 60 mg for maximum cough suppression. 1

Initial Assessment and Red Flags

Before initiating treatment, assess for warning signs that require immediate evaluation: 1

• Hemoptysis (coughing up blood)
• Significant breathlessness or dyspnea
• Prolonged fever beyond expected viral illness duration
• Underlying cardiopulmonary disease (COPD, heart failure)

Treatment Algorithm Based on Cough Duration

Acute Cough (< 3 weeks)

Most acute cough is caused by viral upper respiratory tract infections ("common cold") or acute bronchitis and is self-limiting. 2

First-line therapy:

• Combination first-generation antihistamine plus decongestant is the most effective treatment for cough due to common cold. 2
• Honey and lemon mixtures provide effective symptomatic relief. 3

Pharmacological options if needed:

• Dextromethorphan 60 mg provides maximum cough reflex suppression and prolonged relief, while standard over-the-counter doses are subtherapeutic. 1 4
• Use sugar-free formulations for diabetic patients. 1
• Guaifenesin can help loosen phlegm and thin bronchial secretions for productive cough. 5

Critical pitfall to avoid:

• Antibiotics have absolutely no role in treating post-viral cough and should never be prescribed for this indication, except in cases of suspected pertussis. 1
• Codeine or pholcodine should not be prescribed due to adverse effects and lack of greater efficacy than dextromethorphan. 1

Subacute Cough (3-8 weeks) - Post-Infectious Cough

Consider post-infectious cough when cough persists following acute respiratory infection for 3-8 weeks. 6

Treatment approach:

• Inhaled ipratropium bromide has demonstrated efficacy in attenuating post-infectious cough in controlled trials. 6, 1
• If cough persists despite ipratropium and adversely affects quality of life, consider inhaled corticosteroids. 6
• For severe paroxysms, consider prednisone 30-40 mg daily for a short, finite period after ruling out other common causes (upper airway cough syndrome, asthma, GERD). 6
• Central acting antitussives such as codeine and dextromethorphan should be considered when other measures fail. 6

Important timing consideration:

• Post-viral cough typically resolves within 2-3 weeks; if cough persists beyond 3 weeks, mandatory reassessment is required rather than continuing antitussive therapy. 1
• If cough persists beyond 8 weeks, consider diagnoses other than post-infectious cough. 6

Chronic Cough (> 8 weeks)

For chronic cough, the most effective therapy is identifying and treating the specific underlying cause with targeted therapy. 3

Systematic evaluation for the three most common causes (often multiple causes coexist): 3

1. Upper Airway Cough Syndrome (UACS):

   • Begin with first-generation antihistamine/decongestant combination. 3

2. Asthma or Nonasthmatic Eosinophilic Bronchitis:

   • Initiate inhaled corticosteroids combined with long-acting β-agonists for suspected asthma. 3
   • For nonasthmatic eosinophilic bronchitis, inhaled corticosteroids are first-line. 3

3. Gastroesophageal Reflux Disease (GERD):

   • Initiate empiric treatment with proton pump inhibitors if cough persists after addressing UACS and asthma. 3
   • Add prokinetic therapy if little or no response to PPI therapy. 3

Sequential and additive therapy is crucial because more than one cause is frequently present. 6

Symptomatic Relief for Refractory Cough

When cough interferes with daily activities or sleep despite treating underlying causes:

• Consider codeine or dextromethorphan-containing antitussives for symptomatic relief. 3
• For idiopathic chronic cough refractory to other treatments, consider low-dose morphine (reserved for severe cases). 3, 7
• Gabapentin is the first choice neuromodulator for chronic refractory cough, with opioids or macrolides as alternatives. 8

Common Pitfalls to Avoid

• Do not rely solely on cough characteristics (wet vs. dry) for diagnosis, as they have limited diagnostic value. 3
• Avoid treating only one potential cause, as multiple factors often contribute to chronic cough. 3
• Do not continue empiric antitussive therapy indefinitely without reassessment. 1
• Consider referral to a cough specialist if cough persists despite sequential trials of therapy for common causes. 3