What is the best course of action for a patient with a chronic cough since December, currently on prednisone, azithromycin, and bromfed (Brompheniramine, (Brompheniramine) Guaifenesin, (Guaifenesin) and Pseudoephedrine, (Pseudoephedrine))?

Chronic Cough Management: Reassess Current Treatment and Pursue Systematic Evaluation

This patient requires immediate discontinuation of azithromycin (which has no proven role in chronic cough outside specific conditions like IPF where it has failed), reassessment of the prednisone trial duration and response, and systematic evaluation for the most common causes: upper airway cough syndrome (UACS), asthma/eosinophilic bronchitis, and gastroesophageal reflux disease (GERD). 1, 2

Immediate Actions

Discontinue Ineffective Therapy

• Stop azithromycin immediately - there is no evidence supporting antibiotics for chronic stable cough, and long-term prophylactic antibiotics are not recommended for chronic bronchitis 1. Azithromycin has specifically failed to demonstrate efficacy for chronic cough even in controlled trials 3.

Assess Prednisone Trial Response

• If the patient has been on prednisone for at least 2 weeks without improvement, cough is unlikely due to eosinophilic airway inflammation and prednisone should be tapered and discontinued 1. No currently available tests can reliably exclude corticosteroid-responsive cough, so the therapeutic trial itself is diagnostic 1.
• If prednisone has been given for less than 2 weeks, complete the 2-week trial before making this determination 1.

Evaluate Bromfed Appropriateness

• Bromfed (brompheniramine/pseudoephedrine/dextromethorphan combination) may provide symptomatic relief but does not address underlying causes 4. The first-generation antihistamine component is appropriate for UACS, but this should be part of a systematic diagnostic approach rather than empiric polypharmacy 2, 5.

Systematic Diagnostic Approach

Mandatory Baseline Investigations

• Obtain chest radiograph to rule out infectious, inflammatory, and malignant conditions 1, 6.
• Perform spirometry to identify airflow obstruction and assess for asthma 1.
• Check medication list - discontinue ACE inhibitors immediately if present, as no patient with troublesome cough should continue these medications 1, 2.
• Assess smoking status - smoking cessation should be strongly encouraged as 90% of patients will have resolution of cough after quitting 1.

Most Common Causes to Address

Upper Airway Cough Syndrome (Most Likely Given Winter Onset)

• Look for pathognomonic findings: cobblestoning of posterior pharyngeal wall, constant throat clearing, seasonal pattern (winter exacerbation suggests non-allergic rhinitis) 2, 5.
• Note that approximately 20% of UACS cases present "silently" without typical nasal discharge 2, 5.

First-line treatment for UACS:

• Initiate intranasal corticosteroids (fluticasone propionate 100-200 mcg daily) as first-line therapy - effective for both allergic and non-allergic rhinitis-related cough 2, 5.
• Add ipratropium bromide nasal spray for anticholinergic drying effects, particularly useful given the patient is already on pseudoephedrine in Bromfed 2, 5.
• Trial duration must be at least 1 month before declaring treatment failure 1, 2.

Asthma/Eosinophilic Bronchitis

• Cough may be the only manifestation - normal spirometry does not exclude asthma 1.
• If spirometry shows obstruction, measure FEV1 before and after short-acting β-agonist 1.
• If prednisone trial (2 weeks) shows no response, eosinophilic inflammation is unlikely 1.
• If asthma suspected despite negative prednisone trial, consider bronchial provocation testing (methacholine challenge) 1.

Gastroesophageal Reflux Disease

• GERD is commonly overlooked and may occur without gastrointestinal symptoms 1, 2.
• Initiate intensive acid suppression with proton pump inhibitors (omeprazole 20-40 mg twice daily) plus alginates for minimum 3 months - this is critical, as shorter durations lead to treatment failure 1, 2.
• Include dietary modifications: low-fat diet, avoid coffee, tea, chocolate, citrus, and alcohol 2.

Treatment Algorithm for This Patient

Week 1-2

1. Complete 2-week prednisone trial if not already done 1.
2. Discontinue azithromycin 1, 3.
3. Obtain chest radiograph and spirometry 1.
4. Start intranasal fluticasone 100-200 mcg daily 2, 5.
5. Start ipratropium bromide nasal spray 2, 5.
6. Start PPI (omeprazole 20-40 mg twice daily) plus alginates - begin immediately as GERD treatment requires 3 months minimum 1, 2.

Week 2 Assessment

• If no response to prednisone after 2 weeks, taper and discontinue 1.
• Continue UACS treatment and GERD therapy.

Week 4-6 Follow-up

• Assess response to UACS treatment using validated cough-specific quality of life questionnaires or visual analog scales 2.
• Do not declare UACS treatment failure before 1 month 1, 2.

Month 3 Assessment

• Assess response to GERD therapy - do not declare GERD treatment failure before 3 months 1, 2.

If Chronic Bronchitis is the Diagnosis

If the patient has chronic exposure to respiratory irritants or evidence of chronic bronchitis:

• Ipratropium bromide inhaled (36 μg, 2 inhalations four times daily) is the preferred first-line treatment for improving cough in stable chronic bronchitis 1, 7.
• Short-acting β-agonists should be used to control bronchospasm and may reduce chronic cough 1.
• Expectorants (guaifenesin in Bromfed) have no proven efficacy and should not be used 1.
• Long-acting β-agonist coupled with inhaled corticosteroid should be offered for stable chronic bronchitis 1.

Critical Pitfalls to Avoid

• Never undertreat GERD: requires full 3-month trial of intensive acid suppression, not shorter durations 1, 2.
• Never declare treatment failure prematurely: topical corticosteroids require 1 month minimum, GERD treatment requires 3 months minimum 1, 2.
• Never continue ACE inhibitors in a patient with chronic cough 1, 2.
• Never use long-term prophylactic antibiotics for stable chronic cough 1.
• Never diagnose idiopathic cough without thorough assessment at a specialist cough clinic 1, 2.

Referral Indications

• Refer to specialist cough clinic if no response after adequate treatment trials (1 month for UACS, 3 months for GERD) 1, 2.
• Consider ENT referral for fibreoptic laryngoscopy if upper airway symptoms persist despite adequate treatment 1, 2.
• Multiple causes frequently coexist, requiring systematic evaluation of each potential contributor 1, 6.