What is the recommended treatment for a patient presenting with a cough, considering age, medical history, and current medications?

Cough Suppressant Management

For dry, non-productive cough, dextromethorphan at 60 mg is the preferred pharmacological agent due to superior safety compared to codeine-based alternatives, though simple home remedies like honey and lemon should be tried first. 1

Initial Assessment and Red Flags

Before prescribing any cough suppressant, immediately rule out serious conditions requiring specific treatment rather than symptomatic suppression:

• Do not use cough suppressants if the patient has tachycardia, tachypnea, fever, or abnormal chest examination findings suggesting pneumonia 2
• Refer urgently for hemoptysis, significant breathlessness, or suspected foreign body inhalation 1
• Stop ACE inhibitors if the patient is taking them, as this is a common reversible cause 3
• Counsel smoking cessation in smokers, as this alone produces significant cough remission 1

Treatment Algorithm by Cough Duration

Acute Cough (< 3 weeks)

First-line approach:

• Start with honey and lemon mixture—this is the simplest, cheapest option with patient-reported benefit 1, 4
• Voluntary cough suppression through central modulation may be sufficient 1, 4

If pharmacological treatment needed:

• Dextromethorphan 60 mg provides maximum cough reflex suppression 1, 4
• Standard over-the-counter doses (10-15 mg) are often subtherapeutic 1, 2
• Dosing: 10-15 mg three to four times daily, maximum 120 mg/day 4, 2
• Caution: Check combination products for acetaminophen or other ingredients when using higher doses 1, 4

Alternative options:

• First-generation sedating antihistamines (diphenhydramine, chlorpheniramine) for nocturnal cough disrupting sleep 1, 2
• Menthol inhalation provides acute but short-lived relief 1, 4

Avoid:

• Codeine and pholcodine have no greater efficacy than dextromethorphan but significantly more adverse effects (drowsiness, nausea, constipation, physical dependence) 1, 4, 2

Subacute Cough (3-8 weeks)

Determine if postinfectious or not 3:

For postinfectious cough:

• First-line: Inhaled ipratropium 1, 4
• Second-line: Inhaled corticosteroids if quality of life is affected and ipratropium fails 1
• For severe paroxysms: Prednisone 30-40 mg daily for a short, finite period after ruling out other causes 1, 4
• Central antitussives (dextromethorphan) only when other measures fail 1, 4
• Antibiotics have no role unless bacterial sinusitis or early Bordetella pertussis 1

If non-postinfectious: Manage as chronic cough 3

Chronic Cough (> 8 weeks)

Do not suppress cough symptomatically—instead, systematically treat the underlying causes 3:

1. Upper airway cough syndrome (UACS): First-generation antihistamine/decongestant 3
2. Asthma: Bronchial provocation testing or empiric corticosteroid trial 3, 1
3. Non-asthmatic eosinophilic bronchitis (NAEB): Induced sputum for eosinophils or empiric corticosteroids 3
4. GERD: Intensive acid suppression with proton pump inhibitors for at least 3 months 3, 1

Use sequential and additive therapy as more than one cause may be present 3

For unexplained chronic cough after full workup:

• Multimodality speech pathology therapy first 1
• Gabapentin 300 mg once daily, escalating to maximum 1,800 mg daily in divided doses, with 6-month reassessment 1

Critical Pitfalls to Avoid

• Using subtherapeutic dextromethorphan doses (< 60 mg for maximum effect) 1, 4
• Suppressing productive cough where secretion clearance is beneficial (pneumonia, bronchiectasis, COPD) 1, 2
• Prescribing codeine-based products which offer no advantage but worse side effects 1, 4, 2
• Continuing antitussive therapy beyond 3 weeks without full diagnostic workup 4, 2
• Failing to consider GERD as a cause, which may occur without gastrointestinal symptoms 1
• Not recognizing that cough may be the only manifestation of common causes like asthma or GERD 3

Special Populations

Chronic kidney disease: No dose adjustment needed for dextromethorphan as it is hepatically metabolized via CYP2D6, not renally excreted 4

Pregnancy/breastfeeding: Ask a health professional before use 5

Children under 6 years: Use special measuring device for accurate dosing 5

Productive vs. Non-Productive Cough

For wet/productive cough with significant sputum:

• Do not suppress cough—it serves a physiological clearance function 2
• Guaifenesin may be considered as an expectorant, though evidence is limited 2
• Treat the underlying condition (pneumonia with antibiotics, etc.) 2

For dry/non-productive cough:

• Antitussive therapy is appropriate using the algorithm above 1, 2