What is the recommended treatment for a 10-day cough in an adult?

Treatment of 10-Day Cough in Adults

For a 10-day cough in an adult, start with honey and lemon as first-line treatment, and if pharmacological therapy is needed, use dextromethorphan 60 mg (not the standard 30 mg dose) for optimal cough suppression, while ruling out serious underlying causes that require medical evaluation. 1, 2

Initial Assessment and Red Flags

Before treating symptomatically, you must rule out conditions requiring immediate medical attention:

• Hemoptysis (coughing up blood) - requires immediate evaluation 3, 1
• Breathlessness or tachypnea - may indicate pneumonia, asthma, or anaphylaxis 1, 2
• Prolonged fever with malaise - suggests serious lung infection 3, 1
• Purulent sputum with systemic symptoms - may indicate bacterial pneumonia 1

Critical pitfall: Dextromethorphan should NOT be used when pneumonia assessment is needed, as characterized by tachycardia, tachypnea, fever, or abnormal chest examination findings 1, 2

Treatment Algorithm for 10-Day Cough

Step 1: Non-Pharmacological First-Line Treatment

Honey and lemon mixture is the simplest, cheapest, and often most effective first-line treatment with evidence of patient-reported benefit 1, 4. This works through central modulation of the cough reflex, where voluntary suppression may be sufficient to reduce cough frequency 1, 2.

Step 2: Pharmacological Treatment When Needed

If non-pharmacological measures are insufficient:

Dextromethorphan 60 mg is the preferred agent due to superior safety profile compared to codeine-based alternatives 1, 2, 4.

• Dosing: Maximum cough suppression occurs at 60 mg, which can be prolonged 1, 4
• Common error: Standard over-the-counter dosing (30 mg or less) is often subtherapeutic 1, 2, 4
• Caution: Some combination preparations contain acetaminophen or other ingredients - check carefully to avoid overdose 1, 4
• FDA warning: Do not use if taking MAOIs or within 2 weeks of stopping MAOI therapy 5
• FDA contraindication: Do not use for chronic cough with smoking, asthma, emphysema, or cough with excessive phlegm 5

Step 3: Alternative Options for Specific Situations

For nocturnal cough disrupting sleep:

• First-generation sedating antihistamines (e.g., diphenhydramine) can suppress cough through sedative effects 1, 2, 4
• Particularly useful when cough interferes with sleep 1, 2

For quick temporary relief:

• Menthol inhalation suppresses cough reflex acutely but has short-lived effect 1, 2, 4
• Can be prescribed as menthol crystals or proprietary capsules 1

Step 4: When to Escalate Care

Stop treatment and seek medical evaluation if: 5

• Cough persists beyond 3 weeks (requires full diagnostic workup, not continued antitussive therapy) 1, 4
• Cough comes back after improvement 5
• Fever, rash, or persistent headache develops 5
• Side effects occur 5

At 10 days, most viral coughs are self-limiting and last 1-3 weeks total 1, 2. However, if approaching the 3-week mark without improvement, diagnostic evaluation becomes necessary rather than continued symptomatic treatment 1, 4.

Agents to AVOID

Codeine and pholcodine:

• No greater efficacy than dextromethorphan 1, 2, 4
• Significantly worse adverse effect profile including drowsiness, nausea, constipation, and physical dependence 1, 4
• Should not be prescribed 1, 2

Antibiotics:

• Have no role in viral cough or postinfectious cough 1
• Should not be used due to resistance development 6

Special Considerations for Postinfectious Cough

If the 10-day cough follows a recent upper respiratory infection:

• First-line: Trial inhaled ipratropium before central antitussives 1, 4
• Second-line: Inhaled corticosteroids if cough adversely affects quality of life and persists despite ipratropium 1
• For severe paroxysms: Consider prednisone 30-40 mg daily for a short, finite period after ruling out other causes 1, 4
• Central antitussives: Only when other measures fail 1, 4

Common Pitfalls to Avoid

• Using subtherapeutic doses of dextromethorphan (less than 60 mg for maximum effect) 1, 2, 4
• Prescribing codeine-based products with no efficacy advantage but worse side effects 1, 2, 4
• Suppressing productive cough where secretion clearance is beneficial 1, 2
• Continuing antitussive therapy beyond 3 weeks without diagnostic workup 1, 4
• Not recognizing that most acute viral coughs are self-limiting and don't require prescribed medication 3, 1, 2