When are steroids indicated for a cough in patients with or without underlying conditions such as asthma, Chronic Obstructive Pulmonary Disease (COPD), or allergic reactions?

When Are Steroids Indicated for Cough

Inhaled corticosteroids should be initiated immediately as first-line therapy for chronic cough due to asthma (including cough-variant asthma) or nonasthmatic eosinophilic bronchitis, always combined with inhaled bronchodilators for asthma cases. 1, 2

Asthma-Related Cough

Initial Treatment

• Start combination therapy with inhaled corticosteroids plus inhaled bronchodilators immediately for any patient with chronic cough due to asthma, whether cough is the sole symptom (cough-variant asthma) or accompanies other asthma symptoms 1, 2
• Beta-agonists must be used in combination with inhaled corticosteroids rather than as monotherapy, as long-acting beta-agonist monotherapy increases the risk of serious asthma-related events 2
• This recommendation carries a Grade 1B evidence level, reflecting very strong evidence for stepwise asthma treatment 1

Stepwise Escalation for Incomplete Response

When initial therapy fails to adequately control cough, follow this specific sequence:

1. First step: Increase the inhaled corticosteroid dose before adding other agents 1, 2
2. Second step: Add a leukotriene receptor antagonist to the existing inhaled corticosteroid and bronchodilator regimen after reconsidering alternative causes of cough 1, 2
   • Leukotriene inhibitors have demonstrated efficacy in suppressing cough previously resistant to bronchodilators and inhaled steroids 2
3. Third step: Consider oral corticosteroids only after the above steps fail 1, 2, 3
   • Use a short course of 1-2 weeks of oral corticosteroids (40-60 mg daily in adults) followed by transition back to inhaled corticosteroids 1, 2
   • No tapering is required for short courses 2

Diagnostic Confirmation

• Perform bronchial challenge testing to confirm airway hyperresponsiveness when physical examination and spirometry are non-diagnostic 1, 2
• Non-invasive measurement of airway inflammation (such as sputum eosinophilia) has clinical utility, as eosinophilic airway inflammation predicts more favorable response to corticosteroids 2

Nonasthmatic Eosinophilic Bronchitis (NAEB)

When to Suspect and Treat

• Consider NAEB in patients with chronic cough who have normal chest radiograph, normal spirometry, and no evidence of variable airflow obstruction or airway hyperresponsiveness 1
• Diagnosis is confirmed by the presence of airway eosinophilia (via sputum induction or bronchial wash) and improvement in cough following corticosteroid therapy 1

Treatment Approach

• Inhaled corticosteroids are first-line treatment for NAEB (Grade B recommendation) 1
• If response to inhaled corticosteroids is incomplete, step up the dose and consider adding a leukotriene inhibitor after reconsidering alternative causes 1
• Oral corticosteroids should be given if symptoms are persistently troublesome and/or eosinophilic airway inflammation progresses despite high-dose inhaled corticosteroids 1
• When a causal allergen or occupational sensitizer is identified, avoidance is the best treatment 1

Chronic Bronchitis/COPD Exacerbations

Acute Exacerbations

• A short course (10-15 days) of systemic corticosteroid therapy should be given for acute exacerbations of chronic bronchitis 1
• IV therapy in hospitalized patients and oral therapy for ambulatory patients have both proven effective (Grade A recommendation) 1
• A 2-week trial is equivalent to an 8-week trial, so use the shorter duration to minimize side effects 1

Stable Chronic Bronchitis

• Inhaled corticosteroids are recommended when airflow obstruction is severe or very severe (FEV1 <50%) and when there is a history of frequent exacerbations 1
• For stable patients, ipratropium bromide and short-acting beta-agonists are preferred over corticosteroids for cough control 1

When Steroids Are NOT Indicated

Acute Cough from Respiratory Tract Infection

• There is insufficient evidence to recommend routine use of inhaled corticosteroids for acute RTI in otherwise-healthy adults 4
• Results from trials are mixed, with only some showing benefits in mean cough score 4
• Oral corticosteroids have not been studied for this indication 4

Critical Contraindications

• Never use corticosteroids as primary treatment for status asthmaticus or acute asthma episodes requiring intensive measures 5
• Budesonide is not a bronchodilator and is not indicated for rapid relief of acute bronchospasm 5
• Do not use in patients with hypersensitivity to the specific corticosteroid 5

Important Clinical Pitfalls to Avoid

Common Errors

• Do not jump directly to systemic steroids without trying inhaled therapy first, as this exposes patients to unnecessary systemic side effects when inhaled medications are highly effective 2, 3
• Do not prescribe newer non-sedating antihistamines for asthma cough management, as they are completely ineffective 2, 3
• Do not use expectorants for chronic bronchitis cough, as beneficial effects have not been proven 1

Safety Considerations

• Patients transferring from systemic to inhaled corticosteroids require particular care, as deaths due to adrenal insufficiency have occurred during this transition 5
• Patients previously maintained on ≥20 mg/day of prednisone are most susceptible to adrenal insufficiency 5
• Use with caution in patients with active or quiescent tuberculosis, untreated systemic fungal/bacterial/viral/parasitic infections, or ocular herpes simplex 5
• Monitor for local effects including oral candidiasis; patients should rinse mouth after inhalation 5

Duration and Monitoring

• For chronic asthma or NAEB, inhaled corticosteroids must be used regularly (typically twice daily) for maximum benefit, which may not be achieved for 4-6 weeks or longer 5
• When oral corticosteroids are necessary, limit to 1-2 weeks for asthma/NAEB 1, 2 or 10-15 days for COPD exacerbations 1
• Long-term use increases risk of decreased bone mineral density, cataracts, glaucoma, and growth velocity reduction in children 5