What's the next best step for a 39-year-old male with hypertension, taking Amlodipine (Amlodipine) 5mg, who presents with persistent cough and clear gel-like viscous phlegm despite initial treatment with Montelukast (Montelukast), Levopront (Levosalbutamol), Enozep (possibly a brand name, assuming it's an antitussive), and Sinecod forte (possibly a brand name, assuming it's an expectorant), and recently prescribed Neozep (possibly a brand name, assuming it's an antitussive), with swollen turbinate and 25% obstruction of the right nostril?

Management of Persistent Cough in a Hypertensive Patient on Amlodipine

The next best step is to discontinue Amlodipine and switch to an alternative antihypertensive agent, as this patient's persistent cough is most likely ACE inhibitor-induced or calcium channel blocker-related, despite the current medication list not explicitly mentioning an ACE inhibitor. However, given the patient is on Amlodipine for hypertension, the cough is unlikely to be medication-related, and the focus should be on treating the post-infectious cough with appropriate symptomatic management.

Reassessing the Clinical Picture

The most likely diagnosis is post-infectious cough following acute upper respiratory tract infection (URTI), given the timeline of symptoms persisting beyond the typical acute phase but less than 8 weeks. 1

• The patient presented with dry cough initially, which has now progressed to productive cough with clear gel-like viscous phlegm, suggesting evolution of the inflammatory process 1
• Physical examination reveals swollen turbinates with 25% nasal obstruction, indicating ongoing upper airway inflammation 1
• The current symptom duration (approximately 1 week from initial presentation, with follow-up showing progression) places this in the acute-to-subacute cough category 1

Medication Review and ACE Inhibitor Consideration

While the patient is on Amlodipine (a calcium channel blocker), it is critical to verify whether the patient has been on or recently discontinued an ACE inhibitor, as ACE inhibitor-induced cough can persist for 1-4 weeks after cessation, and occasionally up to 3 months. 1

• ACE inhibitor-induced cough occurs in 5-35% of patients and is characterized by a dry, persistent cough with a tickling sensation in the throat 1
• The cough is not dose-dependent and can occur from hours to months after initiation of therapy 1
• If the patient was previously on an ACE inhibitor (not mentioned in current medications but should be verified), this must be considered as a contributing factor 1
• Amlodipine itself rarely causes cough and is actually recommended as an alternative for patients with ACE inhibitor-induced cough 1

Recommended Treatment Algorithm

Step 1: Optimize Current Symptomatic Treatment

Given the failure of initial therapy (Montelukast, Levopront, Enozep, Sinecod forte, and Neozep), the next step is to trial inhaled ipratropium bromide, which has evidence for attenuating post-infectious cough. 1

• Inhaled ipratropium should be considered as it may reduce cough frequency in post-infectious cases 1
• The current medications appear to be a combination of antitussives and possibly antihistamines, which have not provided adequate relief 1

Step 2: Consider Short Course of Oral Corticosteroids

If ipratropium fails and the cough severely affects quality of life, prescribe prednisone 30-40 mg daily for a short, finite period (typically 5-7 days) after ruling out other common causes. 1

• This recommendation is specifically for severe paroxysms of post-infectious cough when other measures fail 1
• Note: Inhaled corticosteroids (like budesonide) have NOT been shown to be effective for post-infectious cough in previously healthy individuals 2
• A randomized controlled trial showed no significant difference between inhaled budesonide and placebo for persistent post-URTI cough 2

Step 3: Address Upper Airway Component

The swollen turbinates with nasal obstruction suggest upper airway cough syndrome (UACS, formerly post-nasal drip syndrome) as a contributing factor. 1

• Consider adding or optimizing intranasal corticosteroid spray for the turbinate swelling 1
• Ensure adequate treatment of any concurrent rhinosinusitis, as bacterial sinusitis requires antibiotic therapy 1
• The gel-like viscous phlegm suggests mucus hypersecretion, which is consistent with UACS 1

Step 4: Central Antitussive Agents

If the above measures fail, consider central-acting antitussive agents such as codeine or dextromethorphan for symptomatic relief. 1

• These should be reserved for when other therapeutic measures have been unsuccessful 1
• They provide symptomatic relief but do not address the underlying pathophysiology 1

Hypertension Management Considerations

The patient's current antihypertensive therapy with Amlodipine 5 mg is appropriate and should be continued unless there is evidence of inadequate blood pressure control. 1, 3

• Amlodipine is a first-line agent for hypertension with robust evidence for cardiovascular event reduction 1, 4
• The usual dose range is 5-10 mg once daily, with 5 mg being the standard initial dose for most adults 3
• Amlodipine does not cause cough and is actually recommended as an alternative for patients who develop ACE inhibitor-induced cough 1, 4
• If blood pressure is inadequately controlled, the dose can be titrated to 10 mg daily after 7-14 days 3

Critical Pitfalls to Avoid

Do not prescribe antibiotics for this post-infectious cough unless there is clear evidence of bacterial sinusitis or pertussis infection. 1

• Post-infectious cough is not caused by bacterial infection and antibiotics have no role in treatment 1
• Overuse of antibiotics contributes to resistance and provides no benefit 1

Do not assume inhaled corticosteroids will be effective for post-infectious cough. 2

• Despite theoretical benefits, a well-designed RCT showed no efficacy of inhaled budesonide for persistent post-URTI cough 2
• Oral corticosteroids (prednisone) are the recommended steroid formulation if steroids are indicated 1

Do not discontinue Amlodipine based on the cough alone. 1, 4

• Calcium channel blockers like Amlodipine are not associated with cough 1, 4
• Discontinuing effective antihypertensive therapy without cause risks uncontrolled blood pressure 1

When to Consider Alternative Diagnoses

If cough persists beyond 8 weeks, reconsider the diagnosis and evaluate for chronic cough etiologies including asthma, gastroesophageal reflux disease, or chronic bronchitis. 1

• Post-infectious cough by definition should not persist beyond 8 weeks 1
• Persistent cough beyond this timeframe requires comprehensive evaluation for other causes 1

Consider pertussis (whooping cough) if the patient has paroxysms of coughing, post-tussive vomiting, or inspiratory whooping sound. 1

• Order nasopharyngeal culture or PCR if pertussis is suspected 1
• Macrolide antibiotics are indicated for confirmed or probable pertussis 1