What is the recommended treatment for a patient with Cough Variant Asthma (CVA)?

Treatment of Cough Variant Asthma

Initiate treatment immediately with inhaled corticosteroids (ICS) combined with an inhaled bronchodilator—this is the first-line therapy for cough variant asthma and should be started as soon as the diagnosis is established. 1, 2

Initial Treatment Regimen

• Start with inhaled corticosteroids at a dose equivalent to beclomethasone 200-800 μg daily, using twice-daily dosing with proper inhaler technique and a large volume spacer for metered-dose inhalers. 2

• Add an inhaled bronchodilator (short-acting beta-agonist) to the ICS from the outset—never use bronchodilators as monotherapy, as they must be combined with anti-inflammatory therapy. 2, 3

• Continue this initial regimen for 4-8 weeks while monitoring cough symptoms to assess treatment response. 2

Stepwise Escalation for Inadequate Response

If cough persists after 4-8 weeks of initial therapy, follow this algorithmic approach:

Step 1: Increase ICS Dose

• Escalate the inhaled corticosteroid dose up to 2000 μg beclomethasone daily equivalent before adding additional agents. 2, 3

Step 2: Add Leukotriene Receptor Antagonist

• Add montelukast or another leukotriene receptor antagonist (LTRA) to the existing ICS and bronchodilator regimen if cough remains refractory after dose escalation. 1, 2
• This combination has specific evidence supporting efficacy in cough variant asthma, with LTRAs potentially modulating inflammatory effects on sensory cough receptors. 1
• Do not add long-acting beta-agonists at this step, as there is no evidence supporting their use in cough variant asthma at step 3 of therapy. 1, 2

Step 3: Short Course of Oral Corticosteroids

• For severe or refractory cough that fails to respond to maximized inhaled therapy plus LTRA, prescribe oral prednisolone 30 mg daily (or equivalent) for 1-2 weeks, followed by transition back to inhaled corticosteroids. 1, 2, 3
• This represents the final escalation step before considering alternative diagnoses. 1

Diagnostic Confirmation Through Treatment Response

• Expect cough control within 1-2 weeks of starting oral corticosteroids if the diagnosis is correct—lack of response should prompt reconsideration of the diagnosis. 2, 4

• After establishing diagnosis with oral steroids, transition to long-term maintenance with inhaled corticosteroids, as this provides effective control without systemic side effects. 5, 4

Critical Pitfalls to Avoid

• Never use bronchodilators alone without inhaled corticosteroids, as monotherapy with beta-agonists is ineffective for controlling the underlying eosinophilic inflammation and may increase asthma-related risks. 3

• Do not jump directly to oral corticosteroids without first trying adequate doses of inhaled therapy, as this exposes patients to unnecessary systemic side effects when inhaled medications are highly effective. 3

• Assess and ensure medication compliance before escalating therapy—apparent treatment failure is often due to poor inhaler technique or non-adherence. 1

• Exclude contributing conditions before escalating therapy, particularly gastroesophageal reflux disease (which commonly coexists), ACE inhibitor use, and upper airway cough syndrome. 1, 2

Long-Term Management Considerations

• Maintain patients on inhaled corticosteroids for long-term control—discontinuation of anti-inflammatory therapy leads to recurrence of symptoms, worsening pulmonary function, and return of eosinophilic airway inflammation. 6

• Chronic anti-inflammatory therapy is appropriate for cough variant asthma given the presence of subepithelial layer thickening and airway remodeling, though to a lesser extent than typical asthma. 1

• Monitor for progression to classic asthma, as a significant proportion of patients with cough variant asthma develop wheezing and dyspnea over time if inadequately treated. 7

Assessment of Airway Inflammation in Refractory Cases

• Consider measuring sputum eosinophil counts or fractional exhaled nitric oxide (FENO) in patients with persistent cough despite treatment, as demonstration of ongoing eosinophilia identifies those who may benefit from more aggressive anti-inflammatory therapy. 1, 2

• If corticosteroid resistance is apparent, reconsider alternative diagnoses such as non-asthmatic eosinophilic bronchitis, which presents similarly but lacks airway hyperresponsiveness. 1, 2