What is the best medication to manage a persistent, unimproved cough (chronic cough)?

From the Guidelines

For a non-improved cough, I recommend starting with gabapentin at a dose escalation schedule beginning at 300 mg once a day, with additional doses being added each day as tolerated up to a maximum tolerable daily dose of 1,800 mg a day in two divided doses, as it has been associated with improvement in quality of life in a randomized controlled clinical trial 1. This approach is based on the most recent and highest quality study available, which suggests that gabapentin can be an effective treatment for unexplained chronic cough, with a potential benefit in improving quality of life. Some key points to consider when managing a non-improved cough include:

• Identifying the underlying cause of the cough, as treatment will vary depending on the cause
• Considering a therapeutic trial of multimodality speech pathology therapy, as it may be beneficial for some patients with unexplained chronic cough 1
• Avoiding the use of inhaled corticosteroids in patients with negative tests for bronchial hyperresponsiveness and eosinophilia, as they are not recommended in this scenario 1
• Staying hydrated, using a humidifier, and avoiding irritants like smoke can complement medication therapy and help alleviate cough symptoms. It is essential to note that the effectiveness of these medications and therapies varies based on the underlying cause of the cough, which is why proper diagnosis is crucial for persistent symptoms. If the cough persists beyond 2-3 weeks, it is recommended to see a healthcare provider, as you may need prescription medications like inhaled corticosteroids for asthma-related cough, antibiotics for bacterial infections, or codeine-based cough suppressants for severe cases. In patients with chronic or acute bronchitis, peripheral cough suppressants, such as levodropropizine and moguisteine, are recommended for the short-term symptomatic relief of coughing, with a substantial benefit and a grade of recommendation of A 1. However, the most recent study 1 takes precedence, and gabapentin is the recommended treatment for unexplained chronic cough.

From the FDA Drug Label

WARNINGS Ask a doctor before use if you have cough that occurs with too much phlegm (mucus) cough that lasts or is chronic such as occurs with smoking, asthma, chronic bronchitis, or emphysema Stop use and ask a doctor if cough lasts more than 7 days, comes back, or is accompanied by fever, rash, or persistent headache. These could be signs of a serious condition.

The best medication to manage non-improved cough is not explicitly stated in the provided drug labels. However, dextromethorphan (PO) and guaifenesin (PO) are mentioned as options for cough suppression and relief.

• Dextromethorphan (PO) is a cough suppressant, but the labels do not provide information on its effectiveness for non-improved cough 2, 2.
• Guaifenesin (PO) is not explicitly indicated for non-improved cough, but it is used for relieving coughs with excess mucus 3. It is essential to consult a doctor before using any medication, especially if the cough persists or is accompanied by other symptoms.

From the Research

Medication Options for Non-Improved Cough

• The effectiveness of various cough medications has been studied, with some research indicating that codeine, dextromethorphan, and guaifenesin are equally effective in relieving cough symptoms 4.
• However, other studies suggest that there is inadequate evidence for the efficacy of antitussive or expectorant drugs against acute cough 5.
• In the case of chronic cough, a targeted and appropriate approach is necessary, and treatments should be recommended and effective 6.
• A practical approach to treatment and management of cough emphasizes the importance of identifying and treating all contributing factors 7.

Treatment Considerations

• For acute cough, history-taking, exclusion of red flags, and a physical examination are the basis of diagnostic evaluation 5.
• If an acute, uncomplicated bronchitis is likely, no laboratory tests, sputum diagnostics, or chest x-rays should be performed, and antibiotics should not be administered 5.
• In cases of chronic cough, a chest X-ray is usually ordered, and further investigations are carried out in accordance with the most probable suspected diagnosis 6.
• Coughs that are refractory to treatment or unexplained require individualized treatment, including pharmacological and non-pharmacological approaches, and regular re-evaluation 6.