Recommended Cough Syrup for Acute Cough
Dextromethorphan is the recommended first-line cough suppressant for acute cough, with therapeutic dosing of 30-60 mg (not the typical 15-30 mg over-the-counter dose), as it has superior safety compared to codeine-based products and is safe in patients with asthma or COPD. 1, 2
First-Line Pharmacologic Approach
Start with dextromethorphan at therapeutic doses (30-60 mg for maximum cough reflex suppression, rather than standard OTC 15-30 mg doses which are often subtherapeutic). 1, 2
Dextromethorphan is specifically recommended by the American College of Chest Physicians as the preferred antitussive due to its superior safety profile compared to opioid alternatives. 1
Maximum cough suppression occurs at 60 mg, which can be given as a single dose for severe cough or divided as 10-15 mg three to four times daily (maximum 120 mg/day). 2
Critical Safety Considerations for Asthma/COPD Patients
Avoid albuterol for cough not due to asthma - it is specifically not recommended for acute or chronic cough in non-asthmatic patients. 3
Avoid codeine and other opioid antitussives (codeine, pholcodine, hydrocodone) - they offer no efficacy advantage over dextromethorphan but carry significantly greater adverse effects including respiratory depression, constipation, and potential dependence. 3, 1, 4
Codeine has been shown in controlled studies to have no effect on cough in COPD patients despite earlier uncontrolled reports. 5, 6
Alternative Options Based on Cough Type
For Acute Bronchitis (Productive Cough):
- Peripheral cough suppressants (levodropropizine, moguisteine) are recommended for short-term symptomatic relief with Grade A evidence. 3
- Hypertonic saline and erdosteine are recommended short-term to increase cough clearance. 3, 1
For Upper Respiratory Infection (URI):
- Ipratropium bromide is the only inhaled anticholinergic recommended for cough suppression in URI. 3, 1
- Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough and are not recommended by ACCP guidelines. 3
- However, the British Thoracic Society still recommends dextromethorphan as preferred over codeine if pharmacologic treatment is chosen. 3, 1
For Nocturnal Cough:
- First-generation antihistamines with sedative properties may be suitable for nighttime cough disrupting sleep. 3, 1
Non-Pharmacologic First-Line Approach
- Simple home remedies like honey and lemon should be tried first before pharmacologic options, as they are often as effective as medications for benign viral cough with minimal side effects. 1, 7
Products to Avoid
Over-the-counter combination cold medications are not recommended until randomized controlled trials prove effectiveness (exception: older antihistamine-decongestant combinations). 3
Zinc preparations are not recommended for acute cough due to common cold. 3
Avoid decongestant-containing preparations (pseudoephedrine, phenylephrine) in patients with hypertension or cardiovascular disease. 2
Do not use codeine - it has no greater efficacy than dextromethorphan but much greater adverse side effect profile and is specifically not recommended. 3, 4
Common Pitfalls
Using subtherapeutic doses of dextromethorphan (standard OTC 15-30 mg is insufficient; therapeutic doses are 30-60 mg). 1, 2
Prescribing codeine-based products out of habit - these offer no advantage and significantly more harm. 3, 1, 4
Continuing antitussive therapy beyond 3 weeks without diagnostic workup for persistent cough. 2, 7
Using combination products without checking for additional ingredients like decongestants or excessive acetaminophen. 1, 7