What is the recommended dosage of Bensonatate for a patient with a cough?

Benzonatate Dosing for Cough

The standard dose of benzonatate is 100-200 mg three times daily, swallowed whole without chewing or crushing, with a maximum daily dose of 600 mg in divided doses. 1

Standard Dosing Regimen

• Adults and children over 10 years: 100-200 mg orally three times daily as needed for cough 1
• Maximum daily dose: 600 mg divided into three doses if necessary to control cough 1
• Frequency: Every 8 hours (three times daily) 1

Critical Administration Requirements

• Capsules must be swallowed whole - never broken, chewed, dissolved, cut, or crushed 1, 2
• Chewing or breaking capsules causes dangerous local anesthetic effects in the mouth and throat, potentially leading to choking 2
• Local anesthesia of oral mucosa represents a serious choking hazard 2

Position in Treatment Algorithm

Benzonatate occupies a fourth-line position in the stepwise approach to cough management, reserved for refractory cases 3:

1. First-line: Demulcents (simple linctus, honey and lemon, glycerol-based syrups) 3
2. Second-line: Opioid derivatives (hydrocodone, dihydrocodeine, morphine) titrated to acceptable side effects 3
3. Third-line: Peripherally-acting antitussives (levodropropizine, moguisteine, levocloperastine) 3
4. Fourth-line: Local anesthetics including benzonatate or nebulized lidocaine 3

Clinical Efficacy Evidence

• Benzonatate demonstrated 80% effectiveness in controlling cough in patients with malignant pulmonary involvement 3
• Particularly effective for opioid-resistant cough in advanced cancer patients 4, 5
• Evidence quality is low (2C/very low), based primarily on case studies rather than randomized controlled trials 5
• When combined with guaifenesin 600 mg, benzonatate 200 mg showed greater cough suppression than either agent alone in acute viral cough 6

Special Safety Considerations

Aspiration Risk

• Assess aspiration risk before initiating therapy, particularly in frail patients or those with cancer 3
• Local anesthetics like benzonatate increase aspiration risk due to oropharyngeal anesthesia 3

Contraindications

• Hypersensitivity to benzonatate or related ester-type local anesthetics (tetracaine, procaine) 2, 7

Overdose Risk

• Benzonatate overdose can cause rapid life-threatening cardiac events including cardiac arrest, even in adults 7
• As few as 30 capsules (200 mg) with alcohol caused cardiac arrest with severe acidosis in one reported case 7
• Rational prescribing and patient education are essential given the rapid onset of toxicity 7

Common Pitfalls to Avoid

• Do not use as first-line therapy - try demulcents, then opioids, then peripheral antitussives first 3
• Do not prescribe without clear instructions to swallow whole - crushing/chewing causes dangerous local anesthesia 2, 1
• Do not continue indefinitely - if no improvement after a short trial, discontinue and try alternative approaches 3
• Do not overlook aspiration risk in vulnerable populations (frail elderly, advanced cancer, neurological impairment) 3
• Do not prescribe large quantities given the serious overdose potential with relatively small amounts 7

Duration and Reassessment

• Use for short-term symptomatic relief only 3
• Cough persisting beyond 2-3 weeks requires evaluation for underlying causes rather than continued symptomatic suppression 2
• If benzonatate fails after a short course, consider nebulized lidocaine as a last resort in palliative care settings 3