What medications and dosages are recommended for a patient with a chronic cough, considering potential underlying causes such as upper airway cough syndrome, asthma, and gastroesophageal reflux disease (GERD)?

Medications and Dosages for Chronic Cough

Initial Treatment Based on Most Common Causes

For chronic cough, treatment should target the three most common etiologies—upper airway cough syndrome (UACS), asthma, and gastroesophageal reflux disease (GERD)—using specific medications and dosages based on the clinical presentation, with empiric trials preferred over extensive testing. 1

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Upper Airway Cough Syndrome (UACS) Treatment

First-Line Therapy

• First-generation antihistamine/decongestant combination is the most effective initial treatment for UACS 1, 2
  • Specific effective combinations include:
    • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 2
    • Azatadine maleate plus sustained-release pseudoephedrine sulfate 2
  • Start with once-daily dosing at bedtime for 2-3 days to minimize sedation, then advance to twice-daily therapy 2
  • Most patients improve within days to 2 weeks 2

Add-On Therapy if No Response After 1-2 Weeks

• Intranasal corticosteroids should be added if symptoms persist 1, 2
  • Fluticasone propionate 100-200 mcg daily (1-2 sprays per nostril once daily) 1, 2, 3
  • Continue for a minimum 1-month trial to assess response 1, 2
  • Maximum dose: 200 mcg/day (2 sprays per nostril) 3

Alternative for Contraindications to Decongestants

• Ipratropium bromide nasal spray for patients with hypertension or cardiovascular contraindications 1, 2
  • 42 mcg per spray, 2 sprays per nostril 4 times daily 2
  • Provides anticholinergic drying effects without systemic cardiovascular side effects 2

Important Monitoring

• Monitor blood pressure after initiating decongestant therapy, as they can worsen hypertension and cause tachycardia 2
• Common side effects include dry mouth, transient dizziness, insomnia, urinary retention, jitteriness, and increased intraocular pressure in glaucoma patients 2

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Asthma/Cough Variant Asthma Treatment

Diagnostic Trial with Corticosteroids

• If UACS treatment fails after 2 weeks, proceed to evaluate for asthma 1, 2
• Oral prednisolone 30 mg daily for 2 weeks is the diagnostic trial to exclude corticosteroid-responsive cough 1
  • If no response occurs, eosinophilic airway inflammation is unlikely 1

Maintenance Therapy

• Inhaled corticosteroids are the mainstay of treatment for confirmed asthma-related cough 1
  • Follow national asthma guidelines for dosing and step-up therapy 1
• Leukotriene receptor antagonists have evidence for use at step 3 of asthma management 1
• Long-acting beta-agonists have no evidence for cough variant asthma at step 3 1

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Gastroesophageal Reflux Disease (GERD) Treatment

Empiric Medical Therapy

For patients with suspected GERD-related cough (with or without typical GI symptoms), intensive antireflux therapy should include all of the following components: 1

1. Dietary and Lifestyle Modifications

• No more than 45 g of fat in 24 hours 1
• Avoid coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 1
• Head of bed elevation and avoid meals within 3 hours of bedtime 1
• No smoking 1
• Limit vigorous exercise that increases intra-abdominal pressure 1

2. Acid Suppression Therapy

• Proton pump inhibitors (PPIs) are the cornerstone of acid suppression 1
  • Omeprazole 20-40 mg twice daily before meals for at least 8 weeks (up to 3 months) 1, 2, 4
  • Alternative: Lansoprazole 30 mg once daily 5
• H2-receptor antagonists may be added for nocturnal acid breakthrough 1
  • Ranitidine 300 mg daily improved cough in 54% of patients 1
• Alginates or antacids sufficient to control heartburn and regurgitation 1

3. Prokinetic Therapy

• Add prokinetic agents either initially or if no response to acid suppression and lifestyle modifications 1

4. Eliminate Medications Worsening Reflux

• Discontinue bisphosphonates, nitrates, calcium channel blockers, theophylline, and progesterones when possible 1

Critical Timing Considerations

• GI symptoms typically respond within 4-8 weeks, but cough improvement may take up to 3 months 1, 5
• If empiric treatment fails after 3 months, objective testing (24-hour esophageal pH monitoring) is recommended before concluding GERD is not the cause 1

Important Caveat

• In patients WITHOUT heartburn or regurgitation, PPIs alone are NOT recommended (Grade 1C), as they are unlikely to resolve cough when used in isolation 1, 5
• These patients require the full intensive regimen including diet modification and weight loss 1

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Postinfectious Cough (Subacute: 3-8 Weeks)

First-Line Therapy

• Inhaled ipratropium bromide may attenuate postinfectious cough 1
  • 500 mcg via nebulizer 4-6 times daily for acute symptoms 6
  • Or 2-4 puffs via MDI four times daily for maintenance 6

Second-Line Therapy

• Inhaled corticosteroids when cough adversely affects quality of life and persists despite ipratropium 1

Severe Paroxysms

• Prednisone 30-40 mg per day for a short, finite period when other common causes (UACS, asthma, GERD) have been ruled out 1

Symptomatic Relief

• Central antitussives (codeine or dextromethorphan) when other measures fail 1
  • Dextromethorphan 30 mg every 6 hours 6

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Refractory/Unexplained Chronic Cough

When to Consider Refractory

• After 4-6 weeks of empiric treatment for the most likely diagnoses (UACS, asthma, GERD) without resolution 5
• Only after confirming ACE inhibitor discontinuation and smoking cessation 1, 5

Neuromodulatory Therapy

• Low-dose morphine is the preferred symptomatic treatment for refractory chronic cough 5
• Gabapentin is an alternative with weaker evidence 5
  • Start at 300 mg once daily and escalate as tolerated 2
• Pregabalin is another alternative 5
• Baclofen has weaker evidence 5

Speech Pathology Therapy

• Multimodality speech pathology therapy is suggested for unexplained chronic cough (Grade 2C) 2

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Critical Pitfalls to Avoid

• Never continue ACE inhibitors in any patient with troublesome chronic cough—this is one of the most common reversible causes 1, 5
• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa 2
• Never suppress cough when clearance is important (pneumonia, bronchiectasis) 1, 5
• Newer-generation antihistamines are ineffective for non-allergic UACS 2
• Do not assume GERD is ruled out simply because empiric PPI therapy failed—the regimen may not have been intensive enough 1
• Maintain all partially effective treatments rather than discontinuing them prematurely, as multiple causes often coexist 2

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Treatment Algorithm Summary

1. Discontinue ACE inhibitors immediately if present 1, 5
2. Start first-generation antihistamine/decongestant for UACS 1, 2
3. Add intranasal fluticasone 100-200 mcg daily if no response after 1-2 weeks 1, 2
4. If symptoms persist after 2 weeks, proceed to evaluate for asthma with prednisolone 30 mg daily for 2 weeks 1, 2
5. Simultaneously initiate intensive GERD therapy with omeprazole 20-40 mg twice daily, dietary modifications, and lifestyle changes for at least 8 weeks (up to 3 months) 1, 2
6. If refractory after 3 months, consider neuromodulatory therapy or speech pathology 2, 5

This algorithmic approach resolves chronic cough in 82-100% of cases when properly applied 1, 5