What is the best course of treatment for a patient with a history of influenza (flu) treated with prednisone and Tamiflu (oseltamivir), who now presents with a persistent and debilitating cough?

Management of Persistent Debilitating Cough Post-Influenza

Start with inhaled ipratropium bromide (DuoNeb) 2-3 puffs four times daily as first-line therapy for your persistent post-influenza cough—do not extend prednisone or add it back unless severe paroxysms persist after failing ipratropium and inhaled corticosteroids. 1

Why Ipratropium First, Not More Prednisone

Your patient has post-infectious cough, defined as cough persisting 3-8 weeks following acute respiratory infection. 1 The treatment algorithm is clear and evidence-based:

• Inhaled ipratropium bromide has the strongest evidence for attenuating post-infectious cough in controlled trials, with expected response within 1-2 weeks 1, 2
• Prednisone is explicitly reserved as third-line therapy only after failure of both ipratropium and inhaled corticosteroids, and only when severe paroxysms significantly impair quality of life 1, 2
• Extending prednisone is not recommended as it provides no additional benefit for post-viral cough and increases adverse effects without addressing the underlying airway inflammation pattern 3

Step-by-Step Treatment Algorithm

First-Line: Inhaled Ipratropium

• Prescribe ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily 1
• This can be given as DuoNeb (ipratropium/albuterol combination) if bronchospasm is present 1
• Allow 1-2 weeks for response 1

Second-Line: Add Inhaled Corticosteroids (If No Response)

• If cough persists despite ipratropium and adversely affects quality of life, add inhaled corticosteroids 1, 2
• Fluticasone 220 mcg or budesonide 360 mcg twice daily 1
• Allow up to 8 weeks for full response, as this suppresses airway inflammation and bronchial hyperresponsiveness 1

Third-Line: Consider Oral Prednisone (Only If Severe)

• Reserve prednisone 30-40 mg daily for 5-10 days only if all of the following are met: 1, 2
  • Severe paroxysms that significantly impair quality of life
  • Failure of both ipratropium and inhaled corticosteroids
  • Other common causes (UACS, asthma, GERD) have been ruled out or adequately treated

What NOT to Do

• Do not prescribe antibiotics unless there is clear evidence of bacterial pneumonia—they have no role in post-infectious cough and contribute to resistance 4, 1
• Do not use prednisone as first-line therapy for post-infectious cough 2
• Do not extend the prednisone course from the initial influenza treatment, as oral corticosteroids do not reduce symptom duration or severity in acute lower respiratory tract infection without asthma 3

Special Considerations

If Cough Variant Asthma Is Suspected

• A diagnostic-therapeutic trial of prednisone 30 mg daily for 2 weeks can establish the diagnosis of cough variant asthma 1, 5, 6
• However, this should only be considered after ruling out other causes and if the clinical picture suggests asthma (nocturnal cough, response to bronchodilators, personal/family history of atopy) 5, 6

Red Flags Requiring Reassessment

• If fever develops or recurs, reassess for pneumonia with clinical evaluation and consider chest X-ray 7
• If cough persists beyond 8 weeks total duration, reclassify as chronic cough and systematically evaluate for UACS, asthma, and GERD 1, 2
• Hemoptysis, weight loss, or night sweats require chest X-ray and advanced evaluation 1

Supportive Measures

• Recommend adequate hydration, rest, honey and lemon for symptomatic relief 1
• Consider guaifenesin 200-400 mg every 4 hours (up to 6 times daily) as safe over-the-counter option 1
• First-generation antihistamine at bedtime if nocturnal cough is prominent 1