What is the recommended treatment for a patient with cough and allergies, considering their age, medical history (including respiratory issues like asthma), and the severity of their symptoms?

Prescription Treatment for Cough and Allergies

For patients with cough and allergies, start with intranasal fluticasone 100-200 mcg daily combined with a first-generation antihistamine/decongestant combination (such as chlorpheniramine with pseudoephedrine), as this addresses both the allergic inflammation and provides rapid symptom relief. 1, 2

Initial Treatment Algorithm

For Allergic Rhinitis with Cough (Upper Airway Cough Syndrome)

First-line therapy should include:

• Intranasal corticosteroid: Fluticasone propionate 100-200 mcg (1-2 sprays per nostril) once daily for at least 1 month 1, 2

  • Maximum benefit may take several days to weeks 2
  • Can be dosed as 200 mcg once daily or 100 mcg twice daily with similar efficacy 2

• First-generation antihistamine/decongestant combination: Most effective evidence-based treatment for upper airway cough syndrome 1

  • Examples include dexbrompheniramine/pseudoephedrine or chlorpheniramine/pseudoephedrine 1, 3
  • Improvement expected within days to 1-2 weeks 1
  • Older-generation antihistamines are superior to newer non-sedating antihistamines due to anticholinergic properties 1

If Underlying Asthma is Present

For patients with known asthma or respiratory issues:

• Maintain current asthma controller therapy with inhaled corticosteroids plus long-acting beta-agonists as appropriate for asthma severity 4
• Step 2 (mild persistent): Low-dose inhaled corticosteroid 4
• Step 3 (moderate persistent): Low-dose inhaled corticosteroid plus long-acting beta-agonist, OR medium-dose inhaled corticosteroid 4
• Consider subcutaneous allergen immunotherapy for patients with confirmed allergic asthma 4

For Post-Infectious Cough (if symptoms persist 3-8 weeks after viral infection)

If cough began with viral upper respiratory infection:

• Inhaled ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily as first-line treatment 5

  • Strongest evidence for attenuating post-infectious cough 5
  • Response expected within 1-2 weeks 5

• Reserve oral prednisone 30-40 mg daily for 5-10 days only for severe paroxysms significantly impairing quality of life after other causes ruled out 5

Second-Line Options

If inadequate response after 1-2 weeks:

• Add ipratropium bromide nasal spray 42 mcg per spray, 2 sprays per nostril 4 times daily for anticholinergic drying effects without systemic cardiovascular side effects 1

• Consider inhaled corticosteroids (fluticasone 220 mcg or budesonide 360 mcg twice daily) if quality of life significantly affected, allowing up to 8 weeks for full response 5

• High-volume saline nasal irrigation (150 mL) to mechanically remove secretions and improve mucociliary function 1

Symptomatic Cough Relief

For symptomatic control:

• Dextromethorphan 60 mg for maximum cough reflex suppression 5, 6

  • More effective than typical over-the-counter dosing 5
  • May be most effective non-prescription option 4, 6

• Codeine with chlorpheniramine combination for dry cough, particularly valuable if cough disturbs sleep 3

  • Sedation from first-generation antihistamines beneficial for nocturnal cough 5

Critical Considerations Based on Patient Factors

For Patients with Hypertension or Cardiovascular Disease

• Avoid oral decongestants (pseudoephedrine) as they can worsen hypertension and cause tachycardia 1
• Use ipratropium bromide nasal spray as alternative for anticholinergic drying without systemic effects 1
• Monitor blood pressure after initiating any decongestant therapy 1

For Patients with Asthma

• Ensure maintenance therapy optimized before adding treatments 5
• Monitor for asthma exacerbation, a recognized complication of viral respiratory infections 7
• Complete resolution may require up to 8 weeks of inhaled corticosteroids 5

Dosing Strategy to Minimize Side Effects

• Start first-generation antihistamines once daily at bedtime for a few days before increasing to twice-daily to minimize sedation 1
• Common side effects: dry mouth, transient dizziness 1
• Serious side effects to monitor: insomnia, urinary retention, jitteriness, increased intraocular pressure in glaucoma patients 1

What NOT to Do

Critical pitfalls to avoid:

• Never prescribe antibiotics for post-viral cough or allergic rhinitis unless clear evidence of bacterial sinusitis or pneumonia 5, 7

  • Antibiotics explicitly contraindicated for post-infectious cough 5
  • Green or colored sputum does NOT indicate bacterial infection 5

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 1

• Do not use newer-generation antihistamines alone (loratadine, cetirizine) for non-allergic upper airway cough syndrome, as they are ineffective 1, 6

• Do not jump to oral prednisone for mild post-infectious cough; reserve for severe cases after other therapies fail 5

Timeline Expectations and Follow-Up

Expected response times:

• Upper airway cough syndrome: Improvement within days to 1-2 weeks 1
• Post-infectious cough: Response to ipratropium within 1-2 weeks 5
• Inhaled corticosteroids for asthma-related cough: Up to 8 weeks for complete resolution 5
• GERD-related cough (if suspected): 2 weeks to several months for response 5

Red flags requiring re-evaluation:

• Hemoptysis 4, 5
• Fever development or prolongation 4, 5
• Breathlessness 4
• Symptoms persisting beyond 8 weeks (reclassify as chronic cough and systematically evaluate for asthma, GERD, and other causes) 5
• Biphasic course (initial improvement followed by worsening) suggesting bacterial sinusitis 7

Special Considerations

Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms yet still respond to upper airway treatment, so empiric trial is warranted even without classic findings 1

Chronic cough is frequently multifactorial, and cough will not resolve until all contributing causes treated; continue partially effective treatments while adding next intervention rather than stopping and switching 5