What is the appropriate use of steroids for an adult patient with a chronic cough and a history of respiratory issues like asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Steroids for Chronic Cough

For adults with chronic cough, a 2-week trial of oral corticosteroids (prednisolone 30 mg daily) serves as both a diagnostic test and initial treatment when eosinophilic airway inflammation is suspected, followed by transition to inhaled corticosteroids if response is positive. 1

Diagnostic Approach

No currently available test of airway function can reliably exclude a corticosteroid-responsive cough. 1 This fundamental limitation means empirical steroid trials are often necessary:

• Perform a 2-week oral steroid trial (prednisolone 30 mg daily) to establish diagnosis when chronic cough persists despite normal chest radiography and spirometry. 1
• If no response occurs after 2 weeks, cough is unlikely due to eosinophilic airway inflammation. 1
• Bronchial provocation testing (methacholine challenge) can demonstrate airway hyperresponsiveness consistent with asthma, but a negative test does not rule out steroid-responsive cough. 1

Critical pitfall: Many clinicians fail to consider that cough may be the only manifestation of asthma or eosinophilic bronchitis—no wheezing or dyspnea is required for diagnosis. 1

Treatment Algorithm for Asthma-Related Chronic Cough

Step 1: Initial Therapy

Start combination inhaled corticosteroids plus inhaled bronchodilators immediately upon diagnosis of cough-variant asthma. 1, 2, 3

• Use beclomethasone 200-800 μg daily equivalent (or fluticasone 500 μg twice daily). 2, 4
• Never use long-acting beta-agonists as monotherapy—they must be combined with inhaled corticosteroids to avoid increased risk of serious asthma-related events. 3, 5
• Expect cough improvement within 1-2 weeks if eosinophilic inflammation is present. 2

Step 2: Inadequate Response After 4-8 Weeks

Increase the inhaled corticosteroid dose up to beclomethasone 2000 μg daily equivalent before adding other agents. 2, 3

• Verify medication compliance and proper inhaler technique first. 2
• Exclude contributing conditions: ACE inhibitor use (discontinue immediately if present), gastroesophageal reflux disease (treat with proton pump inhibitors for minimum 3 months), smoking (encourage cessation), and upper airway pathology. 1

Step 3: Still Refractory

Add a leukotriene receptor antagonist (montelukast) to the existing inhaled corticosteroid and bronchodilator regimen. 1, 2, 3

• Leukotriene inhibitors have demonstrated efficacy in suppressing cough previously resistant to bronchodilators and inhaled steroids. 3, 5

Step 4: Severe or Refractory Cases

Prescribe oral corticosteroids (prednisolone 30-40 mg daily or equivalent) for 1-2 weeks only after maximizing inhaled therapy plus leukotriene receptor antagonist. 1, 2, 3, 5

• Follow with transition back to inhaled corticosteroids for long-term maintenance. 1, 2
• No tapering is required for short courses (1-2 weeks). 3

Critical pitfall: Never jump directly to systemic corticosteroids without trying inhaled therapy first—this exposes patients to unnecessary systemic side effects when inhaled medications are highly effective. 3, 5

Upper Airway Cough

In the presence of prominent upper airway symptoms (rhinosinusitis), use topical nasal corticosteroids rather than systemic therapy. 1

COPD-Related Chronic Cough

For patients with COPD and chronic cough:

• Inhaled corticosteroids are recommended when FEV1 <50% predicted and there is a history of frequent exacerbations. 6, 7
• Inhaled corticosteroids reduce exacerbation rates (mean reduction 0.19-0.26 exacerbations per patient per year) and slow decline in quality of life. 7
• Oral corticosteroids (10-15 days) are reserved for acute exacerbations only, not stable disease. 6, 8
• Long-term oral corticosteroids at maintenance doses are associated with worse mortality and skeletal muscle myopathy—avoid this practice. 6, 8

Critical pitfall: Inhaled corticosteroids increase pneumonia risk in COPD patients (OR 1.56), so balance benefits against this specific adverse effect. 7

Monitoring and Safety

Common adverse effects of inhaled corticosteroids include:

• Oropharyngeal candidiasis (OR 2.65) and hoarseness—use spacer devices and rinse mouth after use. 7
• Increased pneumonia risk in COPD patients specifically. 7
• Skin bruising in patients with better lung function. 6

For short-course oral corticosteroids (1-2 weeks):

• Monitor blood glucose, particularly in diabetic patients. 9
• No significant bone density concerns with short courses. 9
• Adrenal suppression risk is minimal with courses under 2 weeks. 9

Critical pitfall: Antihistamines are completely ineffective for asthma-related cough management and should not be prescribed. 3, 5

Special Populations

Exclude ACE inhibitor use in all patients with troublesome chronic cough—no patient with chronic cough should continue ACE inhibitors. 1

Smoking cessation is mandatory as smoking is one of the commonest causes of persistent cough and appears dose-related. 1