What is the recommended treatment for a patient with a dry cough due to a cold virus?

Treatment of Dry Cough Due to Cold Virus

For acute viral dry cough from the common cold, start with simple home remedies like honey and lemon, which are as effective as pharmacological treatments, and if medication is needed, use dextromethorphan 30-60 mg (not the standard 15-30 mg subtherapeutic dose) as the first-line antitussive. 1

First-Line Approach: Non-Pharmacological Treatment

• Honey and lemon mixtures are the simplest and most cost-effective initial treatment, with evidence showing they provide symptomatic relief comparable to over-the-counter medications without adverse effects. 1
• Adequate hydration and simple drinks may work through central modulation of the cough reflex, and voluntary cough suppression can reduce cough frequency. 1
• Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived cough suppression by acting on the cough reflex. 1

Pharmacological Treatment When Needed

Dextromethorphan: The Preferred Antitussive

• Dextromethorphan is the recommended first-line pharmacological agent due to its favorable safety profile and proven efficacy in suppressing acute viral cough. 1, 2
• The therapeutic dose is 30-60 mg, with maximum cough reflex suppression occurring at 60 mg—standard over-the-counter dosing of 15-30 mg is often subtherapeutic. 1
• When recommending higher doses, verify that combination preparations don't contain excessive amounts of other ingredients like paracetamol. 1
• FDA labeling confirms dextromethorphan temporarily relieves cough due to minor throat and bronchial irritation from the common cold. 2

First-Generation Antihistamines for Nocturnal Cough

• Sedating antihistamines (like chlorpheniramine) are particularly useful for nighttime cough that disrupts sleep, though they cause drowsiness. 1, 3
• Newer nonsedating antihistamines should not be used as they are ineffective for cough suppression. 1

Combination Therapy Considerations

• First-generation antihistamine/decongestant combinations or naproxen are strongly recommended by guidelines for common cold symptoms unless contraindications exist (glaucoma, benign prostatic hypertrophy, hypertension). 1
• Over-the-counter combination cold medications are generally not recommended except those containing older antihistamine/decongestant ingredients. 1

What to Avoid

Opiate Antitussives Are Not Recommended

• Codeine and pholcodine have no greater efficacy than dextromethorphan but carry a significantly greater adverse side effect profile and are explicitly not recommended for acute viral cough. 1
• Despite FDA approval for cough suppression 4, codeine has not been shown to effectively treat cough caused by the common cold in clinical studies. 5

Antibiotics Have No Role

• Antibiotics are not indicated for acute cough from the common cold and should not be prescribed, as acute viral cough is almost invariably benign and self-limiting. 1
• The diagnosis of "acute bronchitis" is often overdiagnosed, leading to inappropriate antibiotic prescriptions in 65-80% of cases. 1

Bronchodilators Are Not Routinely Indicated

• β2-agonist bronchodilators should not be routinely used for acute viral cough unless there is wheezing or documented airflow obstruction at baseline. 1

Critical Clinical Pitfalls

• Rule out serious conditions before assuming benign viral cough: Look for danger signs including significant hemoptysis, foreign body inhalation, progressive breathlessness, fever with purulent sputum, or systemic illness requiring chest radiograph. 1
• Physical examination findings suggesting pneumonia (dullness to percussion, bronchial breathing, crackles) mandate different management. 1
• If cough persists beyond 3 weeks, stop symptomatic treatment and evaluate for other causes including postinfectious cough, asthma, upper airway cough syndrome, or gastroesophageal reflux. 1

Practical Treatment Algorithm

1. Confirm the diagnosis is common cold (acute nasal symptoms with or without fever, throat irritation, hoarseness) and rule out serious conditions. 1

2. Start with honey and lemon as first-line treatment for all patients without contraindications. 1

3. If pharmacological treatment is needed, prescribe dextromethorphan 30-60 mg for daytime cough suppression. 1

4. For nocturnal cough disrupting sleep, add a first-generation sedating antihistamine. 1

5. Avoid codeine, antibiotics, and newer nonsedating antihistamines as they are either ineffective or have unfavorable risk-benefit profiles. 1, 5

6. Reassess if symptoms worsen or persist beyond expected timeline (typically improving progressively over the first week). 1