What medications are recommended for an adult patient with chronic cough?

Medications for Chronic Cough in Adults

For chronic cough in adults, initiate treatment based on the most likely underlying cause using an algorithmic approach: intranasal corticosteroids (fluticasone 100-200 mcg daily) for upper airway symptoms, proton pump inhibitors (omeprazole 20-40 mg twice daily before meals for minimum 8 weeks) for suspected GERD, and inhaled corticosteroids for asthma-related cough, with gabapentin reserved for refractory cases after addressing all treatable causes. 1, 2, 3

Immediate Actions Before Starting Medications

• Discontinue ACE inhibitors immediately if the patient is taking them—no patient with troublesome cough should continue these medications, as they are one of the most common reversible causes 1, 2, 3
• Mandate smoking cessation for all smokers, as this is dose-related and frequently resolves cough 2, 3
• Obtain baseline chest radiograph and spirometry to exclude other causes before empiric treatment 1, 2

Sequential Medication Algorithm

First-Line: Upper Airway Cough Syndrome (UACS)

When prominent upper airway symptoms are present (nasal congestion, throat clearing, post-nasal drip):

• Intranasal corticosteroids are first-line therapy: fluticasone propionate 100-200 mcg daily for minimum 1 month 1, 3
• Add ipratropium bromide nasal spray for anticholinergic drying effects, particularly useful when oral decongestants are contraindicated 1
• Note: Approximately 20% of UACS cases present "silently" without typical nasal symptoms, so absence of prominent symptoms does not exclude this diagnosis 1

Important caveat: There is conflicting evidence regarding antihistamines—first-generation sedating antihistamines recommended in American literature are not available in the UK, and second-generation antihistamines show inconsistent efficacy 4, 1

Second-Line: Gastroesophageal Reflux Disease (GERD)

For suspected GERD (with or without heartburn/regurgitation):

• Proton pump inhibitors: omeprazole 20-40 mg twice daily or equivalent taken before meals for minimum 8 weeks (not shorter durations) 4, 1, 2
• Add prokinetic agents: metoclopramide 10 mg three times daily in a proportion of patients who require additional motility support 4
• Consider combination therapy: twice-daily PPIs plus nocturnal H2 antagonists (ranitidine 300 mg daily) for full acid suppression, as PPIs may be superior to H2 antagonists alone 4
• Add alginates to the PPI regimen for enhanced reflux control 1, 2

Critical timing consideration: GI symptom improvement occurs in 4-8 weeks, but cough improvement may take up to 3 months—never undertreat by stopping therapy prematurely 1, 3

Important evidence divergence: In patients WITHOUT heartburn or regurgitation, PPIs alone are NOT recommended as they are unlikely to resolve cough 3. However, other guidelines suggest GERD-related cough may occur without GI symptoms 1, 2, so clinical judgment is required.

Third-Line: Asthma and Eosinophilic Airway Disease

For suspected asthma-related cough or eosinophilic bronchitis:

• Two-week oral corticosteroid trial to exclude eosinophilic airway inflammation—if no response occurs, eosinophilic inflammation is unlikely 2, 3
• If responsive, initiate inhaled corticosteroids following national asthma guidelines 4
• At step 3 of asthma management, use leukotriene receptor antagonists rather than long-acting β-agonists, as there is no evidence for LABAs in cough variant asthma 4
• Some evidence supports antihistamines and anti-leukotrienes in cough due to asthma variants, though larger studies are needed 4

Dosing caveat: Insufficient evidence exists for specific dose, preparation, and duration of inhaled corticosteroid therapy, but following BTS asthma guidelines is recommended 4

Multiple Simultaneous Causes

Address causes sequentially AND additively—multiple etiologies frequently coexist, so do not stop after the first intervention 1, 2. This algorithmic approach resolves chronic cough in 82-100% of cases when properly applied 3.

Refractory Chronic Cough Medications

Only after 4-6 weeks of adequate empiric treatment for the most likely diagnoses should symptomatic medications be considered: 3

• Gabapentin is first-choice neuromodulator for chronic refractory cough 5, 6, 7
• Low-dose morphine is the preferred symptomatic antitussive for refractory cases 3
• Baclofen is an alternative option with weaker evidence 3
• Pregabalin or amitriptyline can be considered as alternatives 7

Critical contraindication: Never suppress cough when clearance is important for secretion management (pneumonia, bronchiectasis) 2, 3

Adjunctive Non-Pharmacologic Therapy

• Speech pathology treatment combined with neuromodulators provides enhanced treatment response of longer duration 5, 7

Medications to Eliminate

• Discontinue medications potentially worsening reflux: bisphosphonates, nitrates, calcium channel blockers, theophylline, progesterones 4

Monitoring and Escalation

• Schedule follow-up in 4-6 weeks to assess response using validated cough-specific quality of life questionnaires or visual analog scales 1, 2
• Monitor blood pressure closely given potential need for decongestants 1
• Refer to specialist cough clinic for unexplained chronic cough after complete evaluation and adequate treatment duration—premature diagnosis of idiopathic cough is a critical pitfall 1, 2, 3

Common Pitfalls to Avoid

• Never undertreat GERD: requires full 3-month trial of intensive acid suppression, not 2-4 weeks 1, 2, 3
• Ensure adequate treatment duration before declaring failure: topical corticosteroids require 1 month minimum, GERD treatment requires 3 months minimum 1, 2
• Never continue ACE inhibitors in patients with troublesome cough 2, 3
• Recognize multiple simultaneous causes rather than assuming single etiology 2