What can be done to manage a persistent cough in a 63-year-old female with a history of asthma, currently on inhaled corticosteroids (ICS) and long-acting beta agonists (LABA) and Singulair (montelukast)?

Management of Persistent Cough in Asthma Despite Current Therapy

For this 63-year-old woman with persistent cough despite ICS/LABA and montelukast, the most important next step is to optimize her inhaled corticosteroid dose before adding other agents, while simultaneously evaluating for alternative causes of cough including upper airway cough syndrome (UACS) and gastroesophageal reflux disease (GERD). 1

Immediate Assessment

Before escalating therapy, verify the following:

• Confirm proper inhaler technique – Incorrect use is a common cause of treatment failure, and adding a spacer device can overcome asthma-related cough 2
• Assess medication adherence – Poor compliance must be excluded before escalation 2
• Rule out inhaled steroid-induced cough – The ICS itself may be causing or exacerbating cough due to aerosol constituents; consider switching from one ICS formulation to another (e.g., from beclomethasone to triamcinolone) 2
• Verify she's not on an ACE inhibitor – If present, this must be stopped as it commonly causes chronic cough 2
• Confirm smoking status – Active smoking reduces corticosteroid responsiveness and must be addressed 2

Stepwise Treatment Escalation Algorithm

Step 1: Increase Inhaled Corticosteroid Dose

The American College of Chest Physicians recommends increasing the ICS dose as the first step in sequential escalation for incomplete response to initial therapy. 1 This should be done before adding additional agents, as higher-dose ICS may be necessary to control airway inflammation driving the cough 2.

Step 2: Evaluate for Alternative/Coexisting Causes

Chronic cough often has multiple causes that must be treated sequentially and additively 2:

• Upper Airway Cough Syndrome (UACS) – Previously called postnasal drip syndrome; consider empiric trial of first-generation antihistamine/decongestant combination 2
• Gastroesophageal Reflux Disease (GERD) – Should be evaluated next if cough persists; empiric treatment with proton pump inhibitor plus lifestyle modifications is recommended for patients with chronic cough who failed treatment for UACS and asthma 2

Step 3: Consider Oral Corticosteroid Trial

If cough remains refractory after optimizing ICS dose and addressing alternative causes:

• Prescribe prednisone 40 mg daily for 5-10 days (no taper needed for short courses) 2, 1
• Complete resolution of asthma-related cough may require up to 8 weeks of treatment, and some patients require oral steroids when inhaled therapy fails 2
• After oral steroid response, transition back to high-dose inhaled corticosteroids 1, 3

Assessment of Airway Inflammation

If cough remains refractory to inhaled corticosteroids, assessment of airway inflammation should be performed when available. 2 The presence of persistent airway eosinophilia on induced sputum or BAL identifies patients who may benefit from more aggressive anti-inflammatory therapy (higher-dose ICS or oral steroids) 2.

Role of Current Montelukast Therapy

She is already on montelukast (Singulair), which is appropriate as:

• Leukotriene receptor antagonists have demonstrated efficacy in suppressing cough that was previously resistant to bronchodilators and inhaled steroids 1
• Montelukast works by modulating the inflammatory environment around sensory cough receptors 2, 1
• Studies show 88% response rate for zafirlukast (similar agent) in asthmatic cough 2

However, the question of whether montelukast alone is sufficient or should be used in addition to optimized ICS therapy remains unresolved 2. Given she's already on it, focus should shift to optimizing ICS dose.

Critical Pitfalls to Avoid

• Do not use newer non-sedating antihistamines – They are completely ineffective for asthma cough management and should not be prescribed 1, 4
• Do not jump directly to systemic steroids without optimizing inhaled therapy first – This exposes patients to unnecessary systemic side effects when inhaled medications are highly effective 1, 3
• Do not assume asthma is the only cause – More than one cause of chronic cough may be present and requires sequential, additive treatment 2
• Do not overlook GERD – It should be treated if cough responds only partially or not at all to interventions for UACS and asthma 2

Expected Timeline for Response

• Partial improvement may occur within 1 week of optimized therapy 2
• Complete resolution of cough may require up to 8 weeks of treatment with inhaled corticosteroids 2
• If no improvement after appropriate trials of the above interventions, referral to a cough specialist is indicated 2

Monitoring Considerations

• Watch for inhaled corticosteroid side effects including oral candidiasis, dysphonia (which may resolve by switching from dry-powder inhaler to metered-dose inhaler with spacer), and potential adrenal suppression with high-dose or prolonged use 1
• Ensure she has rescue short-acting beta-agonist available – Patients should seek medical attention if rescue bronchodilator use increases 5