Can I prescribe ibuprofen (400mg every 6 hours for 3-4 days) and dextromethorphan for a cough, and for how many days, in a patient without gastrointestinal issues or kidney disease?

Ibuprofen and Dextromethorphan Prescribing for Acute Cough

Direct Answer

Yes, you can prescribe ibuprofen 400 mg every 6 hours for 3-4 days along with dextromethorphan for symptomatic relief of acute cough, with dextromethorphan typically used for 5-7 days at appropriate doses.

Ibuprofen Dosing and Duration

For symptomatic treatment of fever and pain associated with acute respiratory infections, ibuprofen 400 mg every 4-6 hours (not exceeding 4 times in 24 hours) is appropriate. 1

• The FDA-approved dosing for mild to moderate pain is 400 mg every 4-6 hours as necessary for relief 2
• Your proposed regimen of 400 mg every 6 hours for 3-4 days is well within safe limits and does not approach the maximum daily dose of 3200 mg 2
• Ibuprofen 400 mg provides at least 6 hours of analgesic duration, making your every-6-hour dosing schedule appropriate 3
• At this dose (1600 mg/day maximum if taken 4 times), ibuprofen has a good safety profile comparable to paracetamol 4

Important Caveats for Ibuprofen

• Administer with meals or milk if gastrointestinal complaints occur 2
• In patients with fever, temperatures below 38°C are acceptable and much lower body temperature is not conducive to antiviral treatment 1
• Avoid in patients with gastrointestinal bleeding risk factors, though you've specified the patient has no GI issues 1

Dextromethorphan Dosing and Duration

For acute cough, dextromethorphan should be dosed at 30-60 mg (not standard OTC doses) and can be used for 5-7 days for symptomatic relief. 5

Optimal Dosing Strategy

• Standard over-the-counter dosing of dextromethorphan is often subtherapeutic 5
• Maximum cough reflex suppression occurs at 60 mg, which is higher than typically recommended in OTC preparations 5
• The recommended dosing is 10-15 mg three to four times daily, with a maximum daily dose of 120 mg 5
• For optimal effect, 30-60 mg doses provide superior cough suppression compared to standard 15-20 mg OTC doses 5

Duration of Treatment

• Dextromethorphan should be used for short-term symptomatic relief only 5
• A typical course of 5-7 days is appropriate for acute viral cough 1, 5
• If cough persists beyond 3 weeks, discontinue dextromethorphan and perform a full diagnostic workup rather than continuing antitussive therapy 5

Important Considerations for Dextromethorphan

• Dextromethorphan is the recommended first-line antitussive due to its superior safety profile compared to codeine 5
• Codeine has no greater efficacy than dextromethorphan but has a much worse adverse effect profile (drowsiness, nausea, constipation, physical dependence) 1, 5
• When prescribing higher doses, check combination products carefully to avoid excessive amounts of other ingredients like paracetamol 5
• Dextromethorphan should not be used for productive cough where clearance of secretions is beneficial 5

Common Brand Names Available in India

Ibuprofen Brands (400 mg)

• Brufen 400 (Abbott)
• Ibugesic 400 (Cipla)
• Combiflam (Sanofi) - combination with paracetamol
• Advil 400 (Pfizer)
• Ibuclin (Aristo) - combination product

Dextromethorphan Brands

• Benylin DM (Johnson & Johnson)
• Corex (Pfizer) - combination with chlorpheniramine
• Glycodin (Wockhardt)
• Ascoril D (Glenmark) - combination product
• Chericof (Mankind) - combination with chlorpheniramine

Note: Many Indian formulations combine dextromethorphan with chlorpheniramine (antihistamine), which may provide additional benefit for nocturnal cough due to sedative properties. 5, 6

Practical Prescribing Algorithm

Step 1: Initial Assessment

• Confirm this is acute viral cough (duration <3 weeks) without signs of bacterial pneumonia 1
• Rule out pertussis if cough is paroxysmal and lasting ≥2 weeks 7

Step 2: First-Line Approach

• Recommend simple home remedies first (honey and lemon) as they may be as effective as pharmacological treatments 5
• If pharmacological treatment is needed, prescribe both medications together 1

Step 3: Specific Prescriptions

• Ibuprofen 400 mg orally every 6 hours as needed for fever/pain for 3-4 days 1, 2
• Dextromethorphan 30 mg three times daily (or 60 mg twice daily) for 5-7 days 5

Step 4: Patient Instructions

• Take ibuprofen with food or milk 2
• For nocturnal cough disrupting sleep, consider adding a first-generation antihistamine like chlorpheniramine at bedtime 5
• Advise that cough may persist for 2-3 weeks even with treatment 1

Critical Pitfalls to Avoid

• Do not prescribe codeine-containing products - they have no efficacy advantage over dextromethorphan but significantly more adverse effects 1, 5
• Do not use subtherapeutic doses of dextromethorphan (10-15 mg) - these OTC doses may not provide adequate relief 5
• Do not continue dextromethorphan beyond 3 weeks - persistent cough requires diagnostic workup 5
• Do not prescribe antibiotics for viral cough - they are ineffective and promote resistance 1
• Do not exceed ibuprofen maximum daily dose of 3200 mg (though your regimen uses only 1600 mg/day maximum) 2

When to Reassess

• If cough persists beyond 2-3 weeks, consider post-infectious cough and trial of inhaled ipratropium before continuing central antitussives 5, 7
• If fever persists beyond 3-4 days or worsens, reassess for bacterial superinfection 1
• If patient develops paroxysmal cough with post-tussive vomiting, consider pertussis and start macrolide antibiotics immediately 7