What cough medication is recommended for a patient with a bad cough, considering their age and medical history, including conditions like COPD or asthma?

Recommended Cough Medication

For a patient with a bad cough, prescribe dextromethorphan 60 mg as the first-line pharmacological agent, as it has the best safety profile among antitussives and provides maximum cough reflex suppression at this dose. 1, 2

Initial Assessment Before Prescribing

Before ordering any cough medication, determine if the patient has any of these red flags requiring immediate evaluation rather than symptomatic treatment: 1

• Coughing up blood
• Significant breathlessness
• Prolonged fever with feeling unwell
• Underlying conditions like COPD, heart disease, diabetes, or asthma
• Recent hospitalization

Treatment Algorithm

Step 1: Start with Non-Pharmacological Treatment

Recommend honey and lemon as a home remedy first, as simple home remedies are often as effective as pharmacological treatments for benign viral cough. 1, 2

Step 2: If Pharmacological Treatment is Needed

Prescribe dextromethorphan 60 mg (not the standard over-the-counter doses which are subtherapeutic). 2, 3

• Maximum cough reflex suppression occurs at 60 mg with prolonged relief 2, 3
• Superior safety profile compared to codeine-containing products 2, 3
• Clear dose-response relationship with centrally acting mechanism 2

Additional symptomatic options to consider:

• Paracetamol for associated fever and discomfort 1
• Menthol lozenges or vapor for short-lived acute relief 1, 2

Step 3: For Nighttime Cough Disrupting Sleep

Consider first-generation antihistamines with sedative properties if the cough is primarily nocturnal and disrupting sleep. 2

• These may suppress cough and are particularly useful for nocturnal symptoms 2
• However, avoid in elderly patients due to significant anticholinergic effects, sedation, and fall risk 3

Step 4: Special Populations

For elderly patients or those with COPD/chronic bronchitis:

• Dextromethorphan 60 mg remains first-line 3
• Consider ipratropium bromide 500 µg via nebulizer as it has Grade A evidence for cough suppression in chronic bronchitis and addresses both bronchodilation and cough control 3
• Avoid first-generation antihistamines in elderly patients 3

Critical Medications to AVOID

Never prescribe codeine or pholcodine - they have no greater efficacy than dextromethorphan but carry a much greater adverse side effect profile including drowsiness, nausea, constipation, and physical dependence. 2, 3, 4

Do not prescribe antibiotics for viral cough - they have absolutely no role in treating post-viral cough and should never be prescribed for this indication. 5

Duration and Follow-Up

If cough persists beyond 3 weeks, mandatory reassessment is required rather than continuing antitussive therapy. 5

At that point, systematically evaluate and treat for common causes of chronic cough: 1

• Upper airway cough syndrome (UACS)
• Asthma
• Non-asthmatic eosinophilic bronchitis (NAEB)
• Gastroesophageal reflux disease (GERD)
• ACE inhibitor use (stop and replace if present) 1, 3

Key Clinical Pitfalls

• Standard OTC doses of dextromethorphan are subtherapeutic - you need 60 mg for maximum effect 2, 3
• Do not suppress productive cough in COPD patients, as secretion clearance serves a protective function 3
• Check medication list for ACE inhibitors as a reversible cause of cough 1, 3
• Prescribe sugar-free formulations for diabetic patients 5