When are glucocorticoids appropriate for cough, such as in asthma, chronic obstructive pulmonary disease, bronchiectasis, viral croup with stridor, or a disabling post‑viral cough lasting more than two weeks?

When Glucocorticoids Are Appropriate for Cough

Glucocorticoids are appropriate for cough primarily in asthma-related cough (both inhaled and systemic forms), as third-line therapy for severe post-infectious cough after other treatments fail, and in viral croup with stridor, but they have minimal to no role in COPD-associated cough or bronchiectasis.

Asthma and Cough-Variant Asthma

Inhaled corticosteroids combined with bronchodilators are the first-line treatment for all asthma-related cough, including cough-variant asthma. 1

Initial Treatment Algorithm

• Start with inhaled corticosteroids (e.g., fluticasone or budesonide) plus inhaled bronchodilators as standard first-line therapy for any patient with chronic cough due to asthma 1
• Diagnosis of cough-variant asthma is confirmed only after cough resolution with specific antiasthmatic therapy 1
• If methacholine challenge testing cannot be performed, empiric therapy with inhaled corticosteroids should be administered 1

Escalation for Refractory Cases

• For cough refractory to inhaled corticosteroids and bronchodilators, add a leukotriene receptor antagonist (LTRA) such as zafirlukast before escalating to systemic corticosteroids 1
• Patients with severe and/or refractory asthmatic cough should receive a short course (1 to 2 weeks) of systemic oral corticosteroids (prednisone 20-60 mg/day) followed by maintenance inhaled corticosteroids 1
• Assessment of airway inflammation (e.g., induced sputum eosinophils) should be performed when available; persistent eosinophilia identifies patients who benefit from more aggressive anti-inflammatory therapy 1

Post-Infectious (Post-Viral) Cough

Oral corticosteroids are reserved as third-line therapy only for severe, disabling post-infectious cough lasting more than two weeks that has failed other treatments.

Stepwise Treatment Approach

• First-line: Inhaled ipratropium bromide (2-3 puffs four times daily) has the strongest evidence for attenuating post-infectious cough, with response expected within 1-2 weeks 2, 3, 4
• Second-line: Add inhaled corticosteroids (fluticasone 220 mcg or budesonide 360 mcg twice daily) if cough persists despite ipratropium and adversely affects quality of life; allow up to 8 weeks for full response 2, 3, 4
• Third-line: Oral prednisone 30-40 mg daily for 5-10 days should be prescribed only when all of the following criteria are met: severe paroxysms significantly impair quality of life, failure of both inhaled ipratropium and inhaled corticosteroids, and other common causes (upper airway cough syndrome, asthma, GERD) have been ruled out or adequately treated 2, 3, 4

Critical Pitfalls to Avoid

• Do not prescribe oral corticosteroids as first-line therapy for post-infectious cough—this is explicitly not recommended 2, 3, 4
• Antibiotics are contraindicated for post-infectious cough as the cause is not bacterial infection 2, 3
• If cough persists beyond 8 weeks total duration, reclassify as chronic cough and systematically evaluate for upper airway cough syndrome, asthma, and GERD rather than continuing corticosteroid therapy 2, 3

Viral Croup with Stridor

A single dose of dexamethasone is standard treatment for viral croup with stridor, often combined with inhaled epinephrine for moderate to severe cases. 2

• Combined high-dose systemic dexamethasone and inhaled epinephrine reduces admissions in croup (number needed to treat 11) 2
• This represents one of the clearest indications for systemic glucocorticoids in acute viral respiratory illness 2

COPD-Associated Cough

Glucocorticoids are scarcely effective in COPD patients without concomitant asthma and do not significantly influence disease severity or natural course. 5

• Inhaled corticosteroids in COPD provide modest benefit primarily for reducing exacerbations in advanced disease, not for cough suppression 5, 6
• COPD represents a state of relative glucocorticoid resistance due to abnormal activation of inflammatory pathways 7, 6
• Bronchodilators (particularly tiotropium) and smoking cessation are more effective than corticosteroids for COPD management 5

Bronchiectasis

There is no established role for routine glucocorticoid therapy in bronchiectasis-associated cough based on the provided evidence.

• Bronchiectasis was not specifically addressed in the guideline evidence provided
• The inflammatory pattern in bronchiectasis differs from asthma, and corticosteroids are not standard therapy unless there is coexisting asthma or allergic bronchopulmonary aspergillosis

Key Safety Considerations

• When prescribing higher doses of dexamethasan or prednisone, ensure adequate duration (typically 5-14 days) but avoid prolonged courses to minimize adverse effects 1, 2
• Combined inhaled corticosteroid/LABA therapy enhances glucocorticoid-dependent gene expression and may improve efficacy while reducing systemic exposure 6, 8
• Glucocorticoid resistance is more common in smokers, certain asthma phenotypes, and COPD—these patients may require alternative or adjunctive therapies 7, 6, 8