Pharmaceutical management of cough

What are the key features of an acute cough? (5)

• Duration: < 3 weeks

• Most commonly due to viral upper respiratory tract infection (URTI) – self-limiting

• Cough reflex more sensitive in women

• Common symptom in asthma and COPD exacerbations (may lead to hospitalisation)

• Shows seasonal variation

What are the key features and causes of a chronic cough?

• Duration: > 8 weeks

• Usually dry or minimally productive

• Common causes:

  • GORD (reflux disease)

  • Asthma

D-CATER acronym helps remember the key points when assessing a cough?

• D – Duration: How long has the cough been present?

• C – Character: Dry, productive, tickly, or chesty?

• A – Associated symptoms: Pain, wheeze, shortness of breath?

• T – Timing: Morning, midday, or night?

• E – Exacerbating factors: Weather, activity, eating?

• R – Recent illness

What is Cough Variant Asthma (CVA) and its key features? 5

• Dry cough as the only symptom

• May have other asthma symptoms: wheeze, shortness of breath (SOB)

• Eosinophilic inflammation present

• Bronchial hyper-responsiveness

• Clinical indicators: nocturnal cough, post-exercise, allergen exposure

What is Eosinophilic Bronchitis and its key features?

• Elevated eosinophils in the airway

• Persistent cough without bronchospasm

What are the main treatment options for CVA and Eosinophilic Bronchitis? “E-I-S-A-L: Every Individual Should Avoid Lung-triggers”

• Eliminate allergen triggers

• Inhaled corticosteroids (first-line, e.g., Beclometasone)

• Short-acting Beta-2 receptor agonists (e.g., Salbutamol)

• Antihistamines

• Leukotriene receptor antagonists (e.g., Montelukast)

How does Gastro-oesophageal Reflux Disease (GORD) contribute to cough?

• Increased cough reflex sensitivity in patients with GORD

• Can trigger persistent cough even without classic reflux symptoms

What are the treatment strategies for cough due to GORD?

• Medications: PPI or H2 receptor antagonist (as per local guidelines)

• Eliminate causative drugs: e.g., bisphosphonates, calcium channel blockers

• Lifestyle advice: diet modification

• Follow-up: review after 6–8 weeks

How does upper airway disease cause cough?

• Often accompanied by nasal stuffiness or sinusitis

• Sensation of secretions draining into the posterior pharynx (post-nasal drip)

• Post-nasal drip triggers the cough reflex

What is the treatment for cough due to upper airway disease?

• Antihistamines: may help, but limited efficacy

• Topical nasal steroids: effective if given 2–8 weeks in patients with cough and post-nasal drip

What is undiagnosed or idiopathic chronic cough and who is most affected?

• Considered idiopathic only after full specialist assessment

• Clinical history may show features of reflux cough

• Mainly affects middle-aged women

• Usually presents as a long-standing, chronic dry cough starting around menopause

What is the treatment for idiopathic chronic cough? example of this

• Treatment is generally disappointing

• Mainly non-specific antitussive therapy

• (codeine,dextromethoprhan,diphenhydramines)

When should a patient with cough or respiratory symptoms be referred? Crash

• C – Cough: >3 weeks, recurrent nocturnal (children), whooping cough/croup

• R – Respiratory distress: Shortness of breath, RR >30/min, PEFR <33% predicted

• A – Adverse drug event suspected

• S – Signs of infection: Fever, purulent sputum, other systemic signs

• H – Heart/Circulation warning: HR >130 bpm, Chest pain, Hypoxia (O₂ <92%)

What is the first principle in treating a cough?

Tailor treatment to the underlying cause:

• ACE inhibitor–induced?

• Infection?

• Long-term condition?

Are cough suppressants and expectorants strongly recommended?

• Evidence for their efficacy is weak

• Not routinely recommended by NICE

What are expectorants and how do they work?

• Promote expulsion of bronchial secretions

• May cause vomiting

• Only marginal benefit

When might cough suppressants be useful?

• If there is no underlying cause

• Useful when **sleep is disturbed

What are demulcents and examples in cough treatment?

• Soothing, harmless, inexpensive

• Examples: Honey & lemon, hot water

What are common OTC cough suppressants (antitussives)?

• Codeine (discontinued)

• Pholcodeine (fewer side effects, lower abuse potential)

• Dextromethorphan

What are key points about codeine and pholcodeine?

• Both sedating

• Opioid-related side effects

• Pholcodeine: fewer side effects, less likely to be abused

• Codeine discontinued in some regions

Which antihistamines are sometimes used for cough and what are the cautions?

• Examples: Diphenhydramine, Brompheniramine, Promethazine

• Avoid: Patients on phenothiazines or tricyclic antidepressants

• Avoid: Alcohol

• Sedating

What are key points about sympathomimetics for cough (e.g., pseudoephedrine)?

caution?

• Acts as bronchodilator and decongestant

• Use with caution in:

  • High blood pressure

  • Diabetes

  • Coronary artery disease

  • Hyperthyroidism

• Drug interactions: MAO inhibitors, beta-blockers, tricyclic antidepressants

What are key points about theophylline in cough/bronchodilation?

side effects

toxcity

serum monitoring

• Provides bronchodilation

• Side effects: GI irritation, palpitations, insomnia, headaches

• Toxicity: Dysrhythmias, seizures, hypotension

• Serum monitoring: Toxic if >80 mcg/mL

• Interactions: Multiple, careful use

When should antibiotics be considered for cough associated with respiratory tract infections?

• CRP >100 mg/L: Start antibiotic treatment

• CRP 20–100 mg/L: Delay antibiotics for 3 weeks or until symptoms worsen

• CRP <20 mg/L: Do not offer antimicrobial agents

Which antibiotics are commonly used for respiratory tract infections with cough?

Broad-spectrum options:

• Doxycycline: 200 mg STAT, then 100 mg once daily for 4 days

• Amoxicillin:

What should patients be told when antibiotics are denied or deferred?

• Antibiotics unlikely to improve symptoms

• Can cause adverse effects: diarrhea, vomiting, nausea

• May contribute to antimicrobial resistance

What general measures help manage cough non-pharmacologically? 6

• Maintain adequate fluids

• rest

• hoeny and lemon

• vapour rub

• steam inhaltation

• Supportive care for fever and pain with paracetamol or ibuprofen

Which home remedies are useful for cough in children over 1 year?

• Warm, clear fluids

• Honey and lemon drinks (if >1 year)

• Vapour rub for comfortSteam

Are cough and cold medicines suitable for children under 6 years?

No – Medicines containing discussed OTC cough and cold drugs are not suitable for children <6 years

When can cough and cold medicines be used in children aged 6–12 years?

• Second-line treatment only

• Use for maximum of 5 days

Is codeine linctus recommended for children? is it a antitussive

Not recommended for children <18 years