Treating a Cough Continues to Present Challenges

Cold symptoms are a common patient complaint, with a cough cited as one of the most irritating and persistent symptoms.¹ Patients often ask pharmacists and pharmacy technicians about the best way to stop the cough, but they may be hard-pressed to provide effective advice.

Consider that in 2017, the CHEST Expert Cough Panel assembled to look at the guidelines developed in 2006 and address 6 key clinical questions (Table 1²) about treating acute coughs associated with the common cold.^2,3 Unfortunately, the panel’s overall finding was that clinical trials in this condition have produced nothing significant since 2006.²

What Does Not Work?

The panel’s work yielded dismal results, so the question of what works remains. Nonpharmacologic and pharmacologic treatments crowd pharmacy shelves with combination or monotherapy options. Most new prescription products approved by the FDA since 2006 have been new combinations of previously approved products, including the following^4-8:

• Extended-release codeine polistirex and chlorpheniramine (Tuzistra XR)
• A guaifenesin and hydrocodone bitartrate oral solution (Flowtuss, Obredon)
• A guaifenesin/hydrocodone bitartrate and chlorpheniramine maleate (Vituz)
• A guaifenesin, hydrocodone bitartrate, and pseudoephedrine hydrochloride oral solution (Hycofenix).

Further, the FDA has issued medication safety alerts about using some products in specific populations. Perhaps the most consequential for pharmacists was a strong recommendation not to use OTC cold and cough products for infants and children younger than 2 years, as serious and potentially life-threatening adverse effects (AEs) could occur.”⁹ Additionally, the FDA has warned against using codeine-containing medications to treat colds and coughs in children younger than 18 years, as these products create the potential for AEs such as difficult or slowed breathing.¹⁰

Finally, pharmacy staff members should remember that some individuals abuse certain OTC and prescription products. For example, dextromethorphan in high doses, often informally referred to as robotripping, can cause dissociative effects and euphoria.¹¹ Some younger individuals have adopted the “purple drank” fad, made popular by some celebrities, by mixing promethazine with codeine syrup with alcohol, candy, fruit, or soda, which causes euphoria and intoxication.¹² Unfortunately, such abuse can cause serious complications, including death.

What Works?

With either a lack of or even negative evidence for many products, answering the question “What is the best way to stop an acute cough?” is not simple. A first step is to screen for red flags (Table 2¹³).

Basic counseling starts with recommending patients drink fluids, especially hot beverages, gargle with salt water, humidify the air, and remove irritants (such as fragrances and perfumes) from their homes.^3,13 Nonsmokers should avoid tobacco smoke, and patients who smoke should consider quitting. If congestion or postnasal drip are a concern, using a nasal irrigation device or a saline spray can help. Cough drops can also help and may ease a sore throat.^3,13

OTC options include combination cough products that may include analgesics, antihistamines, and decongestants; cough suppressants, such as dextromethorphan; eucalyptus oil; expectorant guaifenesin, which thins mucus; topical camphor; and topical menthol, which may reduce the amount of coughing.

Patients should choose a product that addresses only their specific symptoms. If the cough is intrusive or persistent, patients may see a prescriber for something stronger.

Generally, prescription options contain codeine, though codeine cough syrups are available without a prescription in some states.^3,13

Conclusion

Despite the considerable number of products available for coughs, few have been evaluated in head-to-head or well-structured clinical trials; this is an unmet need. Nondrug therapies often work, as well as OTC or prescription medications. Sometimes doing nothing is as helpful as doing something. A key concept to remember for patients who want cough products is that more is not necessarily better.

References

1. Common colds: protect yourself and others. CDC. Updated November 29, 2021. Accessed January 10, 2023. http://www.cdc.gov/features/rhinoviruses/

2. Malesker MA, Callahan-Lyon P, Ireland B, Irwin RS; CHEST Expert Cough Panel. Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel report. Chest. 2017;152(5):1021-1037. doi:10.1016/j.chest.2017.08.009

3. Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(suppl 1):72S-74S. doi:10.1378/chest.129.1_suppl.72S

4. Vituz. Prescribing information. Hawthorn Pharmaceuticals Inc; 2017. Accessed January 10, 2023. https://dailymed.nlm.nih.gov/dailymed/drugIn-fo.cfm?setid=35ecdec3-4a59-479f-a3cb-4ffe0d4ab85e

5. Obredon. Prescribing information. ABER Pharmaceuticals LLC; 2016. Accessed January 10, 2023. https://dailymed.nlm.nih.gov/dailymed/drug Info.cfm?setid=31c14c1c-a250-4891-b6ab-9c5961fc8a39

6. Flowtuss. Prescribing information. Mission Pharmacal Company; 2018. Accessed January 10, 2023. https://dailymed.nlm.nih.gov/dailymed/drugIn-fo.cfm?setid=1d0c2c03-ca11-30b1-e054-00144ff8d46c

7. Tuzistra XR. Prescribing information. Tris Pharma Inc; 2018. Accessed January 10, 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aebefc5e-5487-42ef-98f7-01d26eb38362

8. Hycofenix. Prescribing information. Mission Pharmacal Co; 2018. Accessed January 10, 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1cfa7c8f-0309-3591-e054-00144ff8d46c

9. Should you give kids medicine for coughs and colds? FDA. January 5, 2023. Accessed January 20, 2023. https://www.fda.gov/consumers/consumer- updates/should-you-give-kids-medicine-coughs-and-colds#:~:text=But%20most%20children%20will%20get,in%20infants%20and%20young%20children.

10. FDA drug safety communication: FDA evaluating the potential risks of using codeine cough-and-cold medicines in children. FDA. March 6, 2018. Accessed January 20, 2023. https://www.fda.gov/drugs/drug-safe-ty-and-availability/fda-drug-safety-communication-fda-evaluating-potential-risks-using-codeine-cough-and-cold-medicines

11. Linn KA, Long MT, Pagel PS. “Robo-tripping”: dextromethorphan abuse and its anesthetic implications. Anesth Pain Med. 2014;4(5):e20990. doi:10.5812/aapm.20990

12. Burns JM, Boyer EW. Antitussives and substance abuse. Subst Abuse Rehabil. 2013;4:75-82.

13. Tietze KJ. Cough. In: Krinsky DL, Ferreri SP, Hemstreet BA, Hume AL, Rollins CJ, Tietze KJ, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care.20th ed. American Pharmacists Association; 2020:237-250.

About the Author

Jeannette Y. Wick, MBA, RPh, FASCP, is the director of pharmacy professional development in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.