Symptom Relief Cough suppressants a. Codeine or Hydrocodone - Most potent are narcotic cough suppressants, thought to act in the “cough center” in the brainstem. The tendency of narcotic cough suppressants to cause drowsiness and constipation and their potential for addictive dependence limit their appeal for long-term use. Dose: Codeine Cough (Off-label)1 7.5-30 mg PO q4-6hr PRN Dosing Consideration Access to naloxone for opioid overdose Assess need for naloxone upon initiating and renewing treatment Consider prescribing naloxone Based on patient’s risk factors for overdose (eg, concomitant use of CNS depressants, a history of opioid use disorder, prior opioid overdose); presence of risk factors should not prevent proper pain management Household members (including children) or other close contacts at risk for accidental ingestion or overdose Consult patients and caregivers on the following: Availability of naloxone for emergency treatment of opioid overdose Ways to obtain naloxone as permitted by individual state dispensing and prescribing requirements or guidelines (eg, by prescription, directly from a pharmacist, as part of a community-based program) Dose: Hydrocodone Hydrocodone ER formulations are available in both tablets and capsules. Single-entity hydrocodone is only available in extended-release (ER) formulations. Depending on the product, the initial dose of hydrocodone ER formulations in patients who are not opioid-tolerant or are opioid-naïve is between 10 mg to 20 mg every 12 hours to 24 hours. Patients should receive instruction to discontinue all other opioids when starting on a hydrocodone ER medication unless specifically directed by a physician.2 b. Dextromethorphan is an over-the-counter, centrally acting cough suppressant with fewer side effects and less efficacy than the narcotic cough suppressants. Dextromethorphan is thought to have a different site of action than narcotic cough suppressants and can be used in combination with them if necessary. dextromethorphan should be avoided in children and adolescents because of concerns about misuse. c. Benzonatate is thought to inhibit neural activity of sensory nerves in the cough-reflex pathway. It is generally free of side effects; however, its effectiveness in suppressing cough is variable and unpredictable. Attempts to treat cough hypersensitivity syndrome have focused on inhibition of neural pathways. Small case series and randomized clinical trials have indicated benefit from off-label use of gabapentin, pregabalin, or amitriptyline. Recent studies suggest a role for behavioral modification using specialized speech therapy techniques, but widespread application of this modality is currently not practical. Novel cough suppressants without the limitations of currently available agents are greatly needed. Approaches that are being explored include the development of neurokinin receptor antagonists, TRPV1 ion channel antagonists, and novel opioid and opioid-like receptor agonists.1
Cough suppressants a. Codeine or Hydrocodone - Most potent are narcotic cough suppressants, thought to act in the “cough center” in the brainstem. The tendency of narcotic cough suppressants to cause drowsiness and constipation and their potential for addictive dependence limit their appeal for long-term use. Dose: Codeine Cough (Off-label)1 7.5-30 mg PO q4-6hr PRN Dosing Consideration Access to naloxone for opioid overdose Assess need for naloxone upon initiating and renewing treatment Consider prescribing naloxone Based on patient’s risk factors for overdose (eg, concomitant use of CNS depressants, a history of opioid use disorder, prior opioid overdose); presence of risk factors should not prevent proper pain management Household members (including children) or other close contacts at risk for accidental ingestion or overdose Consult patients and caregivers on the following: Availability of naloxone for emergency treatment of opioid overdose Ways to obtain naloxone as permitted by individual state dispensing and prescribing requirements or guidelines (eg, by prescription, directly from a pharmacist, as part of a community-based program) Dose: Hydrocodone Hydrocodone ER formulations are available in both tablets and capsules. Single-entity hydrocodone is only available in extended-release (ER) formulations. Depending on the product, the initial dose of hydrocodone ER formulations in patients who are not opioid-tolerant or are opioid-naïve is between 10 mg to 20 mg every 12 hours to 24 hours. Patients should receive instruction to discontinue all other opioids when starting on a hydrocodone ER medication unless specifically directed by a physician.2 b. Dextromethorphan is an over-the-counter, centrally acting cough suppressant with fewer side effects and less efficacy than the narcotic cough suppressants. Dextromethorphan is thought to have a different site of action than narcotic cough suppressants and can be used in combination with them if necessary. dextromethorphan should be avoided in children and adolescents because of concerns about misuse. c. Benzonatate is thought to inhibit neural activity of sensory nerves in the cough-reflex pathway. It is generally free of side effects; however, its effectiveness in suppressing cough is variable and unpredictable. Attempts to treat cough hypersensitivity syndrome have focused on inhibition of neural pathways. Small case series and randomized clinical trials have indicated benefit from off-label use of gabapentin, pregabalin, or amitriptyline. Recent studies suggest a role for behavioral modification using specialized speech therapy techniques, but widespread application of this modality is currently not practical. Novel cough suppressants without the limitations of currently available agents are greatly needed. Approaches that are being explored include the development of neurokinin receptor antagonists, TRPV1 ion channel antagonists, and novel opioid and opioid-like receptor agonists.1
Cough suppressants
a. Codeine or Hydrocodone - Most potent are narcotic cough suppressants, thought to act in the “cough center” in the brainstem. The tendency of narcotic cough suppressants to cause drowsiness and constipation and their potential for addictive dependence limit their appeal for long-term use.
Dose: Codeine Cough (Off-label)1 7.5-30 mg PO q4-6hr PRN Dosing Consideration
Dose: Codeine Cough (Off-label)1
7.5-30 mg PO q4-6hr PRN Dosing Consideration
7.5-30 mg PO q4-6hr PRN
Dose: Hydrocodone
Hydrocodone ER formulations are available in both tablets and capsules. Single-entity hydrocodone is only available in extended-release (ER) formulations. Depending on the product, the initial dose of hydrocodone ER formulations in patients who are not opioid-tolerant or are opioid-naïve is between 10 mg to 20 mg every 12 hours to 24 hours. Patients should receive instruction to discontinue all other opioids when starting on a hydrocodone ER medication unless specifically directed by a physician.2
b. Dextromethorphan is an over-the-counter, centrally acting cough suppressant with fewer side effects and less efficacy than the narcotic cough suppressants. Dextromethorphan is thought to have a different site of action than narcotic cough suppressants and can be used in combination with them if necessary.
dextromethorphan should be avoided in children and adolescents because of concerns about misuse.
c. Benzonatate is thought to inhibit neural activity of sensory nerves in the cough-reflex pathway. It is generally free of side effects; however, its effectiveness in suppressing cough is variable and unpredictable. Attempts to treat cough hypersensitivity syndrome have focused on inhibition of neural pathways.
Small case series and randomized clinical trials have indicated benefit from off-label use of gabapentin, pregabalin, or amitriptyline.
Recent studies suggest a role for behavioral modification using specialized speech therapy techniques, but widespread application of this modality is currently not practical.
Novel cough suppressants without the limitations of currently available agents are greatly needed. Approaches that are being explored include the development of neurokinin receptor antagonists, TRPV1 ion channel antagonists, and novel opioid and opioid-like receptor agonists.1