Management of chronic refractory cough in adults

Abstract

Cough is a common respiratory symptom that is considered to be chronic when it lasts more than eight weeks. When severe, chronic cough may significantly impact an individual's quality of life, and such patients are frequently referred for specialist evaluation. Current international guidelines provide algorithms for the management of chronic cough: in most cases, treatment of the underlying disease is sufficient to improve or resolve cough symptoms. Severe chronic cough may significantly affect patients' quality of life and necessitate frequent referral for specialist evaluations. In this narrative review, we summarize non-pharmacologic and pharmacologic management of adult patients with chronic cough of known cause that persists after proper treatment (chronic refractory cough, CRC) or chronic cough of unknown cause in adult patients. If chronic cough persists even after treatment of the underlying disease, or if the chronic cough is not attributable to any cause, then a symptomatic approach with neuromodulators may be considered, with gabapentin as the first choice, and opioids or macrolides as alternatives. Speech pathology treatment and/or neuromodulators should be discussed with patients and alternative options carefully considered, taking into account risk/benefit. Novel promising drugs are under investigation (e.g. P2×3 inhibitors), but additional studies are needed in this field. Speech pathology can be combined with a neuromodulator to give an enhanced treatment response of longer duration suggesting that non-pharmacologic treatment may play a key role in the management of CRC.

The efficacy and safety of DW1601 in patients with acute bronchitis: a multi-center, randomized, double-blind, phase III clinical trial

“…Acute bronchitis is a common disease in the outpatient clinical setting and is caused by viral infection or some bacterial infections [1][2][3][4]22]. Although antibiotics are generally not indicated for the majority of patients with acute bronchitis, clinicians might prescribe antibiotics to relieve symptoms if cough and sputum are persistent.…”

Performance of fractional exhaled nitric oxide in predicting response to inhaled corticosteroids in chronic cough: a meta-analysis

“…A recent meta-analysis of randomised clinical trials reported only a modest efficacy of ICS over placebo on chronic cough, thus concluding that a more rigorous patient selection is needed to identify those who may certainly respond to ICS [ 51 ]. Overall, the diagnostic uncertainty often leads to inappropriate ICS prescription, particularly in subjects with undiagnosed non-specific respiratory symptoms [ 52 ], and in those with recent RTI and otherwise self-limiting cough [ 53 ].…”

Impact of refractory and unexplained chronic cough on disease burden: a qualitative study

“…A small proportion of chronic cough patients have persistent cough despite thorough investigations and treatment. In patients with refractory chronic cough, cough symptoms persist even after appropriate treatment of underlying medical condition in accordance with guidelines [ 10 ]. A patient may also be considered as having unexplained chronic cough, where no diagnosable cause for cough can be identified despite extensive evaluation of all possible causes [ 9 , 11 ].…”