NORTHBROOK, Ill., Jan. 10 - Just say no to over-the-counter cough remedies, according to new guidelines issued by the American College of Chest Physicians (ACCP) here.
"There is no clinical evidence that over-the-counter cough expectorants or suppressants actually relieve cough," said guidelines chair Richard S. Irwin, M.D., of the University of Massachusetts Medical School in Worcester, Mass. The guidelines were published as a supplement to the January issue of Chest.
Action Points
- Explain to patients that new cough guidelines issued by the American College of Chest Physicians recommend against the use of OTC products containing expectorants or cough suppressants in both adults and children.
- Point out to patients that the guidelines recommend the use of first-generation antihistamines such as Benadryl (diphenhydramine) and decongestants such as Sudafed (pseudoephedrine) for cough caused by upper airway cough syndrome, a term the ACCP prefers to postnasal drip syndrome.
- Understand that the guidelines recommend the use of a new adult pertussis vaccine. The childhood vaccine offers protection only for about 10 years.
- Consider performing sinus imaging in patients who are suspected of having an upper airway cough syndrome-induced cough but who don't respond to empiric therapy with antihistamines and/or decongestants.
Products containing the expectorant guaifenesin or the cough suppressant dextromethorphan, or both, don't treat the underlying cause of cough, the guidelines noted.
Instead, adults with acute cough or upper airway cough syndrome (also known as postnasal drip syndrome) should be treated with a decongestant and/or a first-generation antihistamine such as Benadryl (diphenhydramine).
"There is considerable evidence that older type antihistamines help to reduce cough, so, unless there are contraindications to using these medicines, why not take something that has been proven to work," Dr. Irwin said.
The guidelines also strongly recommend that adults up to 65 years old receive the new adult pertussis vaccine; about 28% of pertussis cases annually in the U.S. occur in adults, according to the ACCP.
"Although most of us were vaccinated against whooping cough when we were children, the older vaccine only gives protection for less than 10 years," Dr. Irwin said. "Because the older vaccine caused serious side effects when given to older children and adults, it was only given to [young] children. Fortunately, there is a now a new safe and effective whooping cough vaccine that can prevent adults from contracting this disease."
The new guidelines are a comprehensive set of recommendations for the diagnosis and management of cough in both children and adults, and include more than 200 specific recommendations for dealing with cough related to conditions ranging from the common cold to chronic airway disease.
According to the ACCP, the guidelines are the first to provide specific evidence-based recommendations for the diagnosis and management of cough in children.
For example, the guidelines strongly recommend against the use of OTC cough and cold medications in children 14 years-old and younger.
"Cough is very common in children. However, cough and cold medicines are not useful in children and can actually be harmful," Dr. Irwin said "In most cases, a cough that is unrelated to chronic lung conditions, environmental influences, or other specific factors, will resolve on its own."
The ACCP says that nearly 30 million of the estimated 829 million annual visits to office-based physicians in the United States are for cough.
Common causes of chronic cough include upper airway cough syndrome, asthma, gastroesophageal reflux disease (GERD), smoking, and side effects from medications (e.g., ACE inhibitors for high blood pressure).
Among the specific recommendations are:
- In patients with chronic cough who don't smoke and aren't receiving a GERD inhibitor the diagnostic approach should focus on the detection and treatment of upper airway cough syndrome, non-asthmatic eosinophilic bronchitis, or GERD alone or in combination.
- In patients with chronic cough, don't rely solely on the patient's description of his or her cough - it's character, timing, or presence or absence of sputum - to rule a diagnosis in or out or to determine the clinical approach.
- In patients with chronic cough, a diagnosis of upper airway cough syndrome-induced cough should be made by considering symptoms, clinical exam findings, radiographic findings, and response to therapy.
- In children with cough, cough suppressants and other over-the-counter cough medicines should not be used because they can cause significant morbidity and mortality.
- Patients who are suspected of having an upper airway cough syndrome induced cough but who don't respond to empiric therapy with antihistamines or decongestants, or both, should undergo sinus imaging to rule out chronic sinusitis.
- In patients without an apparent cause of chronic cough, clinicians should first prescribe empiric therapy for upper airway cough syndrome in the form of a first-generation antihistamine and decongestant preparation, before embarking on an extensive diagnostic workup.
- Non-specific cough in children may resolve spontaneously, but children should be re-evaluated to rule out the emergence of specific causes.
- Children with chronic productive purulent cough should be evaluated to rule out bronchiectasis and to identify underlying and treatable causes such as cystic fibrosis or immune deficiency syndromes.
Primary Source
Chest
Source Reference: Irwin RS et al. ACCP Evidence-Based Guidelines Supplement to Chest 2006, 129;1