OTC evidence-based strategies for chronic cough, starting with a trial of first-generation antihistamine-decongestant therapy for suspected Upper Airway Cough Syndrome (UACS). If symptoms persist, consider intranasal steroids or antihistamines to address nasal inflammation. For unresolved cases, consult your doctor for asthma or GERD testing and tailored treatment. Seek medical care immediately for systemic symptoms, wet or bloody cough, or immunosuppression.
January 8, 2025

Chronic Cough: The Approach Doctors Follow

Evidence-Based Over-The-Counter Guide

William Shen

William Shen

Co-founder & CPO

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Chronic cough is defined as a cough lasting longer than eight weeks in adults. It can significantly affect quality of life and is often caused by a combination of underlying conditions. The three most common causes are Upper Airway Cough Syndrome (UACS, formerly known as postnasal drip), asthma, and gastroesophageal reflux disease (GERD). 

Per American College of Chest Physician’s Evidence-Based Clinical Practice Guidelines, treatment approach in a low-risk individual involves empirically treating UACS first. The assumption is that if the cough resolves, then the responsible factors have been identified. Seek medical attention and do not manage your cough at home if you are immunosuppressed, have a wet or bloody cough, or have systemic symptoms besides cough. 

First-line recommendations

  • Antihistamine-Decongestant Combination Therapy: As UACS is the most common cause of chronic cough, a diagnostic/therapeutic trial of a first-generation antihistamine-decongestant combination (FDA M012), such as chlorpheniramine maleate 4 mg and phenylephrine HCl 10 mg is recommended. Note that the recent FDA guidance on phenylephrine being ineffective only applies to oral form and not the nasal spray.

Second-line recommendations:

  • Intranasal steroids: If a partial but not complete response is achieved after 1 week of antihistamine-decongestant combination therapy, fluticasone propionate at 50 mcg per spray, 2 sprays in each nostril once daily can be tried if the response to the first-line therapy is partial or if nasal symptoms persist. Fluticasone 50 mcg nasal spray (FDA NDA 205434).

  • Intranasal antihistamines (e.g., azelastine): may be effective at further reducing nasal inflammation. As needed or 2 sprays in each nostril per day. Azelastine 200 mcg nasal spray (FDA NDA 213872).

If little to no response is achieved after 1-2 weeks:

  • Asthma testing: Your doctor may recommend bronchodilator responsiveness testing, or bronchial challenge tests.

  • Nonasthmatic eosinophilic bronchitis testing: May be recommended if asthma workup is negative.

  • GERD treatment: GERD is also a common cause of chronic cough. It can be managed over-the-counter with an antireflux diet and lifestyle modifications and a proton pump inhibitor (PPI) but we would recommend seeking medical attention before self-treating unless you have clear heartburn or reflux symptoms. 

Citation:

Pratter, M. R., Brightling, C. E., Boulet, L. P., & Irwin, R. S. (2006). An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest, 129(1), 222S-231S.

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