The first priority for management of a patient with persistent cough is establishing an etiology, so that therapy can be directed at the underlying cause (
algorithm 1). The best approach is to use a systematic combination of empiric therapy and objective testing. (See
"Evaluation of subacute and chronic cough in adults" and
'Specific treatment' above.)
●In patients with upper airway cough syndrome (UACS) who have a personal or family history suggestive of atopy, we recommend treatment with an intranasal glucocorticoid, rather than an oral antihistamine (
Grade 1B). Combination therapy with an intranasal glucocorticoid and an oral antihistamine is an acceptable alternative, particularly in a patient with severe symptoms. (See
'Upper airway cough syndrome' above and
"Pharmacotherapy of allergic rhinitis".)
●
In patients with suspected upper airway cough syndrome, but no features to suggest atopy, we suggest empiric treatment with a first generation oral antihistamine, rather than a second generation antihistamine (
Grade 2B). A first generation intranasal antihistamine is an acceptable alternative. Addition of an oral decongestant medication may provide additional benefit. (See
'Upper airway cough syndrome' above.)
●In patients with subacute or chronic cough due to suspected cough variant asthma, we recommend regular use of an inhaled glucocorticoid and as-needed use of an inhaled bronchodilator, rather than use of an inhaled bronchodilator alone (
Grade 1B). Combination therapy with a leukotriene receptor antagonist and an as-needed, short-acting inhaled bronchodilator is a reasonable alternative. (See
'Cough variant asthma' above.)
●All patients suspected of having a cough due to gastroesophageal reflux should be advised regarding lifestyle modifications. In addition, we recommend using an empiric trial of acid suppression medication therapy, rather than direct testing for gastroesophageal reflux (
Grade 1B). Proton pump inhibitors appear to be more effective than H2 antagonists in this setting. (See
'Gastroesophageal reflux' above.)
- A small number of patients have cough due to nonacid gastroesophageal or laryngopharyngeal reflux and may be helped by antireflux surgery, although further studies are needed. (See 'Other therapies' above.)
●
For patients with cough following an upper respiratory infection and clinical features suggestive of UACS, we suggest treatment with an oral first generation antihistamine, rather than a second generation antihistamine (
Grade 2B). The addition of on oral or intranasal decongestant may be beneficial to some patients. (See
'Following an upper respiratory tract infection' above.)
●For patients with cough following an upper respiratory infection, but few or no features of UACS, we treat bronchial hyperreactivity, as described above for cough variant asthma. (See
'Following an upper respiratory tract infection' above.)
●For patients who develop a chronic cough while taking angiotensin converting enzyme inhibitors (ACEI), we recommend stopping the ACEI rather than trying to suppress the cough with other agents (
Grade 1C). The cough will usually resolve within a couple of weeks, although it will occasionally last up to four months. (See
'Specific treatment' above.)
