7 Common Medication Types for Cough

Introduction

Cough is considered a “protective reflex…” (Wiki). While it’s not always bad in cases such as aspiration and you need to expel a content, an ongoing cough is not a desired symptom. Many medications exist for cough, but when and what to use for your cough symptoms? When is it time to contact your healthcare provider? Use over-the-counter or prescribed medication? This article discusses the treatment options for a cough, how they work, and how to utilize them.

Types of cough and potential causes

Wet cough	Emphysema, bronchitis, pneumonia
Dry cough	Drainage from allergies, respiratory tract infections
Persistent cough (>90 days)	Asthma, acid reflux, emphysema, smoking, vaping
Tight, tickling, spastic cough	Reactive cough due to infections, allergies

1. Suppressants

This class of medication directly reduces your cough reflex by reducing the simulating effects of airway tissue stretching or by reducing the cough reflex brain pathway. When the airway gets irritated from drainage or pollutants, which are common, the cough reflex ensues. Examples of direct cough suppressants include

Over the counter

• Delsym, the active ingredient is Dextromethorphan, also in cold medicines such as Nyquil

Prescription

• Tessalon Perles, the active ingredient is Benzonatate, prescribed for common colds, and persistent cough
• Codeine, common, it’s a common narcotic that functions through the mu receptor pathway (controlled prescription)

In general, these medications do not address the underlying reasons for the cough. They merely reduce the cough reflex so you should not use these medications alone. In particular, Codeine is a narcotic that promotes the mu receptor response. The benefits vs. risk ratio is questionable for narcotics use in non-surgical and non-emergent settings since the opioid epidemic is evident. Mu-receptor pathway is similarly shared by morphine, the primary psychoactive in opium. In cases of palliative care and hospice, patients may have debilitating coughs due to radiation injuries to their airway and/or esophagus; the benefit/risk ratio of using Codeine is justified.

2. Mucus relief (expectorants)

This class of cough medication thins out the mucus that you make by increasing respiratory secretions into the airway, thus it makes mucus less sticky and easier for the drainage to clear. Examples are

Over the counter

• Mucinex, the active ingredient is guaifenesin, also in Robitussin and many cold medicines

Prescription

• Pima Syrup, active ingredient is potassium iodide

In general, this class of medication used in an acute cough such as the common cold, is questionable. While expectorants make the secretions thin and less sticky, the main question is where is the drainage coming and going. Or are you necessarily getting the mucus out? If you have a head cold, it makes no sense to produce more drainage from your sinuses to go toward your chest and stomach. Notably one of the side effects of Mucinex is stomach upset. You should consider mucolytics if you have a persistent cough due to emphysema or cystic fibrosis; mucus cumulates in the lungs that need to be expelled.

3. Allergy medications

This class of medication indirectly reduces the cough reflex by reducing drainage and inflammation of the airway. Common ones include

Over the counter

• Claritin, the active ingredient is loratadine, with fast onset in one hour if taken on an empty stomach
• Clarinex, active ingredient is desloratadine, an analog of Claritin, has fewer side effects
• Zyrtec, active ingredient is cetirizine, fast onset in one hour if taken on an empty stomach
• Xyzal, active ingredient is levocetirizine, an analog of Zyrtec, less side effects
• Allegra, active ingredient is fexofenadine, SLOW onset, not great for colds

An “allergies” medication for cough? You may ask. Yes, because they are not just great for allergies but are great for colds. You may not know that Nyquil contains an antihistamine (doxylamine), which consumers love to use. However, you would like to function through your cold. You have finances to manage, events to go to, kids to be taken care of, or even working remotely, so taking a drowsing cold medication like Nyquil isn’t ideal. Luckily antihistamines listed above are non-drowsy and last 12 – 24 hours with one pill. Best of all, you can buy these over the counter.

4. Acid reflux medications

Antihistamines type 2: this subclass of antacids works with the histamine receptor type 2 to reduce acid production. This class of indirect cough medication reduces acid reflux and thus cough (“tickle in the throat”).

Over the counter

• Pepcid, the active ingredient is famotidine, fast onset in 1 hour, lasts 10 hours and it can be taken with food
• Rinitadine, also known as Zantac, was taken off the market due to cancer concerns

Proton pump inhibitors (PPI): another subclass of antacids that provides the ultimate acid reduction and reduces that “tickle in throat” feeling, but it carries more long-term effects, must be taken on an empty stomach. If you tried the antacids noted above in “antihistamines type 2″ and it did not help, you can try these medications. However, these types of antacids (PPI) must be taken on an empty stomach.

Over the counter

• Prilosec OTC, active ingredient is omeprazole, widely available over the counter as 20mg
• Nexium OTC, active ingredient is esomeprazole, available over the counter as 20mg
• Prevacid, the active ingredient is lansoprazole, widely available over the counter

Prescription

• Prilosec, active ingredient is omeprazole, 40mg
• Nexium, active ingredient is esomeprazole, 40mg, marginally more effective than Prilosec
• Protonix, the active ingredient is pantoprazole, has fewer interactions with other meds, effective

An antacid to reduce a cough? You may ask. Yes, acid reflux can produce an annoying cough that lasts as long as you have the issue. When you lie down at night, if your stomach muscles and diaphragm cannot efficiently keep the acid from coming up, you can develop a chronic cough. The common symptoms are a globus sensation (something in the throat feeling), waking sore throat, a cough that is tickling and annoying without much production, and also a hoarse quality of your voice. Pepcid is a good test to run to see if it ceases the cough, aside from the general recommendation of GERD diet.

5. Decongestants (Avoid)

It’s just as important to discuss what not to use for cough. The reason to discuss decongestants is that they are not safe to use, and they hide in many over-the-counter and behind-the-counter medications. The most common ones are

Over the counter

• Dayquil, active ingredients include phenylephrine, a decongestant
• Mucinex Cold/Flu, active ingredients include phenylephrine, a decongestant

Behind the counter

• Claritin-D, active ingredients are loratadine and pseudoephedrine
• Zyrtec-D, active ingredients are cetirizine and pseudoephedrine
• Allegra-D, active ingredients are fexofenadine and pseudoephedrine
• Mucinex-D, active ingredients are guaifenesin and pseudoephedrine

Can decongestants make you cough more due to reflux? Yes. The mechanism is more open airway by compressing the arteries lining the airway, thus allowing more space for drainage and more stomach upsets. Decongestants also cause rebound congestion, with elevated heart rate and blood pressure to a dangerous level. The difference between a vein and an artery is the amount of smooth muscle they are made of. Arteries have three layers of smooth muscle, and veins only have one. Veins are more elastic and compliant. Arteries are not very compressible. If you forcibly squeeze arteries by using decongestants, rebound congestion ensues. Bottles of nasal decongestants, such as Afrin (oxymetazoline), and others like phenylephrine in cold remedies, it’s best to avoid it.

6. Bronchodilators (inhaled)

This class of cough suppressants is inhaled or nebulized through a nebulizer machine. They work by dilating the bronchial muscles and thus are called bronchodilators. By relaxing the smooth muscles lining the airway it reduces spasms, which occurs during a cough. Examples are

Prescription

• Albuterol, commonly known as ProAir, Ventolin, or Proventil; common side effect with overuse is an elevated heart rate
• Levalbuterol, or known as Xopenex, same as albuterol, and less likely to induce a fast heart rate

This class of medication does not address the underlying cause of the cough; similar to cough suppressants they reduce the cough reflex directly. Although these are commonly prescribed for a cough, I would not recommend this class of medication to be used alone, especially when you do not have a history of asthma.

7. Inhaled Steroids (ICS)

This class of cough suppressants works by applying a topical anti-inflammatory, a steroid-based one, directly onto the vocal cord via inhalation. Steroids work by reducing inflammatory response, which de-escalates the pathways to more inflammation. Although not commonly branded as cough suppressants, they are great for reactive cough in my practice experience; most if not all cough involves reactive pathways (inflammation). Examples are

Prescriptions only

Singular agent ICS (inhaled corticosteroid)

Advantage: less expensive

• Fluticasone, or known as Flovent, the powder form was discontinued; aerosol (HFA) available
• Mometasone, known as Asthmanex; aerosol (HFA) and Twisthaler (powder)
• Budesonide, known as Pulmicort; aerosol (HFA) or nebulized only

Multi-agent ICS (inhaled corticosteroid)

Advantage: no need for the addition of albuterol, but more expensive (brand mostly)

• Advair Diskus, fluticasone/salmeterol; with a long-acting form of albuterol, twice daily
• AirDuo Respiclick, fluticasone/salmeterol; same as Advair but has a generic, less expensive, twice-daily
• Breo Ellipta, fluticasone/vilanterol; only once daily, expensive
• Symbicort HFA, budesonide/formoterol, aerosol only
• Wixela, fluticasone/salmeterol; same as Advair, but has generic, less expensive, twice daily

With the same argument, nasal steroids can reduce cough by lessening inflammation and drainage. However, the nasal steroid will only reach the sinuses if you use it correctly; it can stop a cough by reducing drainage, but it will not reach the vocal cord directly. In contrast, inhaled corticosteroids can reach the sinuses as well when used correctly. A side effect of ICS is thrush, so you must rinse your mouth after using inhaled steroids.

Conclusion

A cough is a non-specific symptom, but you can assess the cough first before deciding on the next steps. In the case of upper respiratory involvement, including colds, sinus issues, and allergies, start with an antihistamine type 1 first, such as Claritin, then add cough suppressants, such as Tessalon or Delsym. Ultimately, you can consider an ICS (inhaled corticosteroid). If acid reflux occurs without respiratory involvement, try an antacid such as a histamine type 2 blocker like Pepcid or a PPI like Omeprazole; you can add on an ICS (inhaled corticosteroid) as well.  Mucolytics are useful when you have mucus that needs to be expelled from your lungs, which is uncommon unless you have a chronic lung disease. Mucinex is not a good option for coughing during a cold, it can induce more drainage and cough.

Bonus: Antibiotics

Do antibiotics lessen cough? The short answer is yes. Antibiotics not only reduce bacteria, but they also inhibit many other organisms. They reduce the environmental microbes such as mold, thus less burden on the inflamed tissues and resulting in less cough, but with a price. Ultimately, it also reduces the good microbes in your system, thus the common yeast infections, diarrhea, and the worst case scenario, Clostridium Difficile Colitis. Low-threshold prescribing of antibiotics leads to resistance and a public health crisis. Antibiotics are not guided missiles with a targeting system; it’s more like a carpet bomb that blankets all microbes, including the good ones. You should be asking if the use of antibiotics is making you more prone to illnesses. Antibiotics should not be used alone, they should be the last resort as an add-on. When you get a viral infection your immune system gets in hyperdrive, and everything around you makes you more inflamed, including mold, fungus, dust mites, etc. Treat the inflammation and drainage with antihistamines, suppressants, anti-inflammatories such as Motrin, Advil, Aleve, and Ibuprofen, and inhaled steroids if needed. Minimize antibiotic use for a healthier you.

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