Chest physicians: OTC cough syrups don't work

New guidelines also recommend vaccinating adults against pertussis and evaluating patients with chronic cough for GERD and asthma.

By Victoria Stagg Elliott — Posted Jan. 30, 2006

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Over-the-counter cough expectorants or suppressants are not effective, and physicians should urge their patients who are coughing because of the cold or flu to use first-generation antihistamines, decongestants and anti-inflammatories.

This recommendation comes from the new guidelines for the diagnosis and management of cough in adults and children published by the American College of Chest Physicians in the January issue of the journal Chest.

"There is considerable evidence that older-type antihistamines help to reduce cough, so unless there are contraindications to using these medications, why not take something that has been proven to work?" asked Richard S. Irwin, MD, lead author and professor of medicine at the University of Massachusetts Medical School in Worcester.

This guideline is the latest blow to OTC cough drops and syrups. A review published in the Cochrane Library in August 2004 found that there was no good evidence for or against these preparations.

Still, response from primary care physicians was mixed.

All acknowledged that the efficacy of these products was unclear, but there was disagreement over whether they could still be useful. Some felt that they might play a vital role in helping people -- even if only because of the placebo effect -- at a minimal cost, and dissuading patients from asking for antibiotics. Concern also surrounded the idea of recommending the older drugs that can be sedating and have other, possibly undesirable, side effects.

"There are not a whole lot of good data on the various cough suppressants, but the guidelines are coming out from a group that deals with a very different patient population than I do," said Jonathan Temte, MD, PhD, an associate professor of family medicine at the University of Wisconsin in Madison. "I deal with cough all the time, and I will readily use these things. It can provide us something other than an antibiotic to recommend, and it may make [patients] feel a little bit better even though it does not do much."

Other physicians felt they are able to provide solace and assurance to patients that the misery would soon go away without resorting to these products. They praised the recommendations for placing greater emphasis on determining the cause of cough, rather than just reaching for an OTC preparation.

"I haven't recommended them for a long time for any of my patients, adults or children," said Russell Robertson, MD, chair of the Dept. of Family Medicine at Northwestern University Feinberg School of Medicine in Chicago. "It's really important to understand why a cough exists in the first place. Hopefully, [these guidelines] will help us try to understand a little more about what's causing the cough rather than just reflexively trying to suppress it."

This guideline also recommended that adults be vaccinated against pertussis. This directive is in line with advice that came from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices in October 2005.

"That's a good thing," said Edward Schulman, MD, one of the guideline's authors and director of the division of pulmonary and critical care medicine at Drexel University Medical College in Philadelphia, who had pertussis two years ago. "It really is the 100-day cough. I wish I had had [the vaccine]."

The guidelines also included numerous recommendations for dealing with chronic cough. These patients should be evaluated for "silent" gastroesophageal reflux disease and "cough variant" asthma and treated as if they have the more typical versions of these diseases, as appropriate.

These recommendations, however, do not apply to smokers, and the guidelines recommend beginning there before hunting for other causes.

"If the patient is a smoker, that's the first place to start," said ACCP President W. Michael Alberts, MD.

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Investigating the cough

Here are highlights of new guidelines for the diagnosis and management of cough in adults and children by the American College of Chest Physicians:

  • Over-the-counter cough expectorants or suppressants are not effective.
  • Physicians should instead urge patients with a cold- or flu-associated cough to use first-generation antihistamines, decongestants and anti-inflammatories.
  • Physicians should place a greater emphasis on determining the cause of cough.
  • Patients with chronic cough should be evaluated for "silent" gastroesophageal reflux disease and "cough variant" asthma.
  • For smokers, cessation should be considered the first line of attack before hunting for other cough causes.
  • Adults should get the pertussis vaccine.

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External links

American Medical Association Council on Scientific Affairs report on dextromethorphan abuse, December 2004 (link)

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