Cough remedies: how to choose and when to use them

Cough is a protective reflex. The underlying cause of the cough should be treated first, with symptomatic treatments used selectively and sparingly. For acute post-viral cough, non-drug support is sufficient for most people, and antibiotics and "strong syrups" are usually unnecessary. For chronic and recurrent cough, accurate diagnosis of the phenotype and targeted therapy are key. [1]

Key principles of therapy

1. First, diagnose the underlying cause. The most common causes of chronic cough in adults include asthma and eosinophilic bronchitis, postnasal drip syndrome (rhinosinusitis), and gastroesophageal reflux disease. Each cause requires its own treatment plan. [2]
2. Acute cough associated with a cold is treated supportively, without antibiotics and without routine inhaled bronchodilators or steroids, unless there is an underlying respiratory disease. [3]
3. Cough syrups are less effective than many expect. For most over-the-counter cough suppressants and expectorants, evidence of effectiveness is limited or inconsistent. Choice should be cautious and short-term. [4]

Non-drug remedies

• Hydration regimen, warm drinks, quieting the voice, and humidifying the room maintain comfort and can reduce the frequency of coughing during a cold. This is a basic tactic in the first few days. [5]
• Honey at night for nighttime coughs in children over 1 year old. In randomized trials, honey reduced the frequency and severity of coughs better than placebo and no worse than dextromethorphan. Contraindicated for children under 1 year due to the risk of botulism. [6]
• Nasal irrigation with saline solutions for rhinosinusitis indirectly reduces coughing by reducing postnasal drip. [7]

Symptomatic medications for acute cough

• Dextromethorphan. May slightly reduce cough frequency in older children and adults, but the clinical effect is minimal. Do not use in young children; avoid overdose and combination with serotonergic drugs. [8]
• Codeine and other opioids. They are no more effective than placebo for acute cold coughs and carry risks of sedation and respiratory depression. They are not recommended for routine use in colds. [9]
• Benzonatate. May suppress the cough reflex in adults, but severe and fatal intoxications have been reported in children following accidental ingestion. Do not administer to children and keep out of reach of children. [10]
• Expectorants and mucolytics. They are not recommended for acute coughs associated with viral infections due to their limited effectiveness. Exceptions may be made in individual cases at the discretion of a physician. [11]
• Inhaled bronchodilators and steroids are not routinely prescribed for acute bronchitis and the common cold unless asthma or other respiratory disease is confirmed. [12]
• Antibiotics: Not indicated for uncomplicated acute cough without signs of severe bacterial infection. [13]

A quick guide to what to do if you have a cold and cough.

Situation	What helps?	What to avoid
Cough on the 1st to 3rd day of a cold, without shortness of breath	Warm drinks, rest, honey for children over 1 year old, symptomatic antipyretics as indicated	Antibiotics, "strong syrups" for children, routine inhaled steroids and bronchodilators without indications [14]
Night cough in a child over 1 year old	Honey before bed, rinsing the nose for a runny nose	Dextromethorphan and opioids for children, honey up to 1 year [15]
Cough for more than 3 weeks, repeated episodes	Consult a doctor to find the cause.	Self-medication with syrups instead of diagnosing the cause [16]

Medicines for chronic and recurrent cough: treating the cause

• Asthma and eosinophilic bronchitis. Inhaled glucocorticosteroids are the standard treatment, with long-acting bronchodilators added if necessary. Inflammation control is more important than "syrups." [17]
• Postnasal drip syndrome in rhinosinusitis. A classic regimen with a first-generation antihistamine plus an oral decongestant can reduce cough. For allergic rhinitis, nasal steroids are used. [18]
• Gastroesophageal reflux disease. Proton pump inhibitors are appropriate for confirmed symptomatic reflux, not just as a precaution. Empirical long-term treatment without evidence of reflux is not recommended. [19]

Refractory chronic cough: specialized approaches

• Neuromodulators. Gabapentin may reduce the severity of refractory cough in selected adults. Use as directed by a healthcare professional after evaluation of benefit and tolerability. [20]
• A short course of low-dose morphine for severe refractory cough may be considered in selected cases under supervision. The decision is made in a specialized center. [21]
• Speech therapy and behavioral techniques to suppress the cough reflex have been shown to be beneficial and are included in recommendations for chronic cough.[22]
• P2X3 antagonists. Gefapixant has received a positive opinion from the European Medicines Agency's regulatory committee for the treatment of refractory and unexplained chronic cough in adults. Final regulatory decisions and access vary by country. [23]

Drugs with limited benefits or risks

• Most over-the-counter cough syrups are "for every cough." A Cochrane review found no convincing effectiveness in adults or children, with side effects occurring at least as frequently as placebo. These medications are only recommended for short-term trial use in adults if non-drug treatments are ineffective. [24]
• Codeine for colds: No more effective than placebo, but the risks outweigh the benefits. [25]
• Benzonatate in children. Can be fatal if even 1-2 capsules are accidentally ingested. Keep out of reach of children. Do not administer to children. [26]

For children: what is allowed and what is not

• You can: honey over 1 year old, drinking, rinsing the nose, moisturizing, antipyretics as indicated. [27]
• Use with caution or not recommended: dextromethorphan and other antitussives in young children, opioids, benzonatate. For persistent cough, consult a pediatrician instead of repeating "syrups." [28]

Table. Choice of therapy according to the scenario

Scenario	First line	Alternatives and additions	Comments
Acute post-viral cough in an adult	Non-drug support	Short-term trial of dextromethorphan in adults with severe discomfort	Avoid antibiotics and routine inhalants unless indicated [29]
Night cough in a child over 1 year old	Honey	Supportive therapy	Do not give honey to children under 1 year of age, do not use opioids and benzonatate in children [30]
Cough with allergic rhinitis	Nasal steroids, antihistamines	Nasal lavage	Reduces postnasal drip and cough [31]
Cough in asthma, eosinophilic bronchitis	Inhaled glucocorticosteroids	Long-acting bronchodilators as indicated	Manage inflammation, not just the symptom [32]
Refractory chronic cough	Speech therapy, gabapentin	Low-dose morphine in the center, P2X3 antagonists in countries with access	Routing to a cough specialist is mandatory [33]

When to see a doctor urgently

High fever, shortness of breath, wheezing, coughing up blood, chest pain, decreased oxygen saturation, sudden weakness, severe drowsiness, cough lasting more than 3 weeks, and any alarming symptoms in young children. These signs require in-person evaluation and targeted treatment of the underlying cause. [34]