Expert panel offers 6 recommendations for managing unexplained chronic cough

An expert panel offered 6 consensus recommendations for diagnosis and treatment of unexplained chronic cough, based on a systematic review of the existing evidence.

The guideline was published online Oct. 1 by CHEST.

The systematic review included 11 randomized, controlled clinical trials with 570 patients; 10 studies were high quality. It assessed the efficacy of treatments on cough severity, frequency, and related quality of life among studies of people 12 years and older with a chronic cough of more than 8 weeks' duration that was unexplained after investigation and treatment.

The 6 recommendations were as follows:

1. 1. Unexplained chronic cough should be defined as a cough that persists longer than 8 weeks and remains unexplained after investigation and treatment (ungraded consensus-based statement).
2. 2. Patients with chronic cough should undergo a guideline/protocol-based assessment process that includes objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial (ungraded consensus-based statement).
3. 3. In adult patients with unexplained chronic cough, a therapeutic trial of multimodality speech pathology therapy could be tried (Grade 2C). The review found that a multimodality speech pathology intervention improved cough severity.
4. 4. In adult patients with unexplained chronic cough and negative tests for bronchial hyperresponsiveness and eosinophilia (sputum eosinophils, exhaled nitric oxide), inhaled corticosteroids should not be prescribed (Grade 2B). Studies of inhaled corticosteroids suffered from intervention fidelity bias, and when this was addressed, inhaled corticosteroids were not found to be effective.
5. 5. In adult patients with unexplained chronic cough, conduct a trial of gabapentin as long as the potential side effects and the risk-benefit profile are discussed with patients beforehand. Reassess the risk-benefit profile at 6 months (Grade 2C). Patients without contraindications to gabapentin can be prescribed a dose escalation schedule beginning at 300 mg once a day, with additional doses being added each day as tolerated up to a maximum tolerable daily dose of 1,800 mg in 2 doses. While the review showed that gabapentin and morphine were associated with positive effects on cough-related quality of life, only gabapentin was recommended as a treatment.
6. 6. In adult patients with unexplained chronic cough and a negative workup for acid gastroesophageal reflux disease, proton-pump inhibitors should not be prescribed (Grade 2C). Esomeprazole was not effective for unexplained chronic cough without features of gastroesophageal acid reflux, and studies addressing non-acid gastroesophageal reflux were not identified.