Cough Presenting in the Pharmacy: A Practical Approach

Background

A cough is a reflex action that helps to clear the airways from secretions, foreign bodies and irritants.¹

An acute cough is one of the most common presenting complaints encountered in the pharmacy for which patients seek advice about or over-the-counter (OTC) cough treatment. It is most commonly caused by a viral upper respiratory tract infection such as a common cold or flu. The majority of these coughs are self-limiting and rarely require significant medical intervention.² 

Through careful questioning including the identification of red flags/danger symptoms, the pharmacist can determine how to approach a patient with a cough and whether the patient needs to be referred to the GP or seek urgent medical attention.

Finally, there is no good evidence for or against the effectiveness of OTC medicines in acute cough.³

Duration of Cough

• A cough can be described as either productive (chesty), where sputum is produced, or non-productive (dry, tickly or irritating), where no sputum is produced
• Cough is classified as acute, subacute or chronic⁴
• An acute cough is defined as lasting less than 3 weeks⁴
• A subacute cough is defined as lasting 3-8 weeks⁴
• A chronic cough is defined as lasting more than 8 weeks⁴
• Table 1 outlines some possible causes of acute, subacute and chronic cough

Table 1: Causes of cough

Sources: References 4-6

Red Flag Signs/Symptoms for Patients Who Present With a Cough

Patients presenting with any of the following red flag/danger symptoms listed below should be referred to the GP or seek urgent medical attention. Please note this list is not exhaustive.

• Shortness of breath
• Chest pain
• Pain on inspiration
• Cough lasting 3 weeks or more
• Wheezing
• Recurrent nocturnal cough
• Hoarseness lasting more than 3 weeks
• Haemoptysis
• Appearance/characteristic of sputum as described in table 2 (please see below)
• Systemic symptoms (e.g. fever, night sweats, unexplained weight loss)
• Suspected adverse drug reaction
• Excessive sputum production
• Recurrent chest infection
• Difficulty swallowing when eating or drinking
• Symptoms suggestive of whooping cough
• Change in the nature of the smoker’s cough
• People receiving chemotherapy or taking immunosuppressant drugs

Table 2: Characteristics of sputum and possible associated causes

Possible Questions to Ask the Patient

Here are some examples of what questions to ask a patient with a cough:

• Age of patient—is it a child, an adult or an elderly person?
• Onset (acute or gradual) and duration of cough (refer coughs lasting more than 3 weeks)
• Describe the cough e.g. productive, dry, barking
• Travel history e.g. recent travel to a TB-prevalent area or a recent long-haul flight
• Are there any other symptoms associated with the cough e.g. fever, runny/blocked nose, sneezing and/or sore throat indicates cold or flu
• Are there any red flags/danger symptoms that require a referral to the GP or seek urgent medical attention
• Smoking history including those who have recently quit smoking
• Substance misuse—does the patient display any warning signs of substance misuse or addiction (substances such as cocaine, heroin and cannabis can cause respiratory problems)
• Drug history e.g. ACE inhibitors, check for potential drug interactions
• Nocturnal cough e.g. asthma
• Occupational history—is the cough due to the patient’s occupation or an environmental factor?
• Past medical history/co-morbidities—is the cough due to an exacerbation of a pre-existing condition (e.g. asthma or COPD)
• Colour of sputum (see table 2)

In addition to the above questions, the following pharmacy mnemonics can be used to help with the diagnosis.

OTC Cough Treatments

Demulcents

• Demulcent cough preparations e.g. paediatric simple linctus, simple linctus, glycerin, lemon and honey linctus
• Indicated for the symptomatic relief of cough
• They are pharmacology-inert and used mainly for their placebo effect
• Demulcent cough preparations coat and soothe the back of the throat; they contain soothing ingredients such as glycerol, syrup and/or honey
• Safe to recommend in the elderly, children and pregnant women
• Inexpensive

Cough Suppressants (Antitussives)

• e.g. codeine, pholcodine, dextromethorphan
• Indicated for the symptomatic relief of non-productive (dry, tickly or irritating) cough
• Codeine and pholcodine are opioid cough suppressants, whereas dextromethorphan is a non-opioid cough suppressant
• Pholcodine-containing cough and cold medicines have been withdrawn from the UK market following a MHRA review which found that their benefits do not outweigh the increased risk of the very rare event of anaphylaxis to neuromuscular blocking agents used in general anaesthesia.⁷ The use of pholcodine during the 12 months prior to anaesthesia was significantly associated with an increased risk of anaphylaxis to neuromuscular blocking agents.⁷
• Codeine and dextromethorphan all carry the potential for abuse; however, dextromethorphan is thought to have a lower abuse potential compared to codeine
• Codeine can cause sedation and constipation
• Patients should be advised on the possibility of sedation occurring with dextromethorphan
• Cough suppressants should be used with caution in asthmatics
• Codeine-containing OTC liquid medicines should not be used for cough suppression in children younger than age 12 years and are not recommended for adolescents (12 to 18) who have problems with breathing as advised by the CHM/MHRA⁸
• OTC cough and cold medicines containing dextromethorphan should not be used in children under 6 years of age as advised by the CHM/MHRA⁹

Expectorants

• e.g. guaifenesin, ammonium chloride, ipecacuanha, squill
• Indicated for the symptomatic relief of productive cough
• There is little evidence on the effectiveness of expectorants; however, some people report them as being useful in alleviating their cough symptoms (more likely to serve as a placebo effect)
• Guaifenesin has no known clinically significant drug interactions
• OTC cough and cold medicines containing guaifenesin and ipecacuanha should not be used in children under 6 years of age as advised by the CHM/MHRA⁹

Antihistamines

• Antihistamines used in cough/cold preparations include the first-generation antihistamines such as diphenhydramine, promethazine and triprolidine
• They dry up the nasal and bronchial secretions; indicated for the relief of cough and/or nasal symptoms (e.g. rhinorrhoea, sneezing)
• They can cause anticholinergic adverse effects such as dry mouth, constipation, blurry vision, urinary retention, exacerbation and precipitation of acute angle-closure glaucoma; antihistamines should not be recommended in patients with glaucoma or prostate enlargement
• They also cause sedation and may be suitable to recommend where the cough is disturbing sleep
• OTC cold/cough preparations containing brompheniramine, chlorpheniramine, diphenhydramine, doxylamine, promethazine, and triprolidine should not be used in children under 6 years of age as advised by the CHM/MHRA⁹

Other OTC Cough Treatment Points

• Cough/cold preparations containing sodium: Check sodium content and assess whether the cough/cold preparation is suitable for the patient e.g. low sodium diet, renal impairment, cardiovascular disease
• Cough/cold preparations containing alcohol: Check alcohol content and assess whether the cough/cold preparation is suitable for the patient e.g. Is there a history of alcohol abuse? Is the patient taking an existing medicine that may interact with the alcohol present in the cough/cold preparation? Who is it for (e.g. child, pregnant woman or breastfeeding)?
• Recommend a sugar-free cough/cold preparation over one containing sugar in children or those with diabetes
• Do not recommend a cough/cold preparation containing illogical combinations such as an antitussive and expectorant
• Check that the cough/cold preparation is age-appropriate
• Beware of people who might be abusing cough medicines such as cough/cold medicines containing dextromethorphan, codeine linctus
• Chronic cough can affect the person’s quality of life (e.g. anxiety, urinary incontinence). Look for clues that might suggest someone has a chronic cough that they have not sought help for. They could make a simple remark like the cough medicine or cough sweet helps clear their cough and they cannot do without it or notice that someone regularly buys cough lozenges/sweets.

Safety Netting

Do provide the person with safety netting advice that is individualised to the person. Make sure they understand what has been said and when to seek advice from a healthcare professional if their cough worsens or does not resolve in a certain time frame.

Examples of safety netting advice that you may want to give could include the following:

• If your cough doesn’t go away in 3 weeks, please make an urgent appointment with the GP^10-11
• If your cough worsens with time, please make an urgent appointment with the GP^10-11
• If you are coughing up blood, please make an urgent appointment with the GP^10-11
• Call 999 if you are struggling to breathe – you’re choking, gasping and unable to speak^10-11
• If you have chest pain that comes and goes, or when breathing or coughing, please make an urgent appointment with the GP^10-11
• Patients who have had their ace inhibitors stopped due to a troublesome cough, explain that it takes a few weeks for the cough to stop after stopping the ace inhibitor. If the cough hasn’t stopped in 4 weeks, then advise them to return to the GP.

Self-Care Tips

• Drink plenty of fluids
• Get plenty of rest
• Sucking a boiled sweet, pastille or lozenge may help to soothe a cough
• A simple home remedy such as drinking warm water mixed with honey and lemon may help to soothe a cough
• Steam inhalation
• Patients who have diabetes should monitor their glucose more frequently
• Advice on smoking cessation

Patient Education Resources

These patient education resources can be used to educate a patient with a cough and also be shared with them. They are available in multiple languages.

Cough in adults

This fact sheet from the Self Care Forum helps your patients understand what is normal for a cough and what they can expect to happen if they develop a cough. It also provides advice on when the patient should be concerned and seek advice from a health care professional.

This fact sheet is available in the following languages: English and Urdu.

Chronic cough

This fact sheet from the European Lung Foundation is about chronic cough. In this fact sheet, patients can find information on the symptoms of chronic cough, its causes and triggers, and some of the ways they can manage their condition.

The fact sheet is available in the following languages: English, French, German, Italian, Russian, Polish, Spanish and Romanian.

Diagnosing and treating chronic cough in adults

These guidelines have been written to provide information for someone who is suffering from a chronic cough. These guidelines help the person understand their condition, treatment options and to speak confidently to their doctor about this.

These guidelines are available in the following languages: English, French, German, Polish, Spanish, Catalan and Swedish.

In addition to the above, patients seeking advice about their cough gives the pharmacist an opportunity to advise on self-care measures such as reducing weight, stopping smoking and giving advice about any long-term condition they may have. Signpost patients to patient education resources that are relevant to their condition and will be helpful to them in managing and improving their own health.

References

1. Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of chronic cough. The Lancet. 2008;371(9621):1364-1374.
2. Morice AH, McGarvey L, Pavord I. British Thoracic Society Group: Recommendations for the management of cough in adults. Thorax 2006;61:i1-i24.
3. Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database of Systematic Reviews 2014, Issue 11.
4. Irwin RS, French CL, Chang AB, et al. Classification of cough as a symptom in adults and management algorithms: CHEST guideline and expert panel report. Chest 2018;153(1):196-209.
5. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 2020;55(1):1901136.
6. National Institute for Health and Clinical Excellence (NICE). Clinical Knowledge Summaries (CKS) – Cough. Accessed via https://cks.nice.org.uk/cough.
7. Medicines and Healthcare products Regulatory Agency. Drug Safety Update: Pholcodine-containing cough and cold medicines: withdrawal from UK market as a precautionary measure. Accessed via https://www.gov.uk/drug-safety-update/pholcodine-containing-cough-and-cold-medicines-withdrawal-from-uk-market-as-a-precautionary-measure.
8. Medicines and Healthcare products Regulatory Agency. Drug Safety Update: Codeine for cough and cold: restricted use in children. Accessed via https://www.gov.uk/drug-safety-update/codeine-containing-liquid-over-the-counter-medicines.
9. Medicines and Healthcare products Regulatory Agency. Drug Safety Update: Over-the-counter cough and cold medicines for children. Accessed via https://www.gov.uk/drug-safety-update/over-the-counter-cough-and-cold-medicines-for-children.
10. NHS. Cough. Accessed via https://www.nhs.uk/conditions/cough/.
11. NHS. Pneumonia. Accessed via https://www.nhs.uk/conditions/pneumonia/.