Chronic Cough Due to Asthma: Treatment

Despite the demonstrated efficacy of therapy with LTRAs in patients with CVA, the question of whether these agents are sufficient as monotherapy, or whether they should be used in addition to inhaled steroids, remains unresolved at this time, Subepithelial layer thickening, a pathologic feature of airway wall remodeling, is present in CVA, although to a lesser extent than in the typical form of asthma, Hence, chronic antiinflammatory therapy seems appropriate for patients with CVA, but the issue of whether treatment with LTRAs alone is sufficient to prevent the sequelae of chronic airway inflammation awaits further elucidation.
For patients with asthmatic cough that is refractory to treatment with inhaled corticosteroids and bronchodilators, in whom poor compliance or another contributing condition has been excluded, an LTRA may be added to the therapeutic regimen before the escalation of therapy to systemic corticosteroids. Quality of evidence, fair; net benefit, intermediate; grade of recommendation.
Patients with severe and/or refractory cough due to asthma should receive a short course (1 to 2 weeks) of systemic (oral) corticosteroids followed by inhaled corticosteroids. canadian helth& care mall

Quality of evidence, low; net benefit, substantial; grade of recommendation.
Other agents shown in prospective trials to be effective in treating asthmatic cough include inhaled terbutaline, metaproterenol, theophylline, nedocromil sodium, azelastine hydrochloride, a second-generation H1-receptor antagonist, and su-platast tosilate, a Th2 cytokine inhibitor (see Table 1), There are no data to suggest that these agents offer added benefit to a regimen of an inhaled bronchodilator and inhaled corticosteroid, with or without an LTRA. In a patient with chronic cough, asthma should always be considered as a potential etiology because asthma is a common condition with which cough is commonly associated. Quality of evidence, fair; net benefit, substantial; grade of recommendation. In a patient suspected of having CVA but in whom physical examination and spirometry findings are nondiagnostic, MIC testing should be performed to confirm the presence of asthma. However, a diagnosis of CVA is established only after the resolution of cough with specific antiasthmatic therapy. If MIC testing cannot be performed, empiric therapy should be administered; however, a response to steroid therapy will not exclude nonasthmatic eosinophilic bronchitis as an etiology of the patient’s cough. Quality of evidence, good; net benefit, substantial; grade of recommendation. Patients with cough due to asthma should initially be treated with a standard antiasthmatic regimen of inhaled broncho-dilators and inhaled corticosteroids. Quality of evidence, fair; net benefit, substantial; grade of recommendation.

Table 1—Treatment of Chronic Cough Associated With Asthma

Study/Year Age, yr Study Design Patients, No, Treatment Response Rate, % Other Details Quality of Evidence
Corrao et al/1979 16-40 Prospective,descriptive 6 Terbutaline(inhaled) 100 Low
Irwin et al/1997 ъ+1 PRDBPCcrossover 15 Metaproterenol(inhaled) 60 In 40%, cough due to other etiologies Fair
Corrao et al/1979 16-40 Prospective,descriptive 6 Theophylline 100 Low
Crimi et al/1995 20-76 (44)| PRDBPC 62 Theophylline 83 Response rate for all asthma symptoms Fair
Crimi et al/1995 18-55 (37)| PRDBPC 43 Nedocromilsodium 78 Response rate for all asthma symptoms Fair
North American Tilade Study Group/1990 12-70 (35-2)! PRDBPC 121 Nedocromilsodium Improvement in treated patients, (p = 0,02) Patients also ontheophylline and oral p-agonists Fair
Dicpinigaitis et al/ 2002 27-62 PRDBPCcrossover 8 Zafirlukast 88 Suppression of cough reflex sensitivity 100% Fair
Irwin et al/1997 55 ± 16j PRDBPCcrossover 15 Beclomethasonediproprionate

(inhaled)

60 In 40%, cough due to other etiologies Fair
Cheriyan et al/1994 Retrospective,descriptive 10 Prednisone 7-14 d, followed by beclomethasone diproprionate 100 80% required long-term ICSs for cough suppression Low
Di Franco et al/2001 36 ± 16j PRDBPC 36 Beclomethasone diproprionate (and albuterol) Improvement in treated patients (p < 0,01) Compared to placebo and albuterol Fair
Doan et al/1992 4-71 Prospective,descriptive 10 Prednisone (20-60 mg/d) 100 Subsequent therapy with ICSs Low
Shioya et al/1998 25-63 (47,1)! Prospective,unblinded,

uncontrolled

22 Azelastinehydrochloride Improvement in treated patients(p < 0,001) Low
Shioya et al/2002 22-69 (44,7)! PRDBPC 20 Suplatast tosilate Improvement in treated patients(p < 0,01) Fair

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