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Treating acute cough: wet versus dry – have we got the paradigm wrong?

Alyn H. Morice, Ahmad Kantar, Peter V. Dicpinigaitis, Surinder S. Birring, Lorcan P. McGarvey, Kian Fan Chung
ERJ Open Research 2015 1: 00055-2015; DOI: 10.1183/23120541.00055-2015
Alyn H. Morice
1Centre for Cardiovascular and Metabolic Research, Respiratory Medicine, Hull York Medical School, University of Hull, Cottingham, UK
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  • For correspondence: a.h.morice@hull.ac.uk
Ahmad Kantar
2Paediatric Cough and Asthma Centre, Istituti Ospedalieri Bergamaschi, Bergamo, Italy
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Peter V. Dicpinigaitis
3Einstein Division/Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
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Surinder S. Birring
4Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
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Lorcan P. McGarvey
5Queens University Belfast, Belfast, UK
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Kian Fan Chung
6National Heart and Lung Institute, Imperial College London, London, UK
7Biomedical Research Unit, Royal Brompton and Harefield NHS Trust, London, UK
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Abstract

It is time to abandon the dry/wet classification of acute cough due to URTI http://ow.ly/Sfc1X

To the Editor:

Over-the-counter (OTC) medicines are relied on by millions of patients worldwide to provide relief from acute cough, which is almost exclusively caused by acute viral upper respiratory tract infection (URTI). The worldwide market for such medicines is enormous, amounting to €5.77 billion in 2014 (source: IMS Health, Danbury, CT, USA). Doubts have been expressed as to the efficacy of these drugs [1], and there is no doubt that simple measures used in proprietary and home remedies can have significant benefit through a poorly defined “demulcent” effect. However, significant additional benefit from pharmacotherapy can also be demonstrated [2].

No new drug has been licensed for acute cough in over 30 years. Much of the literature supporting the licensed indications for current OTC medicines is, unsurprisingly, poor by modern standards. What is perhaps more worrying is the continuing use of the paradigm of dry and wet/productive URTI cough by the regulatory authorities and in pharmacies (e.g. www.nhs.uk/conditions/cough/pages/introduction.aspx). This is an anachronism from the era of rampant tuberculosis. In acute URTI there is, in our opinion, little difference between a dry cough and that productive of minimal amounts of sputum. Acute cough, along with persistent cough, is now recognised to be a disorder of the vagal sensory afferents: the so-called cough hypersensitivity syndrome [3]. As an example of this paradigm shift, the marketed “expectorant” guaifenesin is now revealed to have significant effects on cough hypersensitivity [4].

We suggest that it is time to abandon the dry/wet classification of acute cough due to URTI. The cough, productive or not, is there for the benefit of the virus, not the patient, by enhancing viral transmission to the next victim [5–7]. This is why URTIs make your nose run. Indeed, it could be beneficial to inhibit cough to diminish person-to-person spread [8]. It is certainly not harmful to normalise the cough reflex in those with simple URTI. Clearly, in patients with protracted productive cough (bronchorrhoea) or in neurologically impaired patients with a decreased cough reflex, a separate and considered opinion is needed. What is paramount to our understanding of the many drugs in the OTC cough market is demonstrating efficacy using the now established measures of cough counting, cough challenge and validated subjective tools, rather than the current paradigm that a bit of phlegm will somehow drown the patient.

Footnotes

  • Conflict of interest: Disclosures can be found alongside this article at openres.ersjournals.com

  • Received August 11, 2015.
  • Accepted September 14, 2015.
  • Copyright ©ERS 2015

This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

References

  1. ↵
    1. Smith SM,
    2. Schroeder K,
    3. Fahey T
    . Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev 2014; 11: CD001831.
    OpenUrlPubMed
  2. ↵
    1. Dicpinigaitis PV,
    2. Morice AH,
    3. Birring SS, et al.
    Antitussive drugs--past, present, and future. Pharmacol Rev 2014; 66: 468–512.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Morice AH,
    2. Millqvist E,
    3. Belvisi MG, et al.
    Expert opinion on the cough hypersensitivity syndrome in respiratory medicine. Eur Respir J 2014; 44: 1132–1148.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Dicpinigaitis PV,
    2. Gayle YE
    . Effect of guaifenesin on cough reflex sensitivity. Chest 2003; 124: 2178–2181.
    OpenUrlCrossRefPubMed
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    1. OConnell F,
    2. Thomas VE,
    3. Studham JM, et al.
    Capsaicin cough sensitivity increases during upper respiratory infection. Respir Med 1996; 90: 279–286.
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    1. Dicpinigaitis PV,
    2. Bhat R,
    3. Rhoton WA, et al.
    Effect of viral upper respiratory tract infection on the urge-to-cough sensation. Respir Med 2011; 105: 615–618.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Abdullah H,
    2. Heaney LG,
    3. Cosby SL, et al.
    Rhinovirus upregulates transient receptor potential channels in a human neuronal cell line: implications for respiratory virus-induced cough reflex sensitivity. Thorax 2014; 69: 46–54.
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Tyrrell D,
    2. Fielder M
    . Cold wars: the fight against the common cold. Oxford, Oxford University Press, 2002.
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Treating acute cough: wet versus dry – have we got the paradigm wrong?
Alyn H. Morice, Ahmad Kantar, Peter V. Dicpinigaitis, Surinder S. Birring, Lorcan P. McGarvey, Kian Fan Chung
ERJ Open Research Oct 2015, 1 (2) 00055-2015; DOI: 10.1183/23120541.00055-2015

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Treating acute cough: wet versus dry – have we got the paradigm wrong?
Alyn H. Morice, Ahmad Kantar, Peter V. Dicpinigaitis, Surinder S. Birring, Lorcan P. McGarvey, Kian Fan Chung
ERJ Open Research Oct 2015, 1 (2) 00055-2015; DOI: 10.1183/23120541.00055-2015
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