Treatments for Subacute Cough in Primary Care: Systematic Review and Meta-analyses of Randomized Clinical Trials Benjamin Speich, Anja Thomer, Soheila Aghlmandi, Hannah Ewald, Andreas Zeller and Lars G Hemkens Powerpoint by Stacy San Diego,MD

Introduction

Cough is one of the most common reasons for seeking medical advice. Subacute cough is cough that: ‘lasts no longer than 8 weeks; the chest radiography findings are negative ruling out pneumonia; and the cough eventually resolves, usually on its own. (American College of Chest Physicians) Often follows non-specific viral infections causing protracted inflammation of the bronchial mucosa Despite a large number of available treatment options for subacute cough there has been no systematic review evaluating these treatments

Objective

To provide a systematic overview of treatment options and outcomes evaluated in randomized clinical trials (RCTs)

Methods

PubMed/ MEDLINE and the Cochrane Central Register of Controlled Trials utilized as source of publications RCTs of adult patients with subacute cough were they keywords Trials evaluating any outcome of any drug or non-drug treatments, apart from traditional Chinese and Asian medicines were included.

Results

Six eligible RCTs 724 patients Treatments assessed: montelukast salbutamol plus ipratropium bromide gelatine fluticasone propionate, budesonide nociception opioid 1 receptor agonist and codeine

Risk of Bias

Results on Cough

Five studies reported on cough severity scores at various time points. No treatment was associated with a clear clinically relevant improvement of cough scores Inhaled fluticasone and salbutamol plus ipratropium were reported to have potential benefit (Ponsioen et al and Zanasi et al) Steroids were found to have no benefits ( et al Pornsuriyasak) Montelukast was found to have no overall effect No association of treatment with a NOP1 agonist or with codeine when compared to placebo. Improvement on cough perception (Zolghadrasli)

Adverse Effects

14% of all patients reported adverse effects Adverse events were typically described as rather mild symptoms

Strengths and Limitations

PubMed/ MEDLINE and the Cochrane Central Register of Controlled Trials were the only databases used. Chinese or Asian herbal medicine was not considered. Trials that only evaluated treatments commonly used by GPs and their patients in Europe and North America were mainly considered. All RCTs except one included some patients with shorter or longer cough duration Cough scores used were different across trials. Failure to report separate treatment effects for patients with a cough duration of 3–8 weeks

Comparison with Existing Literature

Results are similar to those of a 2013 and 2014 Cochrane Review on inhaled corticosteroids Both concluded that ‘the data were too mixed to be able to draw any conclusions’, and that there is ‘... insufficient evidence to recommend the routine use of inhaled corticosteroids

Implications for Practice

Overall, there was no clear benefit associated with any of these treatments, even though two studies found some indications for favorable effects, evidence remains insufficient However, symptoms diminish over time as a natural course of the self-limiting disease Considering the problem of over treatment, spending time with the patient to explain the illness might be crucial for patient satisfaction.

References 1. Benjamin Speich, Anja Thomer, Soheila Aghlmandi, Hannah Ewald, Andreas Zeller and Lars G Hemkens, British Journal of General Practice: The Journal of the Royal College of General Practitioners, 2018