1. 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

2. Introduction

3. 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

4. Objective

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

6. Methods

7. 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.

8. Results

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

11. Risk of Bias

13. Results on Cough

14. 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)

15. Adverse Effects

16. 14% of all patients reported adverse effects
Adverse events were typically described as rather mild symptoms

17. Strengths and Limitations

18. 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

19. Comparison with Existing Literature

20. 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

21. Implications for Practice

22. 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.

23. 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