A new way to look at acute cough in the pharmacy

© 2017 Royal Pharmaceutical Society. All rights reserved. Cough is the most common symptom for which people seek medical advice, and patients with cough frequently present to community pharmacy. Cough can be either acute or chronic. Acute cough, defined as being of less than three weeks' duration, is often caused by viral respiratory tract infection and is probably one of the most common reasons for accessing healthcare in the community. For these infections, no antiviral treatment exists and antibiotics have been shown to be ineffective in patients without pre-existing lung disease. Unfortunately, many of the therapies available over the counter are currently recommended based on custom and traditional practice, which is not supported by clinical studies of sufficient quality to meet the standards of modern evidence-based medicine. Viral infections of the respiratory tract cause the early release of inflammatory mediators that activate the afferent sensory nerves leading to a hypersensitivity state. Coughing is precipitated by minimal stimuli, such as a change in temperature. This hypersensitivity is the major mechanism causing all acute coughs whether 'chesty' or 'dry'. A call for removal of the 'wet' or 'dry' classification for acute cough has been made and a new model proposed, based on a recent European evidence-based review. This model proposes that cough medicines are evaluated according to symptoms; including validated subjective measures of symptoms and accurate measures of antitussive and objective cough counting. Cough counting is now recognised as the gold standard for assessing antitussive activity by the US Food and Drug Administration, but because it is a recent innovation, very few of the currently available cough medicines have been assessed using this methodology. This new model and way of working holds the promise to make assessment of cough easier than previously and, importantly, is evidence-based. Instead of asking patients whether their cough is 'wet' or 'dry', the important thing to identify is whether the cough is acute or chronic, together with the assessment of 'red flag' symptoms, such as haemoptysis, or localising symptoms, such as pleuritic chest pain, which may indicate serious pathology