Relapsed or Refractory Chronic Cough Requires Novel Treatment Options

Clinicians who treat patients for chronic cough have a wide range of treatment options to explore, but effective therapy for chronic cough is a significant unmet clinical need, according to a presentation delivered at the 2021 Fall Managed Care Forum by Peter Dicpinigaitis, MD, director of the Montefiore Cough Center in New York.

Cough is the most common complaint for which U.S. outpatients seek medical attention, amounting to more than 16 million visits per year, Dr. Dicpinigaitis explained. Describing the economic implications of chronic cough, he cited figures that U.S. patients spend $3.6 billion annually on over-the-counter cough/cold therapies, which obviously did not account for the additional costs of health care provider office visits, prescription medications, and lost work and school productivity.

Chronic cough has far-reaching implications for patients, beyond physical symptoms, he added. In a small study of 100 patients presenting to Montefiore Cough Center, 53% scored positive on the Center for Epidemiologic Studies Depression Scale (CES-D), indicating presence of significant depressive symptomatology. Furthermore, when cough symptoms improved, so did depressive symptoms.  

Regarding the evaluation and management of a patient with chronic cough, Dr. Dicpinigaitis reviewed how cough is categorized (according to duration) and the decision-making process for a differential diagnosis of chronic cough. Treatments include oral first-generation antihistamine and inhaled corticosteroids, followed by oral steroids or inhaled steroids, then acid-suppression therapy.

However, Dr. Dicpinigaitis posed the following question: “What if all drugs fail?” Options for refractory chronic cough include narcotics, gabapentin, amitriptyline, and speech-language therapy, but he noted that these options only effective and/or tolerated by a minority of patients. New, safe, effective antitussive drugs are desperately needed.”

He then devoted his time to speaking about P2X3 antagonists, which have demonstrated efficacy in mediating cough neuronal hypersensitivity, and their place in the chronic cough treatment paradigm. The P2X3 antagonist gefapixant, the drug of this class that is furthest along in the Food and Drug Administration review process, is expected to be approved in 2022. Dr. Dicpinigaitis reviewed what is still unknown about how the drug will be used in the clinic – from pricing to duration to who will be allowed to prescribe it.