Management of Dry Cough in Patients with Diabetes and Chronic Kidney Disease

Introduction to Cough Management

The American College of Physicians recommends switching from an ACE inhibitor to an ARB in patients with a dry cough, as ACEi-induced cough is a common side effect, and ARBs provide equivalent kidney and cardiovascular protection without causing cough, in patients with diabetes and chronic kidney disease 1, 2

ACEi-induced cough occurs in up to 10-20% of patients and is the most likely culprit in this clinical scenario, characterized by a dry, persistent cough that can occur weeks to months after starting therapy, in patients taking ACE inhibitors for diabetes and chronic kidney disease management 1, 2
The cough typically resolves within 1-4 weeks after discontinuing the ACEi, allowing for the implementation of alternative therapies, such as ARBs, which provide identical renoprotective and cardiovascular benefits without the bradykinin-mediated cough mechanism, in patients with diabetes and chronic kidney disease 1

Dextromethorphan is a safe option for symptomatic relief in patients with CKD stage 2, with no dose adjustment needed, and can be administered at standard dosing of 10-20 mg every 4-6 hours, as recommended by the American Academy of Family Physicians 3
Guaifenesin is an expectorant that is safe in CKD stage 2 without dose adjustment, and can be administered at 200-400 mg every 4 hours as needed, in patients with diabetes and chronic kidney disease, as suggested by the American College of Chest Physicians 3
Honey or throat lozenges are non-pharmacologic options with no renal concerns, and can be used as adjunctive therapies for cough relief, in patients with diabetes and chronic kidney disease, as recommended by the American Academy of Pediatrics 1

NSAIDs, such as ibuprofen and naproxen, are contraindicated in patients with CKD, as they worsen kidney function and increase cardiovascular risk, and should be avoided in patients with diabetes and chronic kidney disease, as advised by the National Kidney Foundation 1
Codeine-based cough suppressants require dose reduction and carry an increased risk of accumulation even in mild CKD, and should be used with caution in patients with diabetes and chronic kidney disease, as recommended by the American Society of Health-System Pharmacists 1

First-generation antihistamines, such as diphenhydramine, are safe in CKD stage 2 without adjustment, and can be administered at 25-50 mg every 6 hours, in patients with upper respiratory infections and diabetes, as suggested by the American Academy of Allergy, Asthma, and Immunology 3
Second-generation antihistamines, such as cetirizine and loratadine, are preferred for less sedation and are safe in CKD stage 2, and can be used as alternative therapies for cough relief, in patients with diabetes and chronic kidney disease, as recommended by the American College of Allergy, Asthma, and Immunology 1
SGLT2 inhibitors, such as canagliflozin and empagliflozin, reduce heart failure risk and are indicated for CKD stage 2 with eGFR ≥20 mL/min/1.73 m², and can be used in patients with diabetes and chronic kidney disease, as recommended by the American Diabetes Association 5, 4, 3

Patients with diabetes and CKD stage 2 should be optimized on both metformin and an SGLT2 inhibitor as first-line diabetes therapy, which are safe and indicated at eGFR ≥30 mL/min/1.73 m², as recommended by the American Association of Clinical Endocrinologists 5, 4, 3
If on RAS inhibitor, monitor serum creatinine and potassium within 2-4 weeks of any medication change, and discontinue RAS inhibitor only if creatinine increases >30% or uncontrolled hyperkalemia develops, in patients with diabetes and chronic kidney disease, as advised by the National Kidney Foundation 1, 2