Management of Dry Cough in Pulmonary Fibrosis

Initial Assessment and Management

The European Respiratory Society recommends assessing for progression of underlying pulmonary fibrosis or complications from immunosuppressive treatment in patients with pulmonary fibrosis presenting with dry cough 4
Evaluate for common comorbidities that may cause or worsen cough in pulmonary fibrosis patients, including gastroesophageal reflux disease (GERD) 5 and obstructive sleep apnea syndrome 6, 2

The European Respiratory Society recommends codeine as first-line therapy for dry cough in pulmonary fibrosis 1, 3
If codeine is ineffective, low-dose oral corticosteroids can be prescribed for a limited period, with careful monitoring of efficacy and tolerance 1, 2

For patients with IPF and a negative workup for acid gastroesophageal reflux, proton pump inhibitor therapy should not be prescribed, as recommended by the American College of Chest Physicians 4
For patients with pulmonary sarcoidosis, inhaled corticosteroids should not be routinely prescribed to treat chronic cough, according to the American College of Chest Physicians 4
High-dose corticosteroids or thalidomide are poorly tolerated and inadvisable for long-term management, as stated by the European Respiratory Society 1, 2

Opiates may be recommended for symptom control in a palliative care setting, with reassessment of benefits and risks at 1 week and then monthly before continuing, as suggested by the American College of Chest Physicians 4, 5
Low-dose morphine derivatives (<30 mg oral morphine equivalents daily) may be used with careful monitoring of side effects, as recommended by the European Respiratory Society 1, 3
Consider therapies recommended for unexplained chronic cough, including gabapentin or pregabalin (neuromodulators) 5 and multimodality speech pathology therapy 4, 5

Regular clinical visits and pulmonary function tests (including FVC) every 3-6 months are recommended by the European Respiratory Society 1, 3
Monitor for progressive increase in dyspnea 3, progressive decrease in FVC or DLCO 3, and worsening of signs on computed tomography 1, 3

Treatments that work for unexplained chronic cough have not been extensively studied specifically in ILD-associated cough, but may be considered, as noted by the American College of Chest Physicians 5