NICE drafts guidance on acute cough

NICE’s proposed guidance for minimising antibiotic prescribing for acute cough attracted the attention of the lay media with the publication of its draft guideline for consultation.

The proposed guidance endorses the advice of professional bodies down the years not to prescribe antibiotics for acute cough (less than three weeks’ duration) unless the person is identified at a face-to-face examination as being systemically very unwell or at higher risk of complications. Media interest, however, focused on advice about self-management – or rather, the absence of a critical evidence-based approach to remedies that the public has long favoured.

NICE recommends self-care as a preferred alternative to antibiotic use but it doesn’t recommend any options, instead stating: “Be aware that limited evidence suggests that the following have some benefit for the relief of cough symptoms…”before listing honey, pelargonium and, for the over 12s, cough medicines containing guaifenesin or (except for cough that is persistent or accompanied by excessive secretions) dextromethorphan. A reminder that honey should not be given to children younger than one year is buried in a summary of the discussion underpinning the draft; perhaps it should be more prominent. When an antibiotic is indicated, the first choice for adults is doxycycline for five days and, for the under-18s, amoxicillin for five days.

The draft points out there is limited evidence that antihistamines, decongestants and cough medicines containing codeine do not help cough symptoms and there is no evidence one way or the other for pholcodine or simple linctus. By contrast, there is evidence that neither NSAIDs nor bronchodilators help. Consultation on the new guideline closes on 20 September and the final guidance is expected in February 2019.

Clinicians should distinguish the proposed advice on acute cough from NICE guidance on the management of sore throat. NG84 (published in January 2018) recommends paracetamol or ibuprofen for pain. Medicated lozenges containing a local anaesthetic, an NSAID or an antiseptic “only help to reduce pain by a small amount” and there is no evidence to support the use of non-medicated lozenges, mouthwashes or local anaesthetic mouth spray alone.

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