Nonresponse to initial symptomatic management of cough in palliative care
Homsi, 2001Molassiotis, 2010Molassiotis, 2017Vertigan, 2016Wee, 2012Wilcock A, 2020Yancy, 2013
For patients with palliative care needs with a persistent dry cough that does not respond to initial management, and causes distress and reduces quality of life, consider seeking specialist advice. Specialist advice on treatment options for refractory dry cough may be obtained from a respiratory or palliative care physician or team, a multidisciplinary cough clinic or an allied healthcare professional (eg speech pathologist, physiotherapist).
While specialist advice is being sought, consider a trial of morphine. Before starting therapy, consider the general considerations outlined in Overview of opioid use in palliative care. Consider:
morphine immediate-release 1 to 2.5 mg orally, 4-hourly as required12. Adjust dose according to effectiveness and tolerability, up to a maximum of 30 mg in 24 hours; if cough does not improve at this dose, review and consider withdrawing therapy. morphine
Anecdotal reports suggest that the oral liquid formulation of morphine may have beneficial local effects for cough.
If cough persists and as-required immediate-release morphine is effective and well tolerated, continue with as-required use or consider starting regular morphine therapy (with as-required immediate-release morphine for breakthrough symptoms). Consider3:
1morphine (24-hr) modified-release 10 mg orally, once daily. Adjust dose every week according to effectiveness and tolerability, up to a maximum of 30 mg in 24 hours; if cough does not improve at this dose, review and consider withdrawing therapy morphine
OR
1morphine (12-hr) modified-release 5 mg orally, twice daily. Adjust dose every week according to effectiveness and tolerability, up to a maximum of 30 mg in 24 hours; if cough does not improve at this dose, review and consider withdrawing therapy. morphine
The ceiling effect for opioids in cough is unknown, but likely approximates the ceiling effect for breathlessness at approximately 30 mg oral morphine equivalent in 24 hours; beyond this dose, adverse effects may outweigh any additional improvement.
For patients with a persistent productive (moist or wet) cough, seek specialist advice; for example, from a physiotherapist, respiratory physician or multidisciplinary cough clinic. Occasionally, cough suppressants (eg dextromethorphan, morphine) may be considered to allow the patient to rest (eg at night).