"Miss, what can you give me for a cough?" is the worst-worded reason to buy something in a pharmacy. Because a dry cough and a productive cough call for completely different molecules, and the wrong combination (a cough suppressant for a productive cough) can worsen a bronchitis picture. Let us tell them apart clearly.
Two coughs, two approaches
- Dry cough — no sputum, irritative, triggered by upper respiratory viral infections, smoke, ACE inhibitors (captopril, enalapril, perindopril), gastro-oesophageal reflux, asthma. Here the point of cough suppressants is real.
- Productive (wet) cough — with sputum. A clearance mechanism — you are trying to expel secretions. Here cough suppressants are counterproductive; you need mucolytics / expectorants.
Cough suppressants — how they act and which exist
| Active substance | Mechanism | Status | RO examples |
|---|---|---|---|
| Codeine | Central opioid, suppresses the cough centre | P-RF (controlled substance) | Rinofug Plus, Tussin |
| Dextromethorphan | Central NMDA antagonist, non-opioid | OTC | Calmotusin, Tussin DM |
| Butamirate | Non-opioid, central | OTC | Sinecod, Stoptussin (combined) |
| Levodropropizine | Peripheral, on bronchial sensory receptors | OTC | Levopront |
| Cloperastine | Central suppressant + mildly antihistaminic | OTC | Plurituss |
| Pholcodine | Weak opioid | Withdrawn in RO/EU 2022 — risk of cross-anaphylaxis with neuromuscular blockers | — |
Mucolytics and expectorants
| Active substance | Mechanism | RO examples |
|---|---|---|
| Acetylcysteine (NAC) | Breaks the disulfide bonds of mucin → thins it | ACC, Fluimucil, Mucosolvin, Solmucol |
| Carbocisteine | Modifies the mucin structure | Bronchosolvin, Carbosin |
| Ambroxol | Stimulates surfactant, thins | Mucosolvan, Halixol, Brontex, Ambroxol LPH |
| Bromhexine | Ambroxol precursor | Bisolvon, Bromhexin Atb |
| Erdosteine | Mucomodulator, antioxidant | Erdomed |
| Guaifenesin | Osmotic expectorant | component in Robitussin Expectorant |
What the evidence shows
Cochrane ("Over-the-counter (OTC) medications for acute cough in children and adults in community settings", 2014, 2024 update) conclusion: limited evidence that cough suppressants or mucolytics bring clear benefits in acute viral cough. The placebo effect is large in cough — any sweet syrup partly soothes.
Exceptions with a clearer benefit:
- NAC and carbocisteine in COPD with frequent exacerbations — they reduce the exacerbation rate (the Poole et al. meta-analysis).
- Dextromethorphan in persistent dry cough — a modest reduction in frequency.
- Codeine and opioids — effective, but an unfavourable risk-benefit profile in uncomplicated acute cough.
Practical rules
- Dry, irritative cough, no fever for >3 days: butamirate (Sinecod) or levodropropizine. Good hydration, humidified air.
- Productive cough with thick sputum: ambroxol or NAC, plenty of fluids (1.5-2 L/day). Do NOT add a cough suppressant — you block the expectoration.
- Cough + blocked nose: saline nasal spray (Sinomarin, Marimer) ± xylometazoline for 3-5 days. The cough often comes from post-nasal drip.
- Cough + wheezing: it is not just viral — investigate asthma; inhaled salbutamol as needed.
- Dry, persistent cough >8 weeks: medical evaluation — asthma, GORD, ACE inhibitor, chronic sinusitis, fibrosis, neoplasm.
Specific warnings
- Codeine — contraindicated under 12 years (EMA 2015), caution in rapid CYP2D6 metabolisers.
- NAC — caution in asthma patients (rare bronchospasm), not combined with antibiotics in the same hour (chelation).
- Ambroxol and bromhexine — EMA alert 2015, severe skin reactions (SJS/TEN), rare but serious.
- In children <2 years — OTC cough suppressants and mucolytics are contraindicated or strictly indicated (they thin too much, risk of choking on sputum).
- Pholcodine — withdrawn from the EU in 2022 after a signal of cross-anaphylaxis with neuromuscular blockers in general anaesthesia.
Non-drug remedies with evidence
- Honey — 1-2 teaspoons in a child >1 year, before bedtime. Cochrane: a modest but consistent effect in acute cough in children.
- Hydration — water, teas, warm soup.
- Steam inhalation (with or without essential oils, with caution in children).
- Saline nasal spray — reduces post-nasal drip cough.
- Lozenges with menthol/eucalyptus — a mild symptomatic effect.
RO reimbursement and prices
Most cough suppressants and mucolytics are OTC. Codeine is P-RF (a controlled substance under Law 339/2005). Ambroxol, NAC, butamirate have 50% reimbursement on List B/C2 only in chronic pulmonary indications. The price of ACC 600 mg granules syrup or ambroxol solution varies between chains — Catena, Dona, Help Net, Farmacia Tei, Dr.Max — compared on HartaFarmacii.
Frequently asked questions
- Why do I have a dry cough after getting over a cold?
- Post-viral hyper-reactivity — it lasts 3-6 weeks. Soothe with butamirate or a short inhaled corticosteroid (on advice).
- Does NAC really reduce mucus?
- Yes, it thins it in vitro and clinically in thick sputum. A real benefit in COPD, more modest in a simple cold.
- Can I give Sinecod to a child?
- From 2 years, drops; syrup from 3 years — strictly by weight. Not under 2 years.
- What does a "cough with blood" mean?
- Minimal haemoptysis (streaks) after a coughing effort can be innocent; massive or persistent haemoptysis — an emergency, immediate radiological evaluation.
- Does honey work in adults?
- Less studied than in children, but plausible — a demulcent effect.
- Why did the pharmacist tell me "do not take Sinecod with ambroxol"?
- Because the suppressant stops the cough that should expel the thinned sputum — a contradictory effect, with a possible bronchial plug.
Chronic cough >8 weeks: when to worry
The standard definition: a cough lasting >8 weeks in an adult, >4 weeks in a child. The most frequent causes, in order of probability in a non-smoker:
- Post-nasal drip syndrome (chronic, allergic rhinosinusitis) — 30-40%. Test: responds to an intranasal corticosteroid + a second-generation antihistamine.
- Cough-variant asthma — 20-30%. Spirometry with a bronchomotor test or FeNO. Responds to an inhaled corticosteroid.
- GORD — 20-30%. Responds to a double-dose PPI for 8-12 weeks; possibly oesophageal pH-metry.
- ACE-inhibitor-induced cough (enalapril, perindopril, ramipril) — 5-20% of users. Solution: switch to a sartan (losartan, valsartan).
- Non-asthmatic eosinophilic bronchitis — responds to an inhaled corticosteroid.
- Rare causes: tuberculosis, bronchopulmonary neoplasm, pulmonary fibrosis, chronic pulmonary embolism, congestive heart failure, a foreign body, sarcoidosis.
First-stage investigations: chest X-ray, spirometry, complete blood count, possibly chest CT in smokers with a persistent cough. A cough in an active smoker for >3 weeks with a change in character or haemorrhagic sputum — urgent investigation (CT, bronchoscopy).
Cough in children: particularities
- Under 2 years — OTC cough suppressants and mucolytics contraindicated. Saline spray, hydration, honey >1 year.
- A barking cough with inspiratory stridor — acute laryngitis (croup) — nebulised adrenaline, oral dexamethasone.
- A paroxysmal cough in fits, followed by an "inspiratory whoop" — pertussis (whooping cough) — diagnosis, isolation, antibiotic.
- A persistent productive cough in a young child — exclude an inhaled foreign body, cystic fibrosis, immunodeficiency.
- Bronchiolitis in an infant (RSV) — a viral disease, antibiotics do not help; supportive treatment.
COPD and cough: a category apart
In a patient with COPD, a chronic productive cough is part of the picture. The treatment is not a cough suppressant (you suppress the clearance) but:
- Quitting smoking — the only intervention that changes the progression.
- LAMA bronchodilators (tiotropium, glycopyrronium) ± LABA (formoterol, salmeterol) ± an inhaled corticosteroid in the exacerbator phenotype.
- A chronic mucolytic (NAC 600 mg twice a day, erdosteine) in patients with frequent exacerbations — Cochrane meta-analyses.
- Pulmonary rehabilitation.
- Annual influenza vaccination, conjugate and polysaccharide pneumococcal vaccination.
Seasonal allergic cough in Romania
Clear seasons: March-May (birch, beech, poplar), May-July (grasses), August-October (ragweed). A post-nasal drip cough from allergic rhinitis can be the correct diagnosis — treatment: a second-generation antihistamine (loratadine, bilastine) + a nasal spray with mometasone/fluticasone. See also our detailed guide on antihistamines.
Practical cases
- Adult, a dry cough out of nowhere after the flu, 5 days: butamirate syrup (Sinecod) or levodropropizine (Levopront), hydration, honey and warm tea in the evening.
- Adult, a productive cough with thick yellow sputum, 3 days, no fever: ambroxol or acetylcysteine (NAC) — thinning; hydration. If fever >3 days or dyspnoea — see a doctor.
- 4-year-old child with a dry cough at night: honey, head raised, saline nasal spray, butamirate drops as needed over 2 years.
- Adult with hypertension and a persistent dry cough on enalapril: probably drug-induced — discuss switching to a sartan.
- COPD patient with an exacerbation: a bronchodilator, short prednisolone, an antibiotic if the sputum is purulent; not a cough suppressant.
Sources
- Cochrane — OTC medications for acute cough 2014/2024
- Cochrane — Mucolytic agents for chronic bronchitis or COPD (Poole)
- EMA — pholcodine withdrawal 2022; ambroxol/bromhexine SJS alert 2015; codeine paediatric restriction 2015
- ANMDMR — SmPCs for butamirate, ambroxol, acetylcysteine
- BTS / NICE — chronic cough guidelines
- GOLD — Global Initiative for Chronic Obstructive Lung Disease (the 2024 strategy)
- BNF — cough and cold preparations
- CNAS — lists B and C; CANAMED