Management of cough in lung cancer

Clinical guidelines for the management of cough in lung cancer: report of a UK Task Group on Cough. Molassiotis A 1, Smith JA 2, Bennett MI 3, Blackhall F 4, Taylor D 5, Zavery B 6, Harle A 4, Booton R 7, Rankin EM 8, Lloyd-Williams M 9, Morice AH 10.

Epidemiology Cough is common symptom – 23-37% of all cancer patients – 47-86% in lung cancer Not always well managed Little evidence to guide practice

Formation of task group Literature reviews Peer review by UK committees Submitted for publication

Pathophysiology Coughing serves to protect airway from irritants Stimuli provoke cough via vagus nerve through – chemoreceptors (C fibres) – mechanoreceptors (A delta fibres)

In lung cancer Ulceration of mucosa – Mechanical stimulation Release of inflammatory mediators – Chemoreceptor stimulation – Sensitises peripheral nerves Also: – Obstruction – Pleural effusion – Infection – Fistulas – Carcinomatosis

Recommendations

Assessment History – Type of cough (productive / non-productive) – Trigger factors – Nocturnal or day time Co-morbid conditions – COPD – Heat failure No validated symptom scale available

Assessment Drugs causing cough – Methotrexate – Bleomycin – ACE inhibitors Further investigations – ?CXR – CT

Treat reversible causes COPD / asthma – Inhaled bronchodilators – Steroid (prednisolone 30mg daily) Infection (bronchietctasis, LRTI) – antibiotics GI reflux – PPI (omeprazole) – Metoclopramide or domperidone for non-acid reflux-

Treat the cancer Chemo – Improves symptoms including cough External radiotherapy Brachytherapy

Symptomatic management Linctus – Glycerol – Simple linctus Trial of steroid – Prednisolone – (or dexamethasone)

Centrally acting agents Codeine – 30mg qds Morphine or methadone – If codeine no help – Morphine 5-10mg bd No dose response relationship for cough

Peripherally acting agents Antitussive agents – Levodropropizine, – Moguisteine – Levocloperastine Local anaesthetic agents – nebulised bupivacaine – benzonatate

In general Low levels of evidence for these recommendations Peripheral and intermittent approaches before central and continuous treatment In lung cancer – many patients already on opioids for pain Central approaches maximised already

LOCAL ANAESTHETICS Nebulised Lidocaine Benzonatate PERIPHERALLY-ACTING ANTITUSSIVES Levodropropizine, Moguisteine, Levocloperastine OPIOIDS Morphine/Methadone Dextromethorphan, Codeine, Hydrocodone CANCER SPECIFIC systemic chemotherapy/RT endobronchial therapy, PDT, palliative RT CO-MORBIDITIES COPD, reflux, asthma, infections CONSIDER ORAL STEROID TRIAL 2 weeks adjunctive therapies, anxiety management and vocal hygiene techniques EXPERIMENTAL Carbamazepine, Thalidomide, Gabapentin, Baclofen Amitriptylline