Practice Trends in Laryngology: Neuromodulators for Treatment of Chronic Cough.

Objectives: Assess practice trends among laryngologists within the United States surrounding neuromodulator use for chronic cough treatment.

Methods: Anonymous 29-item survey comprised of a mixture of multiple choice, Likert scale, and free-text answers was electronically distributed to practicing laryngologists in the United States.

Results: Eighty-five laryngologists from 26 states responded. The majority (96.5%) prescribe neuromodulators for chronic cough and are the preferred first-line treatment for refractory explained chronic cough (37.8%) and unexplained chronic cough (50.6%). Gabapentin (97.6%), amitriptyline (91.5%), and tramadol (73.2%) are the most used. The preferred first-line drugs were also gabapentin (45.1%), amitriptyline (39.0%), and tramadol (11.0%). Most wait 3-6 months before making changes when a neuromodulator is successful, then wean to the lowest possible cough-controlling dose (68.3%) or taper off completely (24.4%). When a neuromodulator fails: 43.9% wean and try another neuromodulator; others shift to a superior laryngeal nerve (SLN) block (24.4%). When cough recurs almost immediately after weaning an effective neuromodulator, most will re-initiate it again (97.6% likely or highly likely). If the cough recurs in the future, typical practice includes reinitiating the same prior effective neuromodulator at its previously tolerated effective dose (40.5%) or re-titrating to the new effective dose needed (51.9%).

Conclusions: Laryngologists routinely prescribe neuromodulators for unexplained and refractory chronic cough. Gabapentin and amitriptyline are the preferred first-line agents, generally titrated to maximal effect, balancing against side effects. A low threshold to reinitiate previously effective neuromodulators exists when cough recurs. If an initial neuromodulator is unsuccessful, either a different neuromodulator or a SLN block is considered.

Level of evidence: 5: