Hello, I'm Dr. Robert Bastian, this is a video discussion about a chronic–and
sometimes severe–coughing problem called sensory neuropathic cough or
SNC. This segment focuses on medications used for this condition in case you
didn't see earlier presentations about sensory neuropathy cough.
First, a review of what SNC is. It's an intractable neurological form of coughing
based in a sensory disturbance of the throat which patients may describe in various ways as:
a tickle, a dry sensation, pinprick, sandpaper, feeling of mucous, dripping,
and so forth. Those sensations precede–just by an instant–each coughing episode. The sensation is
usually stereotyped, meaning it's fairly identical each time, or at least highly similar, and located
most commonly here at the sternal notch, or at the level of the larynx, or higher, or sometimes
the upper central chest. A person with SNC may have had their call for months, years, or even
several decades. A subset of persons with SNC may have periods of time relatively free of symptoms,
but they often cough for several months after every upper respiratory infection, long past any
active infection. Persons with mild SNC might cough a handful of times per day. By contrast,
persons with severe SNC may endure literally hundreds of coughing spells each day. Now that
can include the night time with, of course, drastic disturbance of sleep. In many cases,
attacks can be violent and protracted, lasting up to several minutes. Trigger events–or actions that
tend to/sometimes seem to lead to the tickling and resultant cough–include talking, singing, taking a
deep breath, touching a spot on the neck, change of position, (such as bending over or lying down)
swallowing, breathing cold air and so forth. Some coughing attacks seemed to happen spontaneously
of course. Well, what does a particularly bad episode of coughing look like to the observer?
The individual may cough so hard that he or she turns red and the eyes and the nose start
running. They make gag, retch, and even throw up. The person may lose urine involuntarily, or
worse. Some described chest wall pain that results from the violent strain on the muscles between the
ribs. We've even seen some cases with broken ribs or a burst blood vessel on the surface of the eye,
caused by the violence of the attack. Once in a while they may experience laryngospasm–when the
vocal folds clamped together and block the airway briefly, causing a panicky feeling of suffocation,
with a loud breathing noise like "Uhhhhh." Commonly, a person with SNC has been unable
to find a clear diagnosis in spite of many doctor visits, tests, and treatment trials. Or he or she
may have been given a firm diagnosis of one of what I call "the usual suspects," that is Allergy,
Asthma, and Acid Reflux, or COPD. But extensive treatments for those diagnoses have all failed
to help. In summary, a very mild case of SNC may just be annoying. Moderate SNC begins to damage a
person sense of well-being, and to interfere with work and social activities. Persons with severe
SNC often say their lives are ruined. I've even had a few patients so severely affected that they
have become depressed and even suicidal. You can imagine how someone in the very severe category
might be unwilling to appear in public places, because they might be humiliated by coughing so
violent that they become the center of attention. Not to mention wetting themselves, gagging,
retching, throwing up and so forth. Fortunately an accurate diagnosis of SNC–either as a primary
diagnosis or a diagnosis of exclusion–can open a brand-new avenue of treatment through the use
of a neuralgia medication. Now neuralgia is pain resulting from nerve damage. SNC patients appeared
to have not typical pain from nerve damage, but instead a tickle, sandpaper feeling, pinprick,
dripping mucus sensation and so forth. The concept is, that if neuralgia medicines calm down the pain
of damaged nerve endings, then they may also calm down other sensations caused by damaged
nerve endings. The catch is that there are several potential medications—they don't all work the same
for different persons. And so, finding the best medication and dosing regimen can be a lot of
work. Let me see now if I can help you become a full partner with your personal physician in the
process of finding the best treatment for your SNC. Some background education about neuralgia
medication: the general category–category of neuralgia medicine—is in order first. Point
one is: neuralgia medications were originally released to the market for another use such as
depression or seizures. If you don't know this and you're given a neuralgia medicine for SNC,
you might be confused to read a pharmacy printout about depression or seizures. As an analogy,
just think about the insert included with aspirin that continues to speak of reducing fever and
treating pain even though a person might be taking it to thin the blood. A second point
about these medications is that to achieve the same benefit, one person may need a tiny dose,
another a medium dose and a third person a high dose. That's why we start every person–with SNC
or laryngospasm–at a low dose and then gradually increase until the desired benefit is achieved.
After all, why use a high dose if a low dose works for you? Point three is that you must be
persistent and motivated even if you are already exhausted with everything you've tried so far.
Sometimes an initial medication tried for SNC does nothing, or it provides minimal benefit,
or it has unacceptable side effects. If so, I would urge you not to give up but to press on
to the next medication trial, and if necessary, a third and fourth and so forth. A fourth point is
that you will need to find a physician who can help you work your way to the optimal dose and
timing of medication. So, an office visit might need to be followed up with several messages back
and forth between you in the office, because the number of those tweaks and changes of medication,
or dose, or strategy, is too great in some cases to permit face-to-face management of each of
those adjustments. Point five is that while we always aim to find complete relief, we consider
85% reduction of symptoms or more, really, a good result. Now some, unfortunately, with our
best try, only get 50% or even 30% reduction, and really, unfortunately, about one in twenty persons
we can't help, even after working our way through many medications. Well with these five points of
general introduction to the medications, let's talk first about some specific ones. One of the
most used is called Amitriptyline, and in persons over 65 years of age, we substitute the highly
related medication Desipramine. We usually allow the patient to titrate him or herself from a tiny
dose of 10 milligrams, and then if no response or partial response, move up to two pills or
20 milligrams, and then up to three pills or 30 milligrams and so forth, until either they
achieve the benefit they need or they start to have some side effects that are beginning to
bother them. We don't typically go above 80 to 100 milligrams with this medication. It seems
appropriate to us that patients have the freedom to figure their exact dose out for themselves.
Of course within the safe boundaries that we have taught them. If you get to 20 milligrams
for example and coughing or laryngospasm is dramatically lessened to your satisfaction,
you don't need to go any higher. If spasms were to start to occur again a few weeks later,
while you're still on 20 milligrams, you can go up to 30 and 40 and so forth. Well, if we get to
80 or 100 milligrams and there's no response, we move on to another medication, and we begin the
same process with it. If there is a good response, but you have some breakthrough coughing late in
the day, then we may add 10 or 20 milligrams of Amitriptyline or Desipramine at noon. Well what
about side effects? I mentioned the morning grogginess. Some also mentioned a dry mouth,
or the occasional man with prostate trouble notes more difficulty urinating. A few have mentioned
weight gain. Low doses seemed fine for persons with high blood pressure, but blood pressure
should be monitored if you're using the higher doses. Now, suppose a person tries Amitriptyline
or Desipramine and it isn't working in one of the ways we've described? Well, we usually move
next to Gabapentin. Here the strategy is a little different. We suggest 300 milligrams as a start at
bedtime for three days. Then we do 300 milligrams at noon and bedtime for three days. Then we do 300
milligrams at breakfast, mid-afternoon with a snack and bedtime for three days and then
finally we reach 300 milligrams at breakfast, lunch, dinner and bedtime. Seems to be better
with food. Now some people take the dose in this same way–much higher–even to 600 milligrams or
900 milligrams, and I have one on 1200 milligrams four times a day (that's considered a huge dose).
But we use the same strategy to get to those higher doses of increasing by just one capsule
every three days. Very occasionally a person may be highly sensitive to the side effects,
and then we use the very same strategy, but we may start with 100 milligram capsules rather than 300
milligram capsules. Now, take special note that for this medication, both going up on the dose and
going down–so increases and decreases–should be done gradually, as I said, usually changing by one
pill every three days. Now, if Amitriptyline and Desipramine, and Gabapentin are not right for you,
then there is a list of other things we work our way through: Pregabalin, Oxcarbazepine,
Citalopram, Topiramate, Capsaicin Spray, and we continue trying all the others,
and if we're having a struggle getting a result with the first one or two. Now, let's summarize
sensory neuropathic cough. Just in brief, it's neurological, the cough is typically associated
with sensory experience of a tickle and/or some sort of a sensation. The location is here or in
the neck typically. "Triggers" means that you talk, or you laugh loudly, or you take that deep
breath, or you walk out in the winter and take the first lung full of cold air, and that triggers a
spasm of coughing. There are a few to hundreds of episodes of cough per day. Some can be very
violent. Treatment is via neuralgia medications such as those I've just been talking about. We
set up the dosage boundaries and then you work within those boundaries and learn something about
how you're responding. And then you report back to the physician via voicemail or email and we
usually use the percent reduction of cough as the the main point of information that helps us decide
what to do next. And we may go through many tweaks and adjustments before we find the best medication
and dose. A great response is considered to be 85% reduction. Some can only achieve a little less
reduction than that however. And then we recommend that you don't quit until all ideas are exhausted,
knowing that unfortunately, maybe one of twenty we simply can't seem to find a solution. Thanks
for listening to this presentation, and remember that it is offered not as medical advice to you,
but to help you work more effectively with your personal physician. I hope it helps you.