Anticoagulation control with vitamin K antagonists: how well are we doing?

might resolve over time is not an optimal approach. We recommend that a first-generation antihistamine-decongestant (our choice is sustained release brompheniramine, 12 mg, and pseudoephedrine, 120 mg every 12 h) be administered as the initial therapy whatever the duration of cough, unless there is a contraindication to one of these drugs. This empiric approach makes sense because postnasal drip syndromes appear to be the most common causes of cough; this approach has been shown to work in patients with acute cough,4 subacute cough,3 and chronic cough.2,5 If 2 weeks of therapy is ineffective, we would proceed with a BPC. Many of these patients will have either cough-variant asthma or virus-induced transient airway hyperresponsiveness. As the results of the study by Kwon et al3 show, a positive BPC result is predictive of a positive response to therapy with inhaled corticosteroids. If BPC is unavailable, then an empiric course of inhaled corticosteroids is reasonable because it will treat cough-variant asthma, transient virus-induced airway hyperresponsiveness, and eosinophilic bronchitis. We agree that when a patient seeks medical attention because of a troublesome cough, the goal of making a specific etiologic diagnosis is desirable. It is important for the physician to remember, however, that usually the primary objective for the patient is eliminating this highly disruptive symptom as quickly as possible. The up-front use of first-generation antihistamine-decongestant therapy helps to facilitate both goals. Indeed, in the just released new guidelines on cough from the American College of Chest Physicians,6 the initial use of antihistamine-decongestant therapy as both a diagnostic and therapeutic trial for cough is recommended in most cases. Based on the new cough guidelines, there are two other points that we would like to emphasize. Because it is not known whether upper airway disease causes cough through the final common pathway of postnasal drip or whether, in fact, in some circumstances they cause irritation or inflammation of upper airway structures that directly stimulate cough receptors and produce cough independently or in addition to any associated postnasal drip, the guidelines recommend that the term upper airway cough syndrome replace the term postnasal drip syndrome.7 Moreover, unless the upper airway cough syndrome is histamine-mediated (ie, allergic), the guidelines recommend that first-generation antihistamines with anticholinergic activity be the antihistamines of choice. With respect to cough due to the common cold, the first-generation antihistamines have been effective, while the new, relatively nonsedating antihistamines have not been effective.8