• Consider symptomatic treatment if one or more of the following applies:
• The option of treating the underlying cause is not possible or is inappropriate.
• The person remains distressed by symptoms despite treatment of the underlying cause.
• The person is in the terminal phase of life. See the CKS topic on Palliative cancer care - general issues.

In depth

• Use simple measures first — humidify room air, Simple Linctus BP.
• If symptom relief is not adequate, use a weak opioid cough suppressant — Pholcodine Linctus BP 10 mL (10 mg) three to four times a day, or Codeine Linctus BP 5 mL to 10 mL (15 mg to 30 mg) three to four times a day, or codeine phosphate tablets 30 mg to 60 mg every 4 hours.
• If cough is persistent, use a strong opioid cough suppressant — morphine in an initial dose of 5 mg every 4 hours, or morphine solution 2.5 mg to 5 mg four times a day up to every 4 hours.
• If all these measures fail, seeking specialist advice.
• If dyspnoea is a feature see the CKS topic on Palliative cancer care - dyspnoea.

In depth

• Treat infection, if present, with an appropriate antibiotic.
• In people with an effective cough mechanism and tenacious secretions — use nebulized saline solution (physiotherapy in addition may be of benefit), or a mucolytic.
• In people with a dry mouth — humidifying the air or oxygen (if needed).
• If a person is at the terminal stage of life and unable to expectorate, consider drying of secretions (see the CKS topic on Palliative cancer care - secretions), or using morphine as a cough suppressant.

In depth

• For people with a moist cough and tenacious secretions, nebulize 0.9% saline solution 2.5 to 5 mL four times a day. If greater relief is required, gradually increase nebulizer use up to every 2 hours. Review after 48 hours.

In depth

• If the person is already taking a strong opioid such as morphine, do not use pholcodine. Use an as required dose of morphine.
• Pholcodine Linctus BP 10 mg may be taken three to four times a day.
• Pholcodine is mildly sedative — warn people to avoid activities where drowsiness may be detrimental.
• If pholcodine is ineffective, switch to morphine solution 5 mg to 10 mg every 4 hours and 'as required'.

In depth

• If the person is already taking a strong opioid such as morphine, do not use codeine. Use an as required dose of morphine.
• Codeine linctus BP 5 mL to 10 mL (15 mg to 30 mg) may be taken three to four times a day.
• If a dose requiring a large volume of linctus is required, consider using codeine phosphate tablets (off-licence use). Codeine phosphate tablets can be taken in a dose of 30 mg to 60 mg three to four times a day.
• If codeine is ineffective, switch to morphine solution 5 mg to 10 mg every 4 hours and 'as required'.

In depth

• For someone not already taking an opioid, a dose of 2.5 mg — every 4 hours and as required.
• For someone in whom a weak opioid (e.g. codeine or pholcodine) was ineffective, use a dose of 5 mg to 10 mg — every 4 hours and as required.
• After 1–2 days, calculate the total dose given over 24 hours, and use this to recalculate the 4-hourly dose. (The new 4-hourly and 'as required' dose is a sixth of the new total daily dose.)
• Repeat this process every 1–2 days until the cough is controlled.
• Once a stable dose has been reached, consider converting to modified-release morphine.
• For someone already taking a strong opioid such as morphine, use an 'as required' dose of morphine.
• If an 'as required' dose relieves cough, either increase the regular daily dose by 30–50% every 2–3 days until symptoms are controlled or adverse effects prevent further dose increases, OR continue to use additional morphine as required. If the total daily dose is increased, recalculate the 'as required' dose.
• If an 'as required' dose of morphine does not relieve cough, there is little point continuing to increase the dose.
• Some people with cough but no pain can benefit from a dose of morphine at bedtime to prevent cough from disturbing sleep.

In depth