Begin with the medication marked with the large “X.” If, over time, the first prescription fails to provide adequate benefit, you will of course let us know this during a phone or encrypted email followup communication. At that point, we would create a new prescription that you would pick up at your pharmacy. You will follow the same procedure, if necessary, for a third medication if the first two do not reduce cough sufficiently. (see Voice Mail and Portal Email Instructions, below).

Option 1: Amitriptyline (Elavil) OR Desipramine (Norpramin)

Begin with 10 mg 2 hours before bed.

1. If grogginess occurs, this often resolves if you persist in taking the medication for two weeks.
2. If you experience some response, but less than 80% reduction of your symptoms, please double to 20 mg. (2 pills) 2 hours before bed.
3. If there is still less than 80% reduction, you may increase step-wise up to 80 mg. (8 pills) 2 hours before bed.
4. If you have afternoon “breakthrough” coughing, you may try adding 10 or 20 mg (1 or 2 pills) at noon.
5. Please leave voicemail or encrypted email for your doctor 14 days after beginning, as instructed below at *.

Option 2: Gabapentin (Neurontin)

300 mg (1 pill) at bedtime for 3 days; then 300 mg noon and bedtime for three days; then 300 mg breakfast, mid-afternoon and bedtime for 3 days; then breakfast, lunch, dinner, and bedtime (300 mg 4 times per day for a total of 1200 mg per day). You may increase slowly in like manner to as much as 600 mg (2 pills) four times a day, assuming side effects allow.

1. You must “taper on” and “taper off” this medication as described above.
2. Side effects are dramatically different between individuals. Some experience none in spite of high dose; a few notice significant side effects with even one pill per day.
3. Main side effect is sleepiness, or a mild feeling of being “drunk.” Also occasionally swelling of feet.
4. To minimize side effects, take the medication with food.
5. If you cannot tolerate side effects, back off to the next lower dose and maintain until you are tolerating the medication well, then try to increase again by one pill.
6. Please leave voicemail or encrypted email for your doctor approximately 14 days after beginning, as instructed below at *.

Option 3: Citalopram (Celexa)

Start at 20 mg (1 pill) every evening. After one week, increase to 2 pills (40 mg)

1. You must “taper on” and “taper off” this medication, and do not make sudden large changes in dose.
2. Main side effects include drowsiness and dry mouth.
3. Please leave a voicemail for your doctor 7-10 days after beginning, as instructed below.

*Voicemail Instructions:

Information we need from you each time you call/email:
a. Your name (Please spell).
b. Name of medication and how long you have been taking it.
c. Your current dose level.
d. What % reduction of symptoms you are experiencing.
e. Side effects, if any.
f. Daytime and evening phone numbers.
g. Any other comments you wish to make, or questions you have.

Sample Voicemail:
“This is John Doe, I’ve been on the amitryptyline 10 days. I increased to 50 mg (5 pills) each evening. My symptoms are diminished by 50%. Side effects are: ________________. My phone numbers are_______________ and _____________. I’d like to know what to do next.”

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