What is the relationship between gastroesophageal reflux disease (GERD) and chronic cough?

From the Guidelines

To manage cough from reflux, start by making lifestyle changes such as avoiding trigger foods, eating smaller meals, not eating within 3 hours of bedtime, and elevating the head of your bed by 6-8 inches, as recommended by the 2016 Chest guideline and expert panel report 1. These changes can help reduce symptoms of gastroesophageal reflux disease (GERD), which is a common cause of chronic cough.

• Avoiding trigger foods such as spicy, fatty, and acidic foods can help reduce acid production in the stomach.
• Eating smaller meals and not eating within 3 hours of bedtime can help reduce pressure on the lower esophageal sphincter and prevent acid reflux.
• Elevating the head of your bed by 6-8 inches can help prevent acid reflux by reducing pressure on the stomach.

In addition to lifestyle changes, over-the-counter medications such as antacids (Tums, Rolaids), H2 blockers (famotidine/Pepcid, 20mg twice daily), or proton pump inhibitors (omeprazole/Prilosec, 20mg daily before breakfast) can help reduce acid production and alleviate symptoms of GERD, as suggested by the 2006 ACCP cough guideline 1.

• Antacids can help neutralize stomach acid and provide quick relief from heartburn and other symptoms.
• H2 blockers can help reduce acid production in the stomach and provide longer-lasting relief from symptoms.
• Proton pump inhibitors can help block the production of acid in the stomach and provide the most effective relief from symptoms.

For persistent symptoms, prescription-strength PPIs like esomeprazole (Nexium, 40mg daily) may be necessary, as recommended by the 2016 Chest guideline and expert panel report 1.

• Prescription-strength PPIs can provide more effective relief from symptoms and help heal the esophagus.
• However, it's essential to consult a healthcare provider before taking any medication, especially if symptoms persist despite lifestyle changes and over-the-counter medications.

It's also important to note that reflux-induced cough can be challenging to diagnose because it may occur without typical heartburn symptoms, and the cough itself can trigger more reflux, creating a vicious cycle that requires consistent treatment to break, as highlighted by the 2023 AGA clinical practice update on the diagnosis and management of extraesophageal gastroesophageal reflux disease 1.

• A thorough medical evaluation, including tests such as esophageal manometry and pH-metry, may be necessary to diagnose GERD and rule out other causes of chronic cough.
• Treatment should be individualized and based on the severity of symptoms and the presence of any underlying conditions.

From the Research

Cough from Reflux: Causes and Treatment

• Cough from reflux, also known as gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux disease (LPRD), is a common cause of chronic cough in adults and children 2, 3.
• The exact mechanism of how reflux causes cough is not fully understood, but it is thought to be related to an esophageal-bronchial reflex 3.
• Symptoms of GERD or LPRD may not always be present, and up to 75% of patients with reflux-induced cough may not experience any gastrointestinal symptoms 3.

Diagnosis and Treatment

• Diagnosis of reflux-induced cough can be made through a combination of clinical evaluation, spirometry, and empiric treatment 2.
• Treatment of reflux-induced cough typically involves lifestyle modifications, such as dietary changes, and medication, such as proton pump inhibitors (PPIs) or histamine H2 receptor antagonists (H2RAs) 4, 5.
• In some cases, surgery may be necessary to treat reflux-induced cough 3.
• An anti-reflux diet has been shown to be effective in treating mild chronic cough caused by LPR, while a combination of diet, PPIs, and alginates may be necessary for severe cases 6.

Medical Treatments

• Proton pump inhibitors (PPIs) are commonly used to treat reflux-induced cough, as they can effectively reduce acid production in the stomach 4, 5.
• Histamine H2 receptor antagonists (H2RAs) may also be used, particularly for patients with nocturnal reflux 4, 5.
• A combination of PPIs and H2RAs may be necessary for patients with severe reflux-induced cough 5.