From the Guidelines
Next steps in managing GERD-related chronic cough after maximum Proton Pump Inhibitor (PPI) therapy include considering an intensive medical treatment regimen that includes an antireflux diet, prokinetic therapy, and acid suppression with a PPI. If cough persists, evaluation with esophageal manometry and pH-metry should be considered to exclude an esophageal motility disorder and confirm a diagnosis of GERD 1.
Key Components of Intensive Medical Treatment Regimen
- Antireflux diet: no more than 45g of fat in 24 hours, no coffee, tea, soda, chocolate, mints, citrus products, including tomatoes or alcohol, no smoking, and limiting vigorous exercise that will increase intraabdominal pressure
- Prokinetic therapy: consider adding prokinetic agents such as metoclopramide if there is no or little response to treatment
- Acid suppression: with a PPI, such as omeprazole up to 40 mg and lansoprazole, 30 mg bid
Evaluation and Diagnostic Testing
- Esophageal manometry and pH-metry: to evaluate for a major motility disorder and to accurately position the pH electrode for the pH monitoring study
- 24-h esophageal pH monitoring: to link GERD and cough in a cause-effect relationship, although it has its limitations and cannot detect non-acid reflux events
- Upper GI endoscopy or a barium swallow study: to evaluate for other causes of cough and to assess the severity of GERD
Consideration for Antireflux Surgery
- Antireflux surgery: may be efficacious when intensive medical therapy has failed in selected patients who have undergone an extensive objective GERD evaluation 1
- Patient selection: patients who meet the criteria, including positive findings of a 24-h esophageal pH-monitoring study, clinical profile suggesting GERD is the likely cause of cough, and failure to improve with intensive medical therapy 1
In patients with persistent cough and no response to medical therapy, a thorough evaluation to exclude other causes of cough and to assess the severity of GERD is necessary before considering antireflux surgery 1.
The FDA Drug Labels for PPI (PO) do not address this question.
From the Research
Next Steps in Managing GERD-Related Chronic Cough
After maximum Proton Pump Inhibitor (PPI) therapy, the next steps in managing gastroesophageal reflux disease (GERD)-related chronic cough may include:
- Considering alternative treatments such as prokinetic agents, as seen in the study by 2, which found that anti-reflux treatment with a PPI and a prokinetic agent improved cough symptoms and reduced neurogenic and neutrophilic inflammation.
- Evaluating the patient's response to PPI therapy, as some studies suggest that PPI may improve cough unrelated to gastric acid reflux, as reported by 3.
- Assessing the need for further diagnostic testing, such as 24-h esophageal pH monitoring, to confirm the presence of GERD and its association with chronic cough, as discussed by 4.
Treatment Options
Other treatment options that may be considered include:
- High-dose acid suppression with PPI, although the study by 5 found no significant difference between PPI and placebo in improving cough-related quality of life or symptoms.
- Antireflux treatment with PPI, Stretta radiofrequency, or laparoscopic fundoplication, which was found to be effective in reducing chronic cough and cough syncope in a case report by 6.
- Conservative measures such as diet manipulation and lifestyle changes, which may be recommended as part of a comprehensive treatment plan.
Key Considerations
When managing GERD-related chronic cough, it is essential to:
- Monitor the patient's response to treatment and adjust the treatment plan as needed, as seen in the study by 2, which found that successful treatment of GER-associated cough was associated with the attenuation of neurogenic and neutrophilic inflammation.
- Consider the potential for placebo effect and natural resolution of symptoms over time, as discussed by 4.
- Evaluate the patient's overall health and medical history to determine the best course of treatment, as reported by 6.