From the Guidelines
A cough is likely due to Gastroesophageal Reflux Disease (GERD) if it is a chronic, persistent cough that worsens at night or after meals, and is accompanied by symptoms such as a sour taste in the mouth, hoarseness, or throat clearing, as suggested by the 2016 Chest guideline and expert panel report 1. The cough is typically dry and non-productive, meaning it doesn't produce mucus, and may improve with antacids. Other associated symptoms include:
- Heartburn
- Regurgitation
- Difficulty swallowing
- A feeling of a lump in the throat
- Worsening of symptoms when lying down or bending over GERD-related cough often doesn't respond well to typical cough medications but improves with acid-suppressing treatments. If you suspect GERD is causing your cough, lifestyle modifications can help, including:
- Avoiding trigger foods (spicy, fatty, acidic)
- Eating smaller meals
- Not eating within 3 hours of bedtime
- Elevating the head of your bed
- Maintaining a healthy weight Medications that may help include over-the-counter antacids for immediate relief, H2 blockers like famotidine (20mg twice daily), or proton pump inhibitors such as omeprazole (20mg once daily before breakfast) for more persistent symptoms, as recommended by the 2016 Chest guideline and expert panel report 1. GERD causes cough through two main mechanisms:
- Direct irritation from stomach acid refluxing into the throat and esophagus
- A reflex mechanism where acid in the lower esophagus triggers the cough center in the brain. It's worth noting that a definitive diagnosis of cough due to GERD requires that cough nearly or completely disappear with antireflux treatment, as stated in the 2006 ACCP evidence-based clinical practice guidelines 1.
From the Research
Signs of Cough due to Reflux Disease
The following are signs that a cough may be due to Gastroesophageal Reflux Disease (GERD):
- Cough that occurs in relation to eating or phonation 2
- Cough that settles at night and does not tend to wake the patient from sleep 2
- Symptoms suggestive of laryngopharyngeal reflux 2
- No gastrointestinal symptoms, such as heartburn and acid regurgitation, up to 75% of the time 3, 4
- Cough that is associated with non-acid reflux, which can be detected by impedance pH monitoring 5
Diagnostic Considerations
Diagnosing GERD as the cause of chronic cough can be challenging, and the following considerations should be taken into account:
- 24-hour esophageal pH monitoring is the most sensitive and specific test for GERD, but it has its limitations and may not detect non-acid reflux events 3, 4
- Empiric trials of treatment, such as proton pump inhibitors, H2 receptor antagonists, pro-motility agents, and liquid alginate preparations, can be useful in diagnosing and treating GERD-related cough 2
- Surgical fundoplication can be effective in treating GERD-related cough in appropriately selected individuals 2, 5, 4
Treatment Considerations
Treatment of GERD-related cough should be tailored to the individual patient, and the following considerations should be taken into account:
- Medical therapy, such as proton pump inhibitors, H2 receptor antagonists, pro-motility agents, and liquid alginate preparations, can be effective in treating GERD-related cough, but may take several months to show improvement 2, 4
- Surgical fundoplication can be effective in treating GERD-related cough in patients who fail to respond to maximal medical therapy 2, 5, 4
- Patients should be aware of the potential for cough as an adverse event to omeprazole, a commonly prescribed proton pump inhibitor for GERD 6