How to treat GERD with chronic cough?

Treatment of GERD with Chronic Cough

For patients with chronic cough due to GERD, treatment should include a comprehensive antireflux regimen consisting of lifestyle modifications, acid suppression with proton pump inhibitors, and prokinetic therapy for at least 2-3 months before considering alternative approaches. 1, 2

Initial Treatment Approach

Lifestyle and Dietary Modifications

• Implement antireflux diet limiting fat to no more than 45g in 24 hours 1
• Eliminate trigger foods: coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 1
• Stop smoking 1
• Limit vigorous exercise that increases intra-abdominal pressure 1
• Elevate head of bed for nocturnal symptoms 2
• Avoid meals within 3 hours of bedtime 2
• Weight management for overweight/obese patients 2

Pharmacological Therapy

1. Acid Suppression

   • Start with proton pump inhibitor (PPI) therapy 1, 3
   • Omeprazole 20mg once daily before meals for 4 weeks initially 3
   • If inadequate response, increase to twice daily dosing 2

2. Add Prokinetic Therapy

   • Add prokinetic agent if no response to PPI alone 1, 2
   • Particularly beneficial in patients with concomitant gastroparesis 2

Treatment Duration and Monitoring

• Minimum treatment duration: 2-3 months 1, 2
• Reassess response after 4-8 weeks of initial therapy 2, 3
• Important: Improvement in cough may take significantly longer than improvement in typical GERD symptoms
• Mean time to recovery may take as long as 161-179 days 4
• Patients may not start to improve for 2-3 months 4

For Refractory Cases

If no improvement after 3 months of intensive therapy:

1. Diagnostic Testing

   • Perform 24-hour esophageal pH monitoring while on therapy 1, 4, 5
   • This is the most sensitive and specific test for GERD 4
   • Evaluate both duration/frequency of reflux episodes and temporal relationship between reflux and cough events 4

2. Intensify Medical Therapy

   • Ensure all components of intensive therapy are being utilized 1
   • Consider increasing PPI dose or switching to different PPI 2
   • Ensure prokinetic therapy has been added 1

3. Consider Surgical Options

   • Antireflux surgery (laparoscopic fundoplication) may be considered when all of the following criteria are met 1:
     • Positive 24-hour esophageal pH monitoring study
     • Patient fits clinical profile for GERD-related cough
     • Cough has not improved after minimum 3 months of intensive therapy
     • Serial pH monitoring or other objective studies show continued GERD despite therapy
     • Patient reports unacceptable quality of life due to persistent cough

Important Clinical Considerations

• Silent GERD: Up to 75% of patients with GERD-related cough may have no gastrointestinal symptoms 4
• Mechanisms: GERD causes cough through micro/macroaspiration, laryngeal injury, and vagally mediated reflexes 6
• Definitive diagnosis: Can only be confirmed when cough resolves with antireflux therapy 4
• Success rates: Medical therapy resolves cough in 70-100% of cases when properly implemented 4

Common Pitfalls to Avoid

• Inadequate treatment duration: Many clinicians discontinue therapy too early; improvement may take 2-3 months to begin 4
• Assuming GERD is ruled out when empiric therapy fails: Failure of empiric therapy does not exclude GERD; objective testing is needed 1, 5
• Insufficient intensity of therapy: Using acid suppression alone without addressing diet, lifestyle, and motility 1
• Ignoring potential side effects of long-term PPI use: Including impaired cognition, bacterial gastroenteritis, pneumonia, drug interactions, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease 2

Following this systematic approach to treating GERD-related chronic cough will maximize the chances of symptom resolution and improved quality of life.