What medication can a patient with a history of asthma or Chronic Obstructive Pulmonary Disease (COPD) and Gastroesophageal Reflux Disease (GERD) take for a cough that worsens at night?

Nighttime Cough Management in Patients with Asthma/COPD and GERD

For a patient with asthma or COPD and GERD who experiences worsening nighttime cough, start with proton pump inhibitors (PPIs) such as omeprazole 20-40 mg twice daily before meals for at least 8 weeks, combined with dietary modifications and head-of-bed elevation, as GERD is a common cause of nocturnal cough in this population. 1

Primary Treatment Approach: Address GERD First

Why GERD Treatment is Critical for Nighttime Cough

• GERD is strongly associated with nighttime cough because the lower esophageal sphincter closes during sleep, but reflux episodes can still trigger cough reflexes 1
• Patients with GERD have increased cough reflex sensitivity that improves with antireflux therapy 1
• Even without heartburn or dyspepsia symptoms, GERD should be considered in patients with poorly controlled asthma and frequent nighttime symptoms 1
• Gastroesophageal reflux treatment particularly benefits patients with frequent nighttime asthma symptoms 1

Recommended GERD Treatment Regimen

Medication:

• PPIs (omeprazole 20-40 mg or equivalent) twice daily before meals for minimum 8 weeks 1
• PPIs may be superior to H2 antagonists like ranitidine 1
• Full acid suppression may require combining twice-daily PPIs with nocturnal H2 antagonists 1
• Add prokinetic agents (metoclopramide 10 mg three times daily) if PPIs alone are insufficient 1

Dietary and Lifestyle Modifications:

• Limit fat intake to no more than 45 grams per 24 hours 1
• Avoid coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 1
• Avoid food and drink within 3 hours of bedtime 1
• Elevate head of bed on 6-inch to 8-inch blocks 1
• Eliminate medications that worsen reflux (bisphosphonates, nitrates, calcium channel blockers, theophylline, progesterones) 1

Important Caveat About GERD Treatment Timeline

• Response to GERD treatment takes time: assess effectiveness at 1-3 months, not sooner 1
• If empiric treatment fails, this does NOT rule out GERD—the therapy may not have been intensive enough 1
• Consider objective testing (24-hour pH monitoring) if intensive medical therapy fails 1

Secondary Treatment: Manage Underlying Asthma/COPD

Asthma-Related Cough Management

• Follow national asthma guidelines for cough variant asthma 1
• Inhaled corticosteroids are effective for eosinophilic bronchitis and atopic cough 1
• At step 3 treatment, leukotriene receptor antagonists have evidence for use 1
• There is some evidence supporting antihistamines and anti-leukotrienes in cough due to asthma 1

Upper Airway Disease Considerations

• In presence of prominent upper airway symptoms (nasal stuffiness, sinusitis, post-nasal drip sensation), try topical intranasal corticosteroids for 1 month 1
• Treatment of allergic rhinitis includes intranasal corticosteroids and antihistamine therapy 1

Symptomatic Nighttime Cough Relief

For Immediate Nighttime Symptom Control

First-generation sedating antihistamines are particularly suitable for nocturnal cough because they suppress cough AND cause drowsiness, helping patients sleep 2, 3

• Sedating antihistamines can suppress cough but their drowsiness effect is valuable when cough disturbs sleep 1
• This provides dual benefit: cough suppression plus sedation for better sleep 4

Alternative Symptomatic Options

Dextromethorphan:

• Preferred antitussive with superior safety profile compared to codeine 2, 3
• Maximum cough suppression occurs at 60 mg (standard OTC doses are often subtherapeutic) 2, 3
• Caution: some preparations contain additional ingredients like acetaminophen 2

Simple remedies:

• Honey and lemon mixtures may be as effective as pharmacological treatments for benign cough 2, 3
• Voluntary cough suppression through central modulation may reduce cough frequency 2, 3

What NOT to Use

• Avoid codeine and pholcodine: no greater efficacy than dextromethorphan but significantly more adverse effects (drowsiness, nausea, constipation, physical dependence) 2, 3, 5, 6

Clinical Algorithm for This Patient

1. Initiate intensive GERD treatment (PPIs twice daily + dietary modifications + head elevation) 1
2. Optimize asthma/COPD control with inhaled corticosteroids and bronchodilators per guidelines 1
3. For immediate nighttime relief, add first-generation sedating antihistamine at bedtime 2, 3
4. Reassess at 8-12 weeks: if no improvement, consider adding prokinetic therapy or intensifying acid suppression 1
5. If still no improvement after 3 months of intensive medical therapy, consider objective GERD testing (24-hour pH monitoring) 1
6. Consider antireflux surgery only if intensive medical therapy documented to fail by objective testing and cough significantly impairs quality of life 1

Common Pitfalls to Avoid

• Not treating GERD aggressively enough: single-dose PPIs or short treatment duration (less than 8 weeks) often fail 1
• Assuming absence of heartburn rules out GERD: many patients with GERD-related cough have no gastrointestinal symptoms 1
• Using subtherapeutic doses of dextromethorphan: standard OTC doses may be inadequate 2, 3
• Stopping GERD treatment too early: response may take 1-3 months 1
• Not addressing medications that worsen reflux: calcium channel blockers, nitrates, theophylline can undermine treatment 1