Is it safe to prescribe systemic prednisone for a patient with severe gastro‑oesophageal reflux disease who has ear pain, throat pain, and cough?

Prednisone Use in Severe GERD with Ear/Throat Pain and Cough

Systemic prednisone should generally be avoided in patients with severe GERD due to the significant risk of worsening reflux, and should only be considered in highly specific circumstances after ruling out GERD as the primary cause of symptoms.

Critical Safety Concern: Prednisone Worsens GERD

• Prednisone is specifically identified as a medication that potentially worsens gastroesophageal reflux and should be eliminated when managing patients with GERD-related symptoms 1
• The FDA label for prednisone explicitly recommends administration of antacids between meals when large doses are given to help prevent peptic ulcers, acknowledging its gastric irritation potential 2
• In systemic sclerosis patients, retrospective studies demonstrate that prednisone ≥15 mg/day is associated with a 4.4-fold increased risk of scleroderma renal crisis, with recent steroid exposure noted in 61% of cases 1

Understanding the Symptom Complex

Your patient's presentation of ear pain, throat pain, and cough with severe GERD likely represents extraesophageal reflux (EER) manifestations rather than an indication for corticosteroids:

• The American Gastroenterological Association recognizes ear disease, throat pain, and chronic cough as possible extraesophageal manifestations of GERD through both reflux pathway (micro-aspiration) and reflex pathway (vagally-mediated airway reactions) 1, 3
• Up to 75% of patients with reflux-related extraesophageal symptoms do not experience classic heartburn, making the GERD connection less obvious 3, 4
• Post-nasal drip sensations and throat clearing can be produced by GERD through direct acid contact or neurologic mechanisms without requiring typical reflux symptoms 5

When Prednisone Might Be Considered (Rare Circumstances)

The only guideline-supported indication for short-term systemic corticosteroids in a cough scenario is:

• Postinfectious cough with severe paroxysms after ruling out upper airway cough syndrome, asthma, and GERD: prednisone 30-40 mg/day for a short, finite period 1
• This recommendation carries only Grade C evidence (low quality, intermediate benefit) and explicitly requires exclusion of GERD as a contributing cause 1

Recommended Management Algorithm

Step 1: Rule Out Primary Otologic/ENT Causes

• Engage otolaryngology early for evaluation of primary ear pathology (vocal cord dysfunction, sinusitis, vocal cord polyps) 1
• Consider laryngoscopy and appropriate ENT imaging before attributing symptoms to reflux 1

Step 2: Optimize GERD Management First

• Proton pump inhibitors (PPIs) such as omeprazole 20-40 mg twice daily before meals for at least 8-12 weeks are the first-line treatment for severe GERD with extraesophageal manifestations 1, 4
• Extraesophageal manifestations typically require 8-12 weeks minimum for adequate response, longer than typical GERD 4
• Add prokinetic agents (metoclopramide 10 mg three times daily) if motility disturbances contribute 1

Step 3: Objective Testing if PPI Trial Fails

• After one failed PPI trial (up to 12 weeks), pursue objective testing with pH-impedance monitoring off PPI rather than trying additional empiric therapy 3, 4
• pH-impedance monitoring is essential because both acid and non-acid reflux can cause extraesophageal symptoms, and standard pH monitoring may miss non-acid events 3
• Upper endoscopy should be performed to assess for erosive esophagitis, strictures, or Barrett's esophagus 1

Step 4: Address Cough Specifically

• For chronic cough with prominent upper airway symptoms, a 1-month trial of topical intranasal corticosteroid is recommended rather than systemic steroids 1
• Inhaled ipratropium may attenuate postinfectious cough without the GERD-worsening effects of systemic steroids 1
• Central acting antitussives (codeine, dextromethorphan) should be considered when other measures fail 1

Critical Pitfalls to Avoid

• Do not prescribe systemic prednisone without first optimizing acid suppression therapy, as it will likely worsen the underlying GERD and create a vicious cycle 1
• Do not continue empiric PPI therapy beyond 12 weeks without objective testing, as 50-60% of patients with extraesophageal symptoms will not have GERD as the primary cause 3, 4
• Do not assume lack of heartburn rules out GERD as the cause of ear/throat/cough symptoms 3, 4
• Lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should guide away from surgical options 3

Multidisciplinary Approach

• A collaborative evaluation between gastroenterology, otolaryngology, and potentially pulmonology produces the best outcomes for suspected extraesophageal reflux patients 1, 5
• Many conditions mimic extraesophageal reflux, including medication reactions (ACE inhibitors causing cough), asthma, vocal cord dysfunction, and occult sinusitis 1