What specific prescription regimen and dosages should be used to treat a patient with laryngopharyngeal reflux and upper airway cough syndrome who has a one‑year history of itchy throat, paroxysmal cough, and hoarseness?

Treatment of Laryngopharyngeal Reflux and Upper Airway Cough Syndrome

For this patient with LPR and UACS presenting with itchy throat, paroxysmal cough, and hoarseness, start immediately with a first-generation antihistamine/decongestant combination (dexbrompheniramine 6 mg + pseudoephedrine 120 mg sustained-release twice daily) and add lifestyle modifications including head-of-bed elevation and avoiding meals within 3 hours of bedtime; reserve PPI therapy only if the patient reports heartburn or regurgitation. 1, 2

Treatment Algorithm for UACS Component

First-Line Therapy (Start Immediately)

Antihistamine/Decongestant Combination:

• Dexbrompheniramine 6 mg + pseudoephedrine 120 mg (sustained-release) twice daily, OR 2, 3
• Azatadine 1 mg + pseudoephedrine 120 mg (sustained-release) twice daily, OR 2, 3
• Brompheniramine 12 mg twice daily, OR 3
• Chlorpheniramine 4 mg four times daily 3

Dosing Strategy to Minimize Sedation:

• Begin with once-daily dosing at bedtime for several days before advancing to twice-daily dosing 2, 3
• Expect improvement within days to 2 weeks 2, 3

Critical Point: First-generation antihistamines work through their anticholinergic properties, not antihistamine effects—this is why second-generation antihistamines (loratadine, fexofenadine, cetirizine) are completely ineffective for UACS. 4, 3

Add-On Therapy if No Response After 1-2 Weeks

Intranasal Corticosteroids:

• Fluticasone propionate 100-200 mcg daily for a 1-month trial 2, 3
• This is the most effective monotherapy for both allergic and non-allergic rhinitis-related UACS 2, 3

Alternative for Patients with Contraindications to Decongestants:

• Ipratropium bromide nasal spray 42 mcg per spray, 2 sprays per nostril 4 times daily 2, 3
• Provides anticholinergic drying effects without systemic cardiovascular side effects 2

Adjunctive Therapy

Nasal Saline Irrigation:

• High-volume saline irrigation (150 mL) is more effective than saline spray 2
• Mechanically removes secretions and improves mucociliary function 2

Treatment Algorithm for LPR Component

Critical Decision Point: Presence of Heartburn/Regurgitation

The CHEST guidelines make a crucial distinction that fundamentally changes LPR management: 1

If Patient Reports Heartburn or Regurgitation:

PPI Therapy:

• Omeprazole 20-40 mg twice daily before meals for at least 8 weeks 1, 2
• Alternative: H2-receptor antagonists, alginate, or antacid therapy sufficient to control symptoms 1

Expected Timeline:

• GI symptoms should respond within 4-8 weeks 1
• Improvement in cough may take up to 3 months 1, 2

If Patient Has NO Heartburn or Regurgitation:

Do NOT use PPI therapy alone—it is unlikely to be effective in resolving the cough. 1

Instead, focus on:

• Lifestyle modifications (see below) 1
• Continue UACS treatment as primary therapy 1

Mandatory Lifestyle Modifications for All LPR Patients:

1. Diet modification to promote weight loss in overweight or obese patients 1
2. Head of bed elevation 1
3. Avoiding meals within 3 hours of bedtime 1

Evidence Note: Studies including diet modification and weight loss had better cough outcomes than PPI therapy alone. 1

Monitoring and Side Effects

Antihistamine/Decongestant Side Effects to Monitor:

Common:

• Dry mouth and transient dizziness 2
• Sedation (minimize with bedtime-first dosing) 2, 3

Serious (Monitor Closely):

• Insomnia, urinary retention, jitteriness 2
• Tachycardia, worsening hypertension 2
• Increased intraocular pressure in glaucoma patients 2

Contraindications:

• Symptomatic benign prostatic hypertrophy or urinary retention 3
• Narrow-angle glaucoma 3

PPI Monitoring:

• Blood pressure monitoring after initiating decongestant therapy 2

When to Escalate or Reassess

If No Response After 2 Weeks of Adequate UACS Treatment:

Proceed with sequential evaluation: 1, 2

1. Obtain sinus imaging (CT scan) if persistent nasal symptoms 2, 4

   • Air-fluid levels indicate acute bacterial sinusitis requiring antibiotics 2
   • Mucosal thickening <8mm is usually sterile 2

2. Evaluate for asthma/cough-variant asthma: 1, 2

   • Consider bronchoprovocation testing if spirometry is normal 2
   • Empiric trial of inhaled corticosteroids if testing unavailable 4

3. Reassess GERD contribution: 1, 2

   • If clinical profile suggests GERD, initiate omeprazole 20-40 mg twice daily before meals for at least 8 weeks plus dietary modifications 2
   • GERD frequently mimics UACS with upper respiratory symptoms 2

If Refractory After 3 Months of Medical Therapy:

Consider physiological testing: 1

• Esophageal manometry and pH-metry with conventional methodology 1
• Reserved for patients being evaluated for antireflux surgery or those with strong clinical suspicion 1

Common Pitfalls to Avoid

1. Do NOT use second-generation antihistamines (loratadine, fexofenadine, cetirizine) for UACS—they lack anticholinergic activity and are ineffective. 4, 3

2. Do NOT use PPI therapy alone in patients without heartburn or regurgitation—it demonstrates no benefit when used in isolation. 1

3. Do NOT overlook "silent" UACS—approximately 20% of patients have no obvious postnasal drip symptoms yet still respond to treatment. 2, 4

4. Do NOT use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa. 2

5. Do NOT discontinue partially effective treatments prematurely—UACS, asthma, and GERD together account for approximately 90% of chronic cough cases and frequently coexist. 2, 4

6. Do NOT rely solely on physical examination—the absence of cobblestoning or visible postnasal drainage does not rule out UACS; response to therapy is the pivotal diagnostic factor. 2, 4

Specific Prescription Example

For a patient with LPR and UACS without heartburn/regurgitation:

Rx 1: Dexbrompheniramine 6 mg + Pseudoephedrine 120 mg SR
Sig: Take 1 tablet at bedtime for 3 days, then 1 tablet twice daily
Disp: 60 tablets
Refills: 2

Rx 2: Fluticasone propionate nasal spray 50 mcg/spray
Sig: 2 sprays each nostril once daily
Disp: 1 bottle (120 sprays)
Refills: 2

Non-pharmacologic:

• Elevate head of bed 6-8 inches
• No meals within 3 hours of bedtime
• Weight loss if BMI >25
• High-volume saline nasal irrigation 150 mL twice daily

If patient has heartburn/regurgitation, ADD:

Rx 3: Omeprazole 40 mg
Sig: Take 1 capsule 30 minutes before breakfast and 1 capsule 30 minutes before dinner
Disp: 60 capsules
Refills: 3 (for 8-week trial)

1, 2, 3