What prescription regimen should be given for a patient with laryngopharyngeal reflux, upper‑airway cough syndrome, and cough‑variant asthma?

Prescription Regimen for Laryngopharyngeal Reflux, Upper Airway Cough Syndrome, and Cough-Variant Asthma

Start immediately with combination inhaled corticosteroid plus inhaled bronchodilator for the cough-variant asthma, add a first-generation antihistamine/decongestant for upper airway cough syndrome, and implement lifestyle modifications with PPIs only if the patient has heartburn or regurgitation symptoms for the laryngopharyngeal reflux. 1, 2

Asthma Component - First Priority

Initiate combination therapy immediately:

• Inhaled corticosteroid (e.g., budesonide 400-800 mcg twice daily or fluticasone 220-440 mcg twice daily) 1, 3
• Plus short-acting beta-agonist (albuterol 2 puffs every 4-6 hours as needed) 1, 3
• Do NOT use beta-agonist monotherapy, as this increases risk of serious asthma events 1

Expected timeline: Partial improvement within 1 week, but complete cough resolution may require up to 8 weeks of treatment 1, 3, 4

Upper Airway Cough Syndrome - Concurrent Treatment

Empiric therapy with first-generation antihistamine/decongestant:

• Prescribe a first-generation antihistamine with decongestant combination (e.g., brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) 2
• Second-generation non-sedating antihistamines are completely ineffective and should NOT be used 2, 1
• Continue for at least 2-4 weeks to assess response 2

Laryngopharyngeal Reflux Management

Lifestyle modifications for ALL patients:

• Elevate head of bed 6-8 inches 2
• Avoid meals within 3 hours of bedtime 2
• Diet modification to promote weight loss if overweight or obese 2

PPI therapy ONLY if symptomatic reflux:

• If patient reports heartburn or regurgitation: Start PPI (omeprazole 20-40 mg twice daily or equivalent) taken before meals for at least 8 weeks 2
• If NO heartburn or regurgitation: Do NOT use PPI therapy alone, as it is unlikely to be effective 2
• Improvement in cough from reflux may take up to 3 months 2

Escalation Strategy if Incomplete Response After 2-4 Weeks

Step 1 - Optimize asthma therapy:

• Verify proper inhaler technique (most common cause of treatment failure) 1, 4
• Increase inhaled corticosteroid dose before adding other agents 1, 4

Step 2 - Add leukotriene receptor antagonist:

• Add montelukast 10 mg orally once daily to existing regimen 1, 4
• This is particularly effective for asthmatic cough resistant to bronchodilators and inhaled steroids 1, 4

Step 3 - Consider oral corticosteroids only after above steps fail:

• Prednisone 40 mg daily for 5-10 days (no taper needed for short courses) 1, 3
• Reserve this for refractory cases after optimizing inhaled therapy 1, 4

Critical Pitfalls to Avoid

• Do NOT jump to oral corticosteroids first - this exposes patients to unnecessary systemic side effects when inhaled medications are highly effective 1
• Do NOT use PPIs alone without lifestyle modifications for suspected reflux-cough syndrome, as PPIs in isolation show no benefit 2
• Do NOT prescribe non-sedating antihistamines - they are completely ineffective for cough 2, 1
• Do NOT diagnose treatment failure prematurely - asthma-related cough may require up to 8 weeks for complete resolution 1, 3, 4

When to Reassess and Refer

• Reassess at 2-4 weeks to evaluate response to initial therapy 2
• If cough persists beyond 8 weeks despite systematic treatment of all three conditions, refer to a cough specialist 2
• Consider bronchoprovocation challenge testing if diagnosis of asthma remains uncertain despite empiric therapy 2