What first‑line medication is recommended for a 35‑year‑old woman with a recent sleeve gastrectomy who has a three‑week persistent cough, mild tachycardia, mild hypertension, and an otherwise unremarkable exam?

Management of Persistent Cough in a Post-Gastric Sleeve Patient

For this 35-year-old woman with a 3-week persistent cough following gastric sleeve surgery, initiate empiric treatment for upper airway cough syndrome (UACS) with a first-generation antihistamine-decongestant combination while simultaneously starting high-dose proton pump inhibitor (PPI) therapy, given the high prevalence of GERD after bariatric surgery. 1, 2

Critical Bariatric Surgery-Specific Consideration

Rule out gastrobronchial fistula first – While rare, patients with persistent cough after sleeve gastrectomy can develop a gastrobronchial fistula from an intractable gastric sleeve leak, presenting with paroxysms of coughing immediately after eating or drinking. 3 This patient's well appearance and lack of fever make this less likely, but if cough worsens with oral intake, urgent imaging with barium study is warranted. 3

Classification and Initial Approach

This is a subacute cough (3 weeks duration, between 3-8 weeks). 1 The ACCP guidelines recommend determining whether the cough followed a respiratory infection; if postinfectious, treat empirically for postnasal drip, upper airway irritation, or bronchial hyperresponsiveness. 1 If not clearly postinfectious, manage as chronic cough. 1

First-Line Medication Recommendations

Step 1: Treat Upper Airway Cough Syndrome (UACS)

• Start a first-generation antihistamine-decongestant combination (e.g., chlorpheniramine with pseudoephedrine) for 1-2 weeks. 2, 4
• UACS (postnasal drip) is one of the three most common causes of chronic cough and typically responds within 1-2 weeks. 2, 5, 4
• The mechanism involves persistent postnasal drip, upper airway irritation, and mucous accumulation. 1

Step 2: Initiate Intensive GERD Therapy Simultaneously

Gastric sleeve patients have significantly increased GERD risk, making empiric PPI therapy particularly important in this population even without typical reflux symptoms. 1

Comprehensive anti-reflux regimen includes: 1, 2

Dietary modifications:

• Limit fat to <45g per 24 hours 1, 2
• Eliminate coffee, tea, soda, chocolate, mints, citrus (including tomatoes), and alcohol 1, 2

Lifestyle changes:

• Avoid eating 2-3 hours before bedtime 1, 2
• Elevate head of bed 1, 2
• Weight management and smoking cessation 2

Pharmacotherapy:

• Start omeprazole 40mg once daily (or equivalent PPI) taken before meals 1, 2
• Up to 75% of patients with GERD-related cough lack typical heartburn or regurgitation symptoms 2
• Medical therapy improves cough in 70-100% of patients when not limited to acid suppression alone 1

Timeline Expectations and Escalation

UACS typically responds within 1-2 weeks, while GERD therapy requires patience – some patients need 4-8 weeks or even several months before improvement. 1, 2

If inadequate response after 4-8 weeks of PPI monotherapy:

• Increase to twice-daily PPI dosing (e.g., omeprazole 20-40mg twice daily) 1, 2
• Add prokinetic agent such as metoclopramide 10mg four times daily 1
  • Caution: Limit metoclopramide to maximum 12 weeks due to tardive dyskinesia risk 6
  • Monitor for extrapyramidal symptoms, especially within first 24-48 hours 6

Additional Considerations

Evaluate for Asthma/Bronchial Hyperresponsiveness

• If UACS treatment fails, consider trial of inhaled corticosteroids or bronchodilators 1, 2, 4
• Postinfectious bronchial hyperresponsiveness can be transient or associated with asthma exacerbation 1

Blood Pressure Management

• Her BP of 154/76 and pulse of 103 warrant attention [@question context@]
• Avoid ACE inhibitors – these cause chronic cough in many patients, with median resolution time of 26 days after discontinuation 1
• Consider alternative antihypertensives (ARBs, calcium channel blockers, or beta-blockers) 1

Common Pitfalls to Avoid

• Do not assume single etiology – chronic cough often has multiple simultaneous causes requiring treatment of all contributors 1, 5
• Do not discontinue partially effective treatments – maintain all therapies that provide even partial benefit 1
• Do not give up on GERD therapy prematurely – 5-10% of patients require up to 8-12 weeks to improve 1
• Do not overlook medication-induced cough – review all medications for potential cough triggers 1