I have heartburn and recurrent cough; what treatment should I pursue?

Treatment for Heartburn with Recurrent Cough

Start with lifestyle modifications and weight loss if overweight, elevate the head of your bed, avoid eating within 3 hours of bedtime, and if you have heartburn symptoms, begin a proton pump inhibitor (PPI) for at least 8-12 weeks—but if you lack typical heartburn or regurgitation, PPIs alone are unlikely to help your cough. 1

Initial Diagnostic Approach

Before treating presumed reflux-cough syndrome, you must systematically exclude other common causes of chronic cough:

• Rule out environmental/occupational irritants and smoking 1
• Stop ACE inhibitors if taking them (common medication-induced cough) 1
• Ensure chest X-ray is normal 1
• Exclude asthma through trial of asthma therapy or negative methacholine challenge 1
• Rule out upper airway cough syndrome (postnasal drip) with first-generation H1-antihistamine trial 1, 2
• Exclude nonasthmatic eosinophilic bronchitis with induced sputum analysis or corticosteroid trial 1

Critical caveat: Up to 75% of patients with reflux-related cough have NO gastrointestinal symptoms like heartburn or regurgitation, making diagnosis challenging. 1, 2

Treatment Algorithm Based on Symptom Profile

If You HAVE Heartburn or Regurgitation:

Implement all three components simultaneously: 1

1. Dietary and lifestyle modifications:

   • Weight loss if overweight/obese 1, 3
   • Elevate head of bed 1
   • Avoid meals within 3 hours of bedtime 1, 3
   • Eliminate trigger foods and stop smoking 3

2. Start acid suppression therapy:

   • PPI (omeprazole 20 mg once daily before meals) 4
   • Alternative options: H2-receptor antagonists, alginate, or antacids 1
   • Dose sufficient to control GI symptoms 1

3. Expected timeline:

   • GI symptoms should improve within 4-8 weeks 1, 3
   • Cough improvement may take up to 3 months 1—this is a common pitfall where providers stop therapy too early

If You LACK Heartburn or Regurgitation:

Do NOT use PPI therapy alone—it is unlikely to be effective. 1 This represents a Grade 1C recommendation from the American College of Chest Physicians. 1

Instead:

• Focus on lifestyle modifications (weight loss, head elevation, meal timing) 1, 3
• Consider adding a prokinetic agent (metoclopramide) if upper GI symptoms are present 1, 3, 5
• A therapeutic trial combining PPI with prokinetic successfully treats 4 out of 5 patients with GERD-related cough within 4-8 weeks 5

Escalation Strategy for Non-Responders

After 3 Months of Initial Therapy:

If inadequate response:

• Increase to twice-daily PPI dosing (before breakfast and dinner) 3, 6
• Add prokinetic agent if not already prescribed 3, 5

Diagnostic Testing Indications:

Consider esophageal manometry and pH-metry if: 1

• Refractory to 3-month trial of medical therapy
• Being evaluated for surgical management (antireflux or bariatric surgery)
• Strong clinical suspicion warrants objective confirmation

Testing methodology: 1

• pH electrode placed 5 cm above lower esophageal sphincter
• Performed OFF antisecretory medications (stop PPIs 7 days, H2-blockers 3 days prior)
• This is the only validated methodology for surgical decision-making

Surgical Consideration:

Antireflux surgery may be considered if: 1

• Adequate esophageal peristalsis is present
• Abnormal esophageal acid exposure confirmed on pH-metry
• Medical therapy has failed after appropriate trial

Do NOT pursue surgery if: 1

• Major motility disorder present (absent peristalsis, achalasia, distal esophageal spasm)
• Normal acid exposure time on pH-metry
• Risk-benefit ratio becomes unacceptable under these circumstances

Common Pitfalls to Avoid

1. Stopping therapy too early: Cough resolution lags behind heartburn improvement by weeks to months 1

2. Using second-generation antihistamines for postnasal drip: First-generation H1-antagonists are more effective for non-histamine-mediated postnasal drip causing cough 2

3. Assuming all cough is from one cause: 52% of patients with GERD-related cough have multiple contributing factors 5

4. Missing aspiration as a complicating factor: Nonresponders to aggressive medical therapy often have aspiration as an additional problem 5

5. Treating with PPI monotherapy when heartburn is absent: This approach has insufficient evidence and is specifically recommended against 1

Maintenance Therapy

Once symptoms resolve:

• Maintain lowest effective PPI dose to minimize long-term adverse effects 3
• Consider on-demand therapy for intermittent symptoms 3
• Continue lifestyle modifications indefinitely 1, 3