How should I manage a cough that is likely caused by gastro‑oesophageal reflux disease?

Management of Cough Caused by Gastro‑Oesophageal Reflux Disease

For chronic cough suspected to be caused by GERD, begin with an algorithmic approach that addresses common cough etiologies first, then implement lifestyle modifications (weight loss if overweight, head‑of‑bed elevation, avoiding meals within 3 hours of bedtime) combined with PPI therapy only if the patient reports heartburn or regurgitation—PPIs alone are ineffective for reflux‑cough without GI symptoms. 1

Initial Diagnostic Framework

• Evaluate for the most common causes of chronic cough before attributing it to GERD: environmental/occupational irritants, smoking (primary or secondary), ACE inhibitor use, abnormal chest radiograph, asthma, upper airway cough syndrome (UACS) from rhinosinus conditions, non‑asthmatic eosinophilic bronchitis, and suppurative lung disease. 1

• Recognize that more than one etiology often contributes to chronic cough, so addressing GERD alone may be insufficient. 1

• Up to 75% of patients with GERD‑induced cough have no typical GI symptoms (heartburn, regurgitation), making the diagnosis challenging. 2

Treatment Algorithm for Suspected Reflux‑Cough Syndrome

Step 1: Lifestyle Modifications (Grade 1C)

• Implement diet modification to promote weight loss in overweight or obese patients (BMI ≥25 kg/m²), as this is the single most effective intervention with the strongest evidence (Grade B). 1, 2, 3

• Elevate the head of the bed by 6–8 inches using blocks under the bed frame to improve nocturnal esophageal pH profiles. 1, 2, 3

• Avoid lying down for 2–3 hours after meals to reduce esophageal acid exposure by 30–50%. 1, 2, 3

• Studies that included diet modification and weight loss demonstrated better cough outcomes than those using PPIs in isolation. 1

Step 2: Pharmacologic Therapy—Conditional on Symptoms

If Patient Reports Heartburn or Regurgitation:

• Add PPI therapy (e.g., omeprazole 20 mg once daily, 30–60 minutes before breakfast), H₂‑receptor antagonist, alginate, or antacid therapy sufficient to control these GI symptoms. 1

• GI symptoms typically respond within 4–8 weeks, but cough improvement may require up to 3 months. 1

If Patient Has NO Heartburn or Regurgitation:

• Do NOT use PPI therapy alone—it is unlikely to resolve the cough (Grade 1C recommendation). 1

• The 2016 CHEST guideline concluded from multiple RCTs that PPIs demonstrated no benefit when used in isolation for reflux‑cough, particularly in the absence of typical GI symptoms. 1

• There was a strong placebo effect for cough improvement in these trials, underscoring the importance of not relying solely on empiric PPI therapy. 1

Timeline and Response Assessment

• Allow a full 3 months of intensive medical therapy before concluding treatment failure, as extraesophageal symptoms respond more slowly than typical heartburn. 1, 2, 4

• Some patients may respond within 2 weeks, while others require 2–3 months of consistent therapy. 2

When to Pursue Physiological Testing

• Reserve esophageal manometry and pH‑metry for refractory patients being considered for antireflux surgery or those with strong clinical suspicion warranting diagnostic testing after failing 3 months of medical therapy. 1

• Perform esophageal manometry to evaluate for major motility disorders and to accurately position the pH electrode 5 cm proximal to the lower esophageal sphincter. 1

• Conduct pH monitoring off medication to determine if therapy needs intensification or has truly failed. 2

Surgical Consideration

• Antireflux surgery improves or cures cough in 85–86% of properly selected patients who have failed at least 3 months of intensive medical therapy, have objective documentation of persistent GERD, and experience significant quality‑of‑life impairment. 2, 4

• All of the following criteria must be met before surgery: failure of ≥3 months of intensive medical therapy, objective documentation of pathological reflux (erosive esophagitis on endoscopy or abnormal off‑PPI pH monitoring), positive symptom‑reflux association on pH‑impedance testing, preserved esophageal peristalsis on manometry, and significant quality‑of‑life impairment. 2, 3

Critical Pitfalls to Avoid

• Do not prescribe PPIs in isolation for chronic cough without typical GI symptoms—the evidence shows no benefit. 1

• Do not use crossover study designs when evaluating PPI efficacy for cough, as carryover effects confound results. 1

• Do not assess response too early—allow the full 8–12 weeks before concluding treatment failure. 2, 4

• Do not continue empiric therapy indefinitely without objective testing if symptoms persist beyond 3 months of optimized treatment. 2

• Do not assume normal endoscopy rules out GERD as the cause of cough—pH monitoring may still be necessary. 2

Evidence Strength and Nuances

The 2016 CHEST guideline 1 provides the most authoritative framework, explicitly recommending against PPI monotherapy for reflux‑cough without GI symptoms (Grade 1C). This contrasts with general GERD management, where PPIs are first‑line. The guideline emphasizes that an algorithmic approach resolves chronic cough in 82–100% of cases when common etiologies (asthma, UACS) are systematically addressed. 1

The Praxis Medical Insights summaries 2, 3, 4 reinforce that extraesophageal GERD symptoms require twice‑daily PPI dosing from the outset and 8–12 weeks of therapy before assessment, but these recommendations apply primarily when there is clinical suspicion of GERD with some GI symptoms or when other causes have been excluded. 2, 4

The 2005 Cochrane review 5 found insufficient evidence to conclude that GERD treatment with PPI is beneficial for cough, with benefit seen only in sub‑analysis and with small effect size, further supporting the CHEST guideline's cautious stance. 5