Chronic Cough Due to Gastroesophageal Reflux Disease: Drugs
Because coughing can induce GER events, it should be appreciated that less than optimal results may occur due to a cough-GER self-perpetuating cycle unless all causes of cough are adequately treated. Reliance on acid suppression alone may not only fail to adequately control the cough but also potentially place the patient at increased risk of community-acquired pneumonia. According to a retrospective case-control analysis, which was nested in a cohort of incident users of acid-suppressive drugs for at least 1 year, the adjusted risk for pneumonia among persons currently using PPIs compared with those who stopped receiving the PPIs was 1.89. Current users of histamine-2 receptor antagonists had a 1.63-fold increased risk of pneumonia compared with those patients who had stopped using them. These data translated into approximately one case of pneumonia for every 100 years of patient exposure. A prospective, randomized, controlled clinical trial will be necessary to confirm the accuracy of these results. in detail
While the role of antireflux surgery has not been clearly defined, it appears that antireflux surgery has been able to effectively eliminate or significantly improve cough that is unresponsive to intensive antireflux medical therapy. The panel by consensus recommends that antireflux surgery be considered in patients who meet the following criteria: (1) the findings of a 24-h esophageal pH-monitoring study before treatment are positive, as defined above; (2) patients fit the clinical profile suggesting that GERD is the likely cause of their cough (Table 1); (3) cough has not improved after a minimum of 3 months of intensive therapy (Table 3), and serial esophageal pH-monitoring studies or other objective studies (eg, barium esophagography, esophagoscopy, or gastric-emptying study with solids) performed on therapy show that intensive medical therapy has failed to control the reflux disease and GERD is still the likely cause of cough; and (4) patients express the opinion that their persisting cough does not allow them a satisfactory quality of life. While one small prospective, uncontrolled and unblinded, descriptive study suggested that an assessment of gastric emptying would not assist in patient management, another small, prospective, before-and-after intervention tri-al found that a gastric-emptying study with solids provided the only insight as to why prior antireflux surgery had failed to control cough. Redo antireflux surgery that included a gastric-emptying procedure in three of four patients was successful. While a variety of endoscopically assisted interventional techniques have been developed and performed in patients with classic GI GERD symptoms, these procedures should be considered experimental at this time in the population of patients with cough.