Chronic Cough Due to Gastroesophageal Reflux Disease: Empiric Trial of Therapy
The first consensus panel report in 1998 recommended that, when 24-h esophageal pH monitoring cannot be performed or is not available, a diagnostic, empiric trial of medical antireflux therapy be performed in patients who meet the clinical profile (Table 1) predicting that silent GERD is the likely cause of chronic cough or in patients with chronic cough who also have prominent upper GI symptoms that are consistent with GERD. The first consensus panel report also recommended that if empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough; rather, objective investigation for GERD is then recommended because the empiric therapy may not have been intensive enough or medical therapy may have failed. review
Since 1998, a number of articles have been published that support the above two recommendations. Poe and Kallay, in a retrospective before-and-after empirical medical intervention trial, provided data suggesting that an empiric trial of therapy can be successful; they were able to avoid the performance of 24-h esophageal pH monitoring in 44 of 56 patients in whom cough due to GERD had been determined. Others have provided data that support the contention that a negative finding in an empiric trial of therapy does not rule out GERD as a cause of cough. Peghini et al, in a controlled investigation that assessed for nocturnal acid breakthrough in patients with GI complaints who were receiving omeprazole (20 mg bid) or lansoprazole (30 mg bid) and in healthy volunteers, showed that nocturnal acid breakthrough occurred in the majority of all subjects. This study underscores the importance of being aware that a fixed dose of medication may not be adequate in all patients. Allen and Anvari, in a prospective before-and-after antireflux surgery intervention trial in patients who had failed to improve with intensive medical therapy, showed that laparoscopic reflux surgery had improved or cured cough in 85% of chronic coughers 6 months after surgery. Novitsky et al, in a prospective before-and-after antireflux surgery intervention trial in patients with chronic cough who had failed to respond to intensive medical therapy, reported an 86% improvement of chronic cough 12 months following surgery.