While the optimal way to treat all patients with cough due to GERD has yet to be determined, medical therapy in adults, based on the results of prospective and retrospective before-and-after intervention trials, when not limited to acid suppression therapy alone, has improved cough in 70 to 100% of patients. When cough in adults has not improved with medical therapy, surgery has improved cough 6 to 12 months following surgery in prospective, be-fore-and-after intervention trials in approximately 85% of patients.
Until multiple randomized controlled clinical trials provide guidance on which treatment regimens will be successful in which groups of subjects, the panel by consensus recommends that clinicians must be aware of the spectrum of treatment options that may favorably affect GERD (Table 3) and that an intensive medical treatment regimen that includes all medical therapeutic options listed in Table 3 be instituted before considering antireflux surgery. While there has been an anecdotal report suggesting that one patient may have developed an intractable cough due to receiving omeprazole therapy, the patient was not rechallenged with the drug to solidify the association. sildenafil citrate pink
Nevertheless, if drug-induced cough is considered to be a clinical possibility, the agent should be discontinued to determine whether it might be playing a role before recommending surgery.
An intensive medical treatment regimen includes the following: (1) an antireflux diet that includes no > 45 g of fat in 24 h and no coffee, tea, soda, chocolate, mints, citrus products, including tomatoes or alcohol, no smoking, and limiting vigorous exercise that will increase intraabdominal pressure; (2) acid suppression with a proton pump inhibitor (PPI); and (3) prokinetic therapy. Even though nocturnal breakthrough gastric acid production has been noted in healthy control subjects and patients with GERD who are receiving PPIs, the addition of a nocturnal H2-antagonist has not been shown to improve clinical outcomes.,, Because comorbid diseases such as obstructive sleep apnea or therapy for comorbid conditions (eg, nitrates, progesterone, and calcium channel block-ers) can potentially make GERD more difficult to control, routinely consider trying to mitigate the influences of these factors whenever possible.
Table 3—Spectrum of Options for Treating Chronic Cough Due to GERD
|Antireflux medical therapy||Diet|
|Address risk factors|
|Treat other causes of cough|
|Treat comorbid conditions|
|Obstructive sleep apnea|
|Consider changing medications for comorbid conditions|