Chronic Cough Due to Gastroesophageal Reflux Disease: Treatment

For patients with chronic cough, the following tests are not routinely recommended to link cough with GERD: (a) assessing for lipidladen macrophages in BAL fluid and induced sputum, because this test has not been studied in patients with chronic cough and because a positive test result is not specific for aspiration; (b) exhaled nitric oxide measurements, because they do not appear to be helpful in diagnosing cough due to GERD; (c) a Bernstein test, because a negative Bernstein test result cannot be used to exclude the diagnosis of cough due to GERD; and (d) inhaled tussigenic challenges with capsaicin, because they are not specific for coughs due to GERD and because the test result can be positive in patients with GERD without cough. Level of evidence, low; benefit, conflicting; grade of recommendation, I Here

Based on the apparent heterogeneity of patient populations with differing pathogenetic mechanisms and differing risk factors that can adversely affect GERD, it is not likely that all patients will theoretically respond to the same treatment. A review of the literature on the treatment of cough due to GERD, which is summarized in Table 2, supports this statement. The review suggests the following: that when medical therapy is effective, some patients with cough due to GERD will favorably respond to acid suppression therapy alone>; that proton pump inhibition may be effective when H2-antagonism has been ineffective; that prokinetic therapy and diet, when added to proton pump inhibition, may be effective when proton pump inhibition alone has been ineffective; that while medial therapy may eliminate cough within 8 weeks in some patients, it may still lead to a favorable outcome despite taking months before it starts to work>; and that cough in other patients will only improve or be eliminated with antireflux surgery, after cough in these patients has failed to improve with maximal medical therapy that includes an intensive antireflux diet, maximum acid suppression, and prokinetic therapy. These findings have come from prospective and retrospective before-and-after intervention trials, and from two imperfectly designed (see Table 2), prospective, double-blind, randomized placebo-controlled trials, that have compared the effects of omeprazole with placebo.

Table 2—Evidence for the Treatment of Chronic Cough Due to GERD