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Therapy Insight: treatment of gastroesophageal reflux in adults with chronic cough

Nature Clinical Practice Gastroenterology & Hepatology volume 4, pages 604–613 (2007)Cite this article

Abstract

Gastroesophageal reflux (GER) is the second most common cause of chronic cough in immunocompetent patients who are nonsmokers, not on angiotensin-converting-enzyme inhibitors and have normal chest radiographs. Identification of GER in chronic cough patients can be difficult; most patients with GER-related cough have no esophageal symptoms and no esophageal test is adequate to make this diagnosis. Post-hoc analysis of four prospective intervention trials has identified a clinical patient profile that can predict the presence of GER-related cough 91% of the time. Clinical practice guidelines from the American College of Chest Physicians and the British Thoracic Society recommend initiating an initial empiric GER therapy trial, with esophageal testing being reserved for nonresponders. The empiric trial should include conservative measures and PPIs twice daily for 3 months. Selected patients who have dysphagia might benefit from the addition of a prokinetic agent. Esophageal manometry and pH testing with impedance monitoring (if available) should be performed in nonresponders while they are on therapy. It can take more than 50 days for cough to respond to medical GER therapy. Surgical fundoplication might be helpful in very carefully selected patients. Careful evaluation and treatment resolves cough in ∼80% of patients with GER-related cough.

Key Points

  • There are more than 30 causes of chronic cough (cough lasting for >8 weeks), and more than one cause is present in 8–75% of cases

  • GER is the second most common cause of chronic cough when GER-related cough is defined as a cough that is improved or resolved by GER therapy; nonacid or weakly acidic GER can elicit cough

  • Up to 75% of patients with GER-related cough have no esophageal GER symptoms, but it is still possible to predict the presence of GER-related cough. An empiric trial of conservative measures plus twice-daily PPIs for 3 months can successfully identify and treat GER-related cough in approximately 80% of patients; GER-related cough can take more than 3 months to improve even with aggressive medical GER therapy

  • Esophageal diagnostic testing is recommended if an empiric therapy trial fails and should include esophageal manometry, pH monitoring and impedance monitoring, if available, while maintaining GER therapy

  • Surgical fundoplication can be considered in selected patients who desire surgical therapy and who respond to medical therapy after a comprehensive evaluation, or in patients with documented nonacid reflux who do not respond to medical therapy

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Acknowledgements

The authors wish to thank Arren Graf for her outstanding editorial assistance and patience. Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. AL and at the time of writing was a Senior Fellow in the Department of Medicine, Division of Pulmonary, University of Alabama at Birmingham. SM Harding is a Professor of Medicine in the Department of Medicine, Division of Pulmonary, KMD Chandra is in private practice in Tuscaloosa, Allergy & Critical Care Medicine, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,

    KM Dinesh Chandra & Susan M Harding

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Correspondence to Susan M Harding.

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Competing interests

SM Harding serves as a consultant for, and has, in the past, received research support from, AstraZeneca LP. Dr Harding currently receives research support from the National Institutes of Health (NHLBI). KMD Chandra declared no competing interests.

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Chandra, K., Harding, S. Therapy Insight: treatment of gastroesophageal reflux in adults with chronic cough. Nat Rev Gastroenterol Hepatol 4, 604–613 (2007). https://doi.org/10.1038/ncpgasthep0955

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