At the United European Gastroenterology Week, Dr. Sabine Roman, an esteemed figure in gastroenterology and physiology at Lyon University Hospital in France, delved into the intricate relationship between chronic cough and gastroesophageal reflux disease (GERD). She highlighted the importance of accurate diagnosis and cautious treatment approaches and significant aspects of managing this prevalent issue.
Chronic cough presents a multifaceted challenge, with clinical studies reporting a prevalence ranging from 9% to 33%. Its origins often stem from diverse factors, primarily respiratory conditions (such as asthma, chronic obstructive pulmonary disease, respiratory infections, or smoking) and conditions in the ear, nose, and throat domain (like postnasal drip). Certain medications, notably angiotensin-converting enzyme inhibitors, can also contribute to this condition.
Why Chronic Cough Requires Precise GERD Evaluation?
GERD emerges as a potential cause of chronic cough, albeit one that might be overly estimated. A recent Spanish study revealed an overestimation of the GERD-cough link, with suspicions of GERD accounting for 46% of cough cases (compared to 32% for asthma and 15% for postnasal drip).
Commonly, treatments prescribed for chronic cough encompass proton pump inhibitors (PPIs) and respiratory medications. However, despite inadequate diagnostic assessments, Dr. Roman highlighted a trend where GERD is frequently singled out as the culprit for chronic cough. She emphasized the need for comprehensive evaluations, citing low percentages of patients undergoing gastroenterologist consultations, endoscopies, or esophageal pH monitoring in related studies.
Establishing a direct cause-effect relationship between GERD and cough remains challenging. Studies using automatic cough detection revealed a complex interplay: while GERD often preceded cough in 48% of cases, cough preceded GERD in 56% of patients. Complicating matters further, both mechanisms coexisted in a third of patients.
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Regarding PPIs, commonly used as a diagnostic trial, their effectiveness does not necessarily confirm underlying GERD. Placebo-controlled studies demonstrated that in cases without a prior GERD diagnosis, PPIs showcased no superior efficacy. When reflux is confirmed, PPI improvement over placebo typically ranges between 12% and 35%, emphasizing the crucial need for established GERD presence, especially in patients lacking typical GERD symptoms like heartburn and acid reflux.
Understanding factors influencing PPI response, an Italian study highlighted that typical symptoms, severe esophagitis, abnormal acid exposure, and low nocturnal baseline impedance were independent predictors of positive treatment response.
Furthermore, studies revealed heightened cough reflex sensitivity in GERD patients with chronic cough. Trials exploring medications like gabapentin and baclofen exhibited promising outcomes, showing around 50% improvement. Although a newer drug, lesogaberan, demonstrated a 26% benefit, it did not attain statistical significance and needed further development.
For patients considering anti-reflux surgery, careful consideration is imperative. While meta-analyses suggested an 84% improvement rate in symptoms, these findings originated from non-controlled, retrospective studies with diverse patient populations, demanding careful interpretation. Notably, lack of response to medical treatment and extraesophageal symptoms like chronic cough were linked to nonresponse or recurrence after surgery.
The recent recommendations from the American Gastroenterological Association underscore the significance of evaluating patients rigorously before surgical consideration, emphasizing the failure of medical treatment as a key determinant of surgical outcomes.
In summary, managing chronic cough in association with GERD warrants a meticulous approach. While PPIs may serve as initial treatment for patients with typical GERD symptoms, a diagnostic investigation for GERD confirmation becomes essential in scenarios of treatment failure or isolated cough without classic symptoms. Tests, including endoscopy or pH monitoring, are pivotal in accurate diagnosis and tailored treatment strategies.
Medscape contributed to this report.
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