Praxis Medical Insights

Introduction to PPIs for Cough

The American College of Chest Physicians recommends that PPIs should not be used as a first-line treatment for chronic cough due to the lack of significant benefit over placebo, with most randomized controlled trials demonstrating no significant difference between PPIs and placebo 1, 2
The 2016 CHEST guidelines found that only 1 of 13 trials demonstrated statistically significant improvement in chronic cough with rabeprazole 20mg twice daily, with response rates ranging from 36-57% when PPIs did work 1, 2, 3

Acid suppression reduces direct acid-induced irritation of the esophageal mucosa and potentially the airways, which may contribute to the reduction of cough reflex sensitivity in patients with GERD 4, 3
Decreased esophageal acid exposure reduces cough reflex hypersensitivity, as patients with GERD demonstrate heightened cough reflex sensitivity that may improve with antireflux therapy 3

The CHEST guidelines recommend an empiric trial of intensive antireflux therapy for chronic cough when other causes have been excluded, with initial therapy including omeprazole 40mg twice daily (or equivalent PPI) taken 30-60 minutes before meals, strict antireflux diet, and lifestyle modifications such as elevating the head of bed 6-8 inches and avoiding lying down 2-3 hours after meals 4, 6, 7
A minimum of 8-12 weeks of therapy is required before assessing response, with some patients taking up to 6 months for cough resolution, and if no response is seen after 8 weeks on twice-daily PPI, prokinetic therapy (metoclopramide 10mg three times daily) may be added 4, 7

The presence of typical GERD symptoms (heartburn, acid reflux) predicts better response to PPI therapy for cough, while patients with cough as an isolated symptom without heartburn are less likely to respond 1
Heartburn is not required for diagnosis, and many patients with GERD-related cough have no typical reflux symptoms 5, 4

Antireflux surgery (fundoplication) improves or cures cough in 85-86% of properly selected patients who have failed at least 3 months of intensive medical therapy and have objective documentation of GERD on pH monitoring 4, 6, 7