PURPOSE: The current initial approach to the diagnosis and therapy of GERD-associated chronic cough is empiric therapy. Ambulatory 24 hour esophageal pH study while on proton pump inhibitor therapy is recommended only if there is inadequate response in case medical therapy has to be intensified. The aim of our study was to examine how ambulatory esophageal pH test results were used in patients with chronic cough when GERD remains a diagnostic consideration. We hypothesized that treatment decisions would be most consistently and logically guided by esophageal pH tests performed off of PPI therapy.
METHODS: Retrospective review of 103 consecutive patients presenting with chronic cough to the pulmonary clinic between 1999 and 2003. Experienced gastroenterologists not involved in the study utilized visual inspection, SI, and SSI to determine cough-reflux correlation, and DeMeester score and acid exposure time to determine whether pathologic reflux was present. The concordance of the pulmonologists’ treatment decision with the test result was determined by comparison with present guidelines, and logistical regression was used to determine key factors influencing concordance.
RESULTS: : The most important determinant of concordant treatment decisions was whether ambulatory esophageal pH testing was performed on or off PPI therapy. When the test was performed off of PPI therapy, 84.7% of treatment decisions were concordant, compared with only 35.5% on PPI (p<0.0001). Only 2/21 patients with a negative test and an incomplete clinical response to an empiric trial of PPI and were asked to discontinue PPI therapy.
CONCLUSION: Interpretation and “rules” for stopping an empiric trial of PPI are not confidently understood in patients who have a “negative” esophageal pH study (common result in this kind of patients). Clinicians tend to continue PPI therapy for the patients who remain on PPI therapy during the study even with completely negative results.
CLINICAL IMPLICATIONS: Chronic cough patients who have already failed a trial of PPI therapy should probably have their pH study done off therapy, which when negative, can provide a rationale for discontinuing an expensive therapy.
DISCLOSURE: Kaiser Lim, None.