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Successful Resolution of Refractory Chronic Cough Induced by Gastroesophageal Reflux With Treatment of Baclofen FREE TO VIEW

Xianghuai Xu*, MD; Zhong-Min Qiu, PhD; Han-Jing Lv, MD; Qiang Chen, MD; Si-Wei Liang, MD
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Shanghai Tongji Hospital, Shanghai, China

Chest. 2012;142(4_MeetingAbstracts):16A. doi:10.1378/chest.1385291
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SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Gastroesophageal reflux induced cough is a common cause of chronic cough, and proton pump inhibitors are a standard therapy. However, the patients unresponsive to the standard therapy are difficult to treat and remain a challenge to doctors. Here, we summarized the experience of successful resolution of refractory chronic cough due to gastroesophageal reflux with baclofen in a patient. It is concluded that baclofen may be a selectable option for gastroesophageal reflux induced cough failing to proton pump inhibitor therapy.

CASE PRESENTATION: A 26-year-old male patient with persistent cough for 3.5 years was referred to our respiratory clinic. A further 24-hour esophageal pH monitoring revealed an abnormal acid-reflux with a DeMeester score of 61.4 and the symptom association probability of 99%. Then, the presumptive diagnosis of GERC was established and oral omeprazole 20 mg twice a day was commenced. The patient’s cough persisted despite the subsequent treatment with oral montelukast and inhaled corticosteroid. Since no relief of cough was observed, multi-channel intraluminal impedance combined with pH monitoring was ordered, and the abnormal non-acid reflux and positive symptom association probability for non-acid reflux was found (Table 1). After 8 week of additional augmented antireflux medical therapy comprising omeprazole, 20 mg twice a day and domperidone, 10 mg three times a day, the patient did not feel any improvement. Then, baclofen, 20 mg three times a day was used to replace domperidone. His cough attenuated obviously in a week, and completely resolved in two months, as indicated by the decreased cough symptom score and cough reflex sensitivity to capsaicin (Figure 1, 2). Within the next four months of follow-up, no reoccurrence of cough was reported. The dosage of baclofen was currently reducing to 20 mg daily. No discernable side effects were noted during the treatment with baclofen.

DISCUSSION: In theory, the therapeutic options available for non-acid GERC resistant to proton pump inhibitors include prokinetic agents, transient lower esophageal sphincter relaxation inhibitors and antireflux surgery because they all have the ability to reduce the frequency of reflux and volume of refluxate. At present, the efficacy of prokinetic agents has not been ascertained. Antireflux surgery should not be the preferred choice since a cause and effect relationship between reflux and chronic cough is not definitely established. As transient lower esophageal sphincter relaxations account for the vast majority of reflux events, 4 baclofen, a potent inhibitor of transient lower esophageal sphincter relaxation, may be selected as an add-on trial for GERC unresponsive to proton pump inhibitors. To our knowledge, it is the first report for successful resolution of refractory GERC with baclofen even though there has been several studies on its use in the difficult to treat gastroesophageal reflux disesase.

CONCLUSIONS: Baclofen may be a selectable option for refractory cough due to gastroesophageal reflux. Further study is needed to validate its therapeutic efficacy for GERC in the future.

1) Irwin RS. Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest, 2006, 129: 80S-94S. 2. Boeckxstaens GE, Smout A. Systematic review: role of acid, weakly acidic and weakly alkaline reflux in gastro-oesophageal reflux disease. Aliment Pharmacol Ther, 2010, 32: 334-343. 4. Boeckxstaens GE. Reflux inhibitors: a new approach for GERD? Curr Opin Pharmacol, 2008, 8: 685-689. 5. Beaumont H, Boeckxstaens GE. Does the presence of a hiatal hernia affect the efficacy of the reflux inhibitor baclofen during add-on therapy? Am J Gastroenterol, 2009, 104:1764-1771. 6. Zhang Q, Lehmann A, Rigda R, et al. Control of transient lower oesophageal sphincter relaxations and reflux by the GABA(B) agonist baclofen in patients with gastro-oesophageal reflux disease. Gut, 2002, 50: 19-24. 8. Vela MF, Tutuian R, Katz PO, et al. Baclofen decreases acid and non-acid post-prandial gastroesophageal reflux measured by combined multichannel intraluminal impedance and pH. Aliment Pharmacol Ther, 2003, 17: 243-251.

DISCLOSURE: The following authors have nothing to disclose: Xianghuai Xu, Zhong-min Qiu, Han-jing Lv, Qiang Chen, Si-wei Liang

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Shanghai Tongji Hospital, Shanghai, China




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