Acid Reflux and Coughing

WITHDRAWAL OF RANITIDINE

In April 2020, the Food and Drug Administration (FDA) requested that all forms of prescription and over-the-counter (OTC) ranitidine (Zantac) be removed from the U.S. market. This recommendation was made because unacceptable levels of NDMA, a probable carcinogen (cancer-causing chemical), were found in some ranitidine products. If you’re prescribed ranitidine, talk with your doctor about safe alternative options before stopping the drug. If you’re taking OTC ranitidine, stop taking the drug and talk with your healthcare provider about alternative options. Instead of taking unused ranitidine products to a drug take-back site, dispose of them according to the product’s instructions or by following the FDA’s guidance.

Ranitidine, brand name Zantac, is now marketed as Zantac 360, which contains a different active ingredient (famotidine). Famotidine is in the same class as ranitidine and works the same way but has not been found to contain unacceptable levels of NDMA.

While most people experience occasional acid reflux, some people may develop a more serious form of acid problems. This is known as gastroesophageal reflux disease (GERD). People with GERD experience chronic, persistent reflux that occurs at least twice a week.

Many people with GERD have daily symptoms that can lead to more serious health problems over time. The most common symptom of acid reflux is heartburn, a burning sensation in the lower chest and middle abdomen. Some adults may experience GERD without heartburn as well as additional symptoms. These can include belching, wheezing, difficulty swallowing, or a chronic cough.

GERD is one of the most common causes of a persistent cough. In fact, researchers at the University of North Carolina School of Medicine estimate that GERD is responsible for over 25 percent of all cases of chronic cough. The majority of people with a GERD-induced cough don’t have classic symptoms of the disease such as heartburn. Chronic cough can be caused by acid reflux or the reflux of nonacidic stomach contents.

Some clues as to whether a chronic cough is caused by GERD include:

• coughing mostly at night or after a meal
• coughing that occurs while you’re lying down
• persistent coughing that occurs even when common causes are absent, such as smoking or taking medications (including ACE inhibitors) in which coughing is a side effect
• coughing without asthma or postnasal drip, or when chest X-rays are normal

GERD can be difficult to diagnose in people who have a chronic cough but no heartburn symptoms. This is because common conditions such as postnasal drip and asthma are even more likely to cause a chronic cough. The upper endoscopy, or EGD, is the test used most often in a complete evaluation of symptoms.

The 24-hour pH probe, which monitors esophageal pH, is also an effective test for people with chronic cough. Another test, known as MII-pH, can detect nonacid reflux as well. The barium swallow, once the most common test for GERD, is no longer recommended.

There are other ways to find out whether a cough is related to GERD. Your doctor may try putting you on proton pump inhibitors (PPIs), a type of medication for GERD, for a period of time to see if symptoms resolve. PPIs include brand name medications such as Nexium, Prevacid, and Prilosec, among others. If your symptoms resolve with PPI therapy, it is likely you have GERD.

PPI medications are available over the counter, though you should see a doctor if you have any symptoms that aren’t going away. There may be other factors causing them, and a doctor will be able to suggest the best treatment options for you.

Many infants experience some symptoms of acid reflux, such as spitting up or vomiting, during their first year of life. These symptoms can occur in infants who are otherwise happy and healthy. However, infants who experience acid reflux after 1 year of age may indeed have GERD. Frequent coughing is one of the main symptoms in children with GERD. Additional symptoms may include:

• heartburn
• repeated vomiting
• laryngitis (hoarse voice)
• asthma
• wheezing
• pneumonia

Infants and young children with GERD may:

• refuse to eat
• act colicky
• become irritable
• experience poor growth
• arch their backs during or immediately following feedings

You’re at greater risk for developing GERD if you smoke, are obese, or are pregnant. These conditions weaken or relax the lower esophageal sphincter, a group of muscles at the end of the esophagus. When the lower esophageal sphincter is weakened, it allows the contents of the stomach to come up into the esophagus.

Certain foods and drinks can also make GERD worse. They include:

• alcoholic beverages
• caffeinated beverages
• chocolate
• citrus fruits
• fried and fatty foods
• garlic
• mint and mint-flavored things (especially peppermint and spearmint)
• onions
• spicy foods
• tomato-based foods including pizza, salsa, and spaghetti sauce

Lifestyle changes will often be enough to reduce or even eliminate a chronic cough and other symptoms of GERD. These changes include:

• avoiding foods that make symptoms worse
• avoiding lying down for at least 2.5 hours after meals
• eating frequent, smaller meals
• losing excessive weight
• quitting smoking
• raising the head of the bed between 6 and 8 inches (extra pillows don’t work)
• wearing loose-fitting clothing to relieve pressure around the abdomen

Medications, especially PPIs, are generally effective in treating symptoms of GERD. Others that may help include:

• antacids such as Alka-Seltzer, Mylanta, Rolaids, or Tums
• foaming agents such as Gaviscon, which reduce stomach acid by delivering an antacid with a foaming agent
• H2 blockers such as Pepcid, which decrease acid production

You should contact your doctor if medications, lifestyle changes, and diet changes do not relieve your symptoms. At that point, you should discuss other treatment options with them. Surgery can be an effective treatment for those who don’t respond well to either lifestyle changes or medications.

The most common and effective surgery for long-term relief from GERD is called fundoplication. It is minimally invasive and connects the upper part of the stomach to the esophagus. This will reduce reflux. Most patients return to their normal activities in a couple of weeks, after a brief, one to three day hospital stay. This surgery usually costs between $12,000 and $20,000. It may also be covered by your insurance.

If you suffer from a persistent cough, talk to your doctor about your risk for GERD. If you’re diagnosed with GERD, be sure to follow your medication regime and keep your scheduled doctor’s appointments.