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Old 08-19-2006, 06:53 AM   #3
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Join Date: Sep 2005
Posts: 565
aswander HB Useraswander HB User
Re: Coughing for 5 years


MountainReader is right. You have the classic symptoms of a form of acid reflux called laryngopharyngeal reflux, known as "LPR", and widely discussed on the acid reflux message board.

LPR is characterized by one or more of the following:

-Severe, unrelenting cough
-Better relief from untreated symptoms at night (or when lying down)
-Sensation of lump in the throat
-Asthma-like symptoms that don't respond to asthma meds
-Sinusitis-like symptoms that don't respond to sinusitis meds

These are the gamut of classic symptoms, but most patients only have 1-3 of them, though some have all of them.

I know it may initially seem coutnerintuitive to connect acid reflux to coughing, but it's a very real problem. The esophogous connects your stomach to your throat, and where your stomach meets your esophogous is called the lower esophogeal spinchter muscle (LES). Where your throat meets your esophogous is called the upper esohogoeal spinchter muscle (UES). When people experience what is called heartburn, it's really caused by a weakness of the LES allowing excess acid into the lower esophogous where it causes erosions and pain. However, everyone experiences some reflux - even in normal people, some acid escapes the LES several times a day, but it isn't enough to cause pain and lasting damage. However, for those people with a functioning LES but weakened UES, there is a problem. Less acid gets into the esophogous, but it rises highter, and irritates the UES, which is also called the laryngeal/pharyngeal area. This is enough to cause chronic coughing, because the acid in your stomach has a super-low PH of 2 (hydrochloric acid). To make it worse, some of that acid escapes the UES, and gets into your throat, where it can mix with your mucous and then spread around your sinuses and nasal passages. In many LPR patients, they also aspirate a little of that acid into their lungs, causing asthma-like symptoms that cannot be treated with asthma medication.

The only solution for LPR is to reduce the amount of acid in the stomach, because there is no medication or surgery that will tighten the UES.

We use proton-pump inhibitors (PPIs) to reduce the amount of acid in the stomach. A proton is a stripped-down hydrogen atom, which is essentially the smallest unit of acid. Hence, a PPI reduces the number of protons (acid particles) in your stomach.

The good news is that you don't need fancy expensive time-consuming tests. In the medical community, a positive response to a PPI regimen (reduction of symptoms) is considered sufficient diagnosis for LPR.

So you're asking what should I take?

You need a prescription for a PPI. More importantly, LPR is always always treated with 2 doses a day of a maximum strength PPI, not 1 dose. Heartburn gets treated with 1 dose, LPR requires 2. I cannot say that enough.

Your choices are:
Nexium 2 doses of 40 mg capsules per day for a total of 80 mg
Prescription Prilosec - 2 doses of 40 mg capsules daily for a total of 80 mg
Generic Ompeprazole (this is generic Prilosec) = 2 40 mg doses
Aciphex- 2 20 mg doses daily for a total of 40 mg.
Prevacid -2 30 mg doses daily for a total of 60 mg.
Zegerid - 2 40 mg doses daily for a total of 80 mg

In addition, there is Prilosec OTC (sold without a prescription) but I cannot say this strongly enough - there is no evidence that it works for LPR, and this is a big topic of discussion on the acid reflux board - noone with LPR has been helped by OTC in the last year. It only works for heartburn patients. Just don't bother.

There is another prescription PPI called Protonix. It also doesn't work for LPR. Doctor's will disagree - but most of us at the acid reflux board have tried it at some point at it just doesn't work for LPR.

Timing of the doses is also important. You need to take the 2 doses together, in the morning. It usually will not work as well to split up the doses into morning and evening. Just take them together. Once you are feeling better, feel free to experiment, but it's more important to get well first!

You can get the PPIs from your PCP. Your PCP will probably never have heard of LPR, but since PCPs commonly treat heartburn, she will have a medical supply cabinet filled with PPI samples from her drug reps.

If you want to do it right, you need to go to a knowledgable ENT. Most small-town ENTs have never seen LPR, but most big city ENTs have seen it, especially those who cater to singers and actors - who commonly get LPR from overuse of their vocal instruments. When you see the ENT, they will scope you - insert a thin wire with a camera at the end up your nose and into your throat (it isn't that bad - uncomfortable, but not painful because the numb you up). They are looking for a red and swollen layrnx - which is evidence of LPR reflux. It's the telltale sign.

While you can't cure LPR, you can effectively manage it and significantly reduce the coughing. In addition to taking PPIs, you will learn to manage your diet to avoid the foods that cause increased reflux. All fats slow digestion and keep food in your stomach longer, which equates to increased reflux. The best solution is to start on a very low-fat diet, which will digest much faster. You'll find that eating anything made out of pure sugar (like basic candies) will not cause increased reflux, but anything with a a lot of fat will cause coughing fits. You won't notice theses differences until after you start the PPI treatment, because right now you are coughing all the time.

It usually takes 1-30 days to notice significant improvement. I was one of the lucky ones who went from a 0 to a 10 after my first double dose of Nexium. Other people take longer.

I have taken Nexium, 2 doses of 40 mg capsules, for 4 years and am doing very well on this regiment. The symptoms had become unbearable before I received diagnosis and treatment 4 years ago. But I still struggle with my diet every day and tempting no-nos like fatty steaks, cheese and fried foods.