aswander

JOT,

You have come to the right place. Chronic cough is frequently caused by acid refluxing into the throat, and unfortunately, most doctors have never heard of this condition, which is called layngopharyngeal reflux (LPR). It can strike at any age, and is thought to be caused by a weakened upper esophogeal spinchter muscle (though researchers are currently investigating the possibibility that the larynx itself begins producing acid by mistake).

When the acid (super strong HCl, pH of 2) gets into the throat, it damages the soft tissues that have no natural protection against acid. A typical response is to constantly cough (or throat clear) to move the acid off the larynx.

Most LPR patients have 1 or more of the following symptoms: chronic cough (like you), chornic throat clearing, sensation of something stuck in the throat/"lump" in the throat. Some people also develop asthma-like symptoms that don't respond to asthma treatments. This happens because when the acid gets into the throat, it gets accidentally aspirated back down the other pipe - the windpipe and into the lungs, damaging the lung tissue.

But it's treatable, and despite what you read on this board, it does not require any tests at all to make a diagnosis. Instead, your doctor should go ahead and prescribe you the medication used to treat the condition. If you respond (improvement after about 30 days, though it can be earlier), it is sufficient to be considered a diangosis in itself. However, since you have had this condition for 15 years, they should schedule you for an endoscopy anyway - which is usually done under sedation, in which the doctor uses a scope to check the condition of your esophogous - looking for damage. However, the same medications that you will be on for LPR are used to treat a damaged esophogous, so you should absolutely go and start the medications now!

The medications are called Proton-Pump Inhibitors (PPIs) and they simply reduce the amount of acid your stomach produces. The less acid your stomach produces, the less that can escape and irritate your throat. Alas, it only treats the symptoms of the disease and not the cause, but it's the best we've got and can be very very effective.

Now this is the critical part - whatever PPI you choose to take, you MUST MUST MUST take 2 doses per day! Standard treatment for LPR is 2 doses, and most doctors do not know this, because they've learned that standard treatment for its sister condition, hearburn/GERD is 1 PPI dose per day. So it is probably going to be up to you to correct them if they are incorrect. If they resist, simply direct them to the U.S. government's pubmed database ([url]http://www.pubmedcentral.nih.gov/[/url]) where they can find citation after citation that confirms LPR must be treated with 2 doses of a PPI per day.
You can even search it yourself for "LPR" or "laryngeal reflux" or "laryngopharyngeal reflux" and pull up dozens of citations that describe the latest research and treatment.

In the U.S.A., we have 5 PPIs to choose from and they might have different names in your country. By prescription, we have Nexium, Aciphex, Prevacid and Protonix. Nexium is the latest drug on the market (2001) and though usually the most expensive here, is often the one that works when the others fail. It has a significantly different structure that my doctor says "allows more people to significantly metabolize it better". I've been on 2 doses of it per day for 4 years.

We also have an over-the-counter PPI (we can buy it without a prescription) called Prilosec. It used to be available by prescription, but went OTC when it lost its patent. Prilosec was the first PPI to ever be produced. It's maker, Astrazeneca, followed it up with Nexium in 2001. However, from reading the posts on this board over the last year, it seems that most people with LPR do not greatly benefit from Prilosec - it seems to be a better treatment for GERD. There are people with LPR on it - and seems mostly because it's a cheaper drug, but they aren't the ones I'm seeing who have achieved a good recovery, in general.

When you begin taking your PPIs, you need to consider the timing of your doses. Some people take them together first thing in the morning (like me) and many others take 1 dose in the morning and the other dose in the evening (because PPIs typically wear off after about 17 hours). You simply need to expermiment to find out what works best for you. My morning version works for me because I am a classic daytime refluxer - one of the hallmarks of LPR is the tendancy for a LPR patient to reflux and have symptoms mostly during the daytime when they are upright. As soon as I lie down, I stop coughing (no reflux when I am prone). This is the opposite of someone with GERD - who typically refluxes when lying down at night.
So for me, I need the double dose of my Nexium first thing in the morning when I wake up. If I stay up late I begin to feel it wear off, but as soon as I hop into bed, any breakthrough symptoms go away until I wake up in the morning.

And finally, you may need to experiment with which PPI you take. There are too many instances on this board where people have tried 4 or 5 of the PPIs before settling on the one that works for them. Not every PPI will likely work the same for you.

And since you haven't been treated before, it may take about 30 days for you to notice improvement after beginning the PPI regimen, so hang in there and keep going - because given time, these medications usually work! Sometimes improvement comes faster, but you've probably developed a lot of erosions in your throat over time, and just like a cut or scrape on your skin, those erosions will need a few weeks of being acid-free to heal!

I hope you get better - and please note that the PPIs may have different names in the U.K. I just dont' know what they are.