A 56-year-old woman comes to the office due to progressive asthma symptoms. The patient describes nighttime cough and wheezing that have increased in recent months. Sometimes she has to use her albuterol inhaler right after a meal. She also reports feeling tired each morning as she works late and has no time to relax after dinner. The patient has no dyspnea on exertion but says that her throat has been sore lately and describes hoarseness in the morning that clears during the day. She has gained 5 kg (11 lb) over the last 6 months. Her medical history is significant for bronchial asthma, type 2 diabetes mellitus, and hypertension. Medications include low-dose inhaled fluticasone, an albuterol inhaler, lisinopril, amlodipine, and aspirin with no change in her medications for years. Blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 16/min. BMI is 32 kg/m2. Lung auscultation indicates normal breath sounds without wheezing. Heart sounds are normal. Which of the following is the most appropriate next step in management of this patient?
Comorbid gastroesophageal reflux disease (GERD) is common in patients with asthma and can exacerbate asthma symptoms through microaspiration of gastric contents, leading to an increase in vagal tone and bronchial reactivity. This patient with asthma has several clues in her history suggesting comorbid GERD, including sore throat, morning hoarseness, worsening cough only at night, and increased need for her albuterol inhaler following meals. In addition, obesity increases the risk of developing GERD, and this patient's worsening asthma symptoms coincide with her recent weight gain. Other symptoms suggestive of GERD that are not present in this patient include dysphagia, chest pain/heartburn, and sensation of regurgitation.
Proton-pump inhibitor (PPI) therapy has been shown to improve both asthma symptoms and peak expiratory flow rate in asthma patients with evidence of comorbid GERD, and a PPI trial (eg, esomeprazole) should be initiated in this patient.
(Choice A) Benzocaine lozenges can provide temporary relief of throat pain but would not address the primary cause of the problem.
(Choice B) The anticholinergic effect of diphenhydramine is useful in the treatment of chronic cough caused by rhinitis in patients with upper airway cough syndrome (UACS), previously known as postnasal drip syndrome. This patient's symptoms are more suggestive of comorbid GERD than comorbid UACS (no rhinorrhea, no sensation of something "dripping" into throat).
(Choice D) Oral corticosteroids are used for acute asthma exacerbation (eg, dyspnea at rest, wheezing), which this patient does not have.
(Choice E) Aspirin-exacerbated respiratory disease occurs in patients with asthma and chronic rhinosinusitis. Symptoms include a sudden worsening of asthma and nasal congestion 30 minutes to 3 hours after ingestion of nonsteroidal anti-inflammatories. This patient does not have symptoms suggestive of significant nasal congestion.
(Choice F) Cough associated with ACE inhibitors may occur at any time during therapy (usually within 2 weeks of drug initiation). However, it would be unlikely to occur only at night and to be associated with wheezing and morning hoarseness.
Educational objective:
Comorbid gastroesophageal reflux disease (GERD) is common in patients with asthma and can worsen asthma symptoms as a result of microaspiration. In asthma patients with signs and/or symptoms suggestive of comorbid GERD, proton-pump inhibitor therapy has shown benefit in improving asthma symptoms and peak expiratory flow rate.