Patient With a History of Bronchial Asthma, Chronic Sinusitis, Allergies, and Gastroesophageal Reflux Disease

Richard J. Martin, MD

Disclosures

April 13, 2004

Question

I have a 35-year-old patient with a history of bronchial asthma, chronic sinusitis (status post recent endoscopic sinus surgery), allergies, and gastroesophageal reflux disease (GERD), which do not seem to be alleviated with a combination of oral steroids, beta-agonists, salmeterol, or intranasal corticosteroids. He is constantly requiring codeinated cough suppressants, sometimes exceeding the amount approved. He can't tolerate benzoates. Please advise.

Maribel Aviles, MD

Response from Richard J. Martin, MD

The most common causes of chronic cough include asthma, sinusitis, and gastroesophageal reflux. Thus, the question regarding this patient is whether he is adequately treated for each process. Because oral steroids and short- and long-acting beta-agonists are being used, presumably for asthma control, the question is if he is either taking them as prescribed or using the inhaled medications correctly. Many patients have absolutely no idea how to use inhaled medications in regard to appropriate technique. The patient should be instructed and observed with the proper technique. Most often, teaching the appropriate technique is all that is needed. If he does have the appropriate technique, then I would suggest adding an inhaled steroid in combination with a long-acting beta-agonist (salmeterol/fluticasone [Advair] 500/50 mcg twice daily ). Additionally, a leukotriene receptor antagonist may also be tried in this patient in combination with his other medications for asthma. Finally, if the patient indeed has severe, uncontrolled asthma; has a positive, perennial allergen skin test or radioallergosorbent test and an IgE level above 30, that individual could be given a trial of omalizumab. This is a very expensive monoclonal antibody to use, but it may be effective in difficult-to-control asthma.

For control of the chronic sinusitis, in addition to the intranasal corticosteroids, the patient should be irrigating the sinuses at least twice daily with a saline preparation. The easiest to use is a preparation called Sinus Rinse with premixed saline packets -- 8 oz used 2-4 times daily should help keep the sinuses clear. Additionally, an oral decongestant and antihistamine may be helpful.

For GERD the patient should be aggressively treated with a proton-pump inhibitor, of which there are many on the market at maximum doses, and should be instructed on GERD preventive measures from diet to timing of eating, ie, nothing past 8 pm in the evening. Additionally, the head of the bed should be elevated on 4- to 6-inch blocks to prevent reflux from occurring at night. If the patient has severe reflux without benefit of the above-described treatment, then that individual should be considered for fundoplication if a hiatal hernia is present or marked reflux is objectively documented by pH probe monitoring.

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