2023-09-11 19:26:01
Chronic cough took center stage during the Congress session l’European Respiratory Society (ERS) entitled ” Conditions we are just dealing with the tip of the iceberg in primary care“(We only treat the tip of the iceberg in primary care).
“When it comes to chronic cough, GPs often feel helpless,” he told Medscape. Miguel Román Rodríguez, general practitioner and associate professor of family medicine at the Medical School of the University of the Balearic Islands, in Palma, Mallorca, Spain, and one of the session chairs. “General practitioners play a central role in the diagnosis of diseases such as chronic cough. We bring something that specialists do not: knowledge of the context, the family, the patient’s history,” mentioned the second president of the session, Hilary Pinnock, family physician and professor of primary care respiratory medicine at the University of Edinburgh, Scotland.
Understanding the many facets of chronic cough
Imran Satia, assistant professor at McMaster University, Hamilton, Ontario, Canada, guided this session’s participants through a comprehensive exploration of chronic cough. He first returned to the definition of this condition, emphasizing that it is defined by its duration, with chronic cough generally lasting more than eight weeks. I. Satia highlighted the common associations of chronic cough including asthma, nasal diseases and reflux diseases. Interested in epidemiology, he cited a meta-analysis indicating an overall prevalence of approximately 10% in the adult population, with significant regional variability: from 18.1% in Australia to 2.3% in Africa. The Canadian Longitudinal Study on Aging (Canadian Longitudinal Study on Aging, CLSA) notably revealed an overall prevalence of 16% at inclusion “The most common risk factor was smoking, but even among non-smokers, the prevalence reached 10%”, a added I Satia, emphasizing that it increased with age and changed depending on location. “The most common associated comorbidities were heart failure and hypertension, but also conditions related to chronic pain, mood and anxiety,” he explained. Mental health has been identified as a crucial factor in chronic cough, with psychological distress and depressive symptoms emerging as risk factors for developing chronic cough over the next three years, contributing to a 20% increase in risk.
Effective management strategies
I Satia proposed using algorithms to facilitate the management of patients suffering from chronic cough in primary care. He presented a Canadian algorithm that offers specific recommendations for primary and secondary care.
The primary care evaluation of the algorithm, Step 1, includes a comprehensive assessment of cough history (duration, severity, triggering factors, nature, location), cardiorespiratory, gastrointestinal and nasal symptoms, as well as use of ACE inhibitors and smoking exposure. Emphasis was placed on essential diagnostic tests, such as chest X-ray (to check for structural disease), complete blood count, and spirometry (with or without bronchodilator reversibility). Criteria for urgent referral include symptoms such as hemoptysis, weight loss, fever, or abnormal chest x-ray findings. “When checking cough history, GPs should always consider factors such as the presence of a dry or productive cough, mental health, presence of chronic pain, stroke and swallowing” , said I Satia, emphasizing the importance of documenting the impact of chronic cough on quality of life, professional life, social life and family life. “This is a question doctors don’t always ask. They may think these are not major issues, but recognizing their importance can help the patient,” he added.
Step 2 The algorithm focuses on treatment options tailored to specific diagnoses, such as asthma or chronic obstructive pulmonary disease. I. Satia called for caution, stressing that treatment should only be implemented if there is evidence of these pathologies. Additionally, he encouraged early consideration of cough hypersensitivity syndrome when patients exhibit coughing in response to low levels of mechanical stimulation.
Current treatments and future prospects
I. Satia presented an overview of existing treatments for chronic cough, highlighting their respective advantages and disadvantages. For example, talk therapy is a patient-directed approach with no side effects, but has issues with access, cost, and patient motivation. On the other hand, low-dose morphine provides rapid relief but is associated with problems such as nausea, stigma, and constipation. Regarding prospects for new treatments, I. Satia presented results from COUGH-1 and COUGH-2, pivotal phase 3 trials evaluating gefapixant, an orally administered peripherally acting P2X3 receptor antagonist. This drug, currently approved in Switzerland and Japan, has demonstrated a significant reduction in cough frequency compared to placebo, with rapid and long-lasting effects. “The estimated relative reduction for 45mg was 18.45% in COUGH-1 (12 weeks) and 14.64% in COUGH-2 (24 weeks). It should be noted that the reduction in cough is very rapid and sustained with gefapixant, but a reduction of 40% is observed in the placebo group”, commented I. Satia. The experts unanimously underlined the importance, for specialists and general practitioners, of effective communication in the management of chronic cough, involving both patients and their families. “As GPs, we are essential for managing common issues, but we are also essential for spotting the needle in the haystack: it is both extremely difficult and challenging, and we need the support of our colleagues”, concluded H. Pinnock.
I. Satia reported funding from Merck MSD, AstraZeneca and GSK; consultant fees from Merck MSD, Genentech and Respiplus; and speaker fees from AstraZeneca, GSK and Merck MSD.
This article was written by Cristina Ferrario and was first published on Medscape.com.
1694461828
#ERS #Chronic #cough #adopt #strategy
