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Gabapentin decreases cough in patients with refractory chronic cough

Clinical Question:
Is gabapentin effective in treating patients with refractory chronic cough?

Bottom Line:
In adults with refractory chronic cough, gabapentin improves cough-related quality of life and decreases cough frequency. However, once treatment is stopped, the cough tends to return. (LOE = 1b)

Reference:
Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial. Lancet 2012;380(9853):1583-1589.  [PMID:22951084]

Study Design:
Randomized controlled trial (double-blinded)

Funding:
Government

Allocation:
Concealed

Setting:
Outpatient (any)

Synopsis:
These Australian researchers evaluated nonsmoking adults with at least 8 weeks of cough that persisted in spite of trials of inhaled or oral corticosteroids, nasal corticosteroids, antihistamines, or proton-pump inhibitors. After a ton of baseline assessments (quality of life, cough severity, a variety of lung function tests, and so forth), the investigators administered gabapentin (n = 32) or placebo (n = 30) to the patients. The initial gabapentin dosage was 300 mg daily with a dose increase of 300 mg each day to a maximum dosage of 1800 mg daily unless the cough completely resolved or the side effects became intolerable. At the end of 6 weeks, 2 gabapentin-treated patients were lost to follow-up, 4 gabapentin-treated patients stopped treatment, and 4 placebo-treated patients stopped treatment. However, the researchers evaluated all enrolled patients (a true intention-to-treat analysis) to determine the main outcome: cough-specific quality of life. On average, the cough score improved by 2.5 points for gabapentin-treated patients compared with 1.1 points for placebo-treated patients. The authors report that a difference of 1.3 is the minimum clinically relevant difference. They further report that one only needs to treat 4 patients with gabapentin to achieve this degree of difference. Gabapentin-treated patients also improved in many other measures (cough severity, urge-to-cough score, and so forth). Additionally, gabapentin-treated patients had 22 fewer coughs per hour compared with 4 fewer coughs per hour in placebo-treated patients. Once the treatment stopped, however, the cough returned. In addition to concluding that gabapentin is an option in treating patients with refractory chronic cough, the authors state that central reflex sensitization is a relevant mechanism in chronic cough. Nonsense. Although this might be true, it is pure conjecture at this point and cannot be determined by this study. Just because we know a drug works in one fashion, we can not conclude that it's the only mechanism by which it works.

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