Editorial: breaking the cycle of cough in GERD—neuromodulators to the rescue? Authors’ reply

improvement of symptoms in both arms in patients with chronic cough who had not previously improved, there is concern that this model is benefiting from regression to the mean for symptom control. When patients with severe symptoms are enrolled in a study without a placebo arm, there can be improvement in symptoms that is independent of the intervention (Figure 1). Given a heterogeneous inclusion population, it is important to note that cough may not be triggered by acidic or non‐acidic contents, but rather reflux hypersensitivity. Ideally, outcome measures would include objective measurements of acidic and/or non‐acidic contents to show that the mechanism of action of these medications is through the oesophagobronchial axis or is reflux‐mediated (Figure 1). Without physiological objective outcomes data, we are left with improvement in symptoms but are no closer to a better understanding of the physiology of improvement. Prior studies also using subjective outcomes measures have shown improvement in chronic cough with gabapentin, baclofen and amitriptyline in three randomised controlled studies.5‐8 Lack of objective outcomes data prevents clarifying the physiological link between chronic cough and GERD. Despite these limitations, this was an important study on the use of neuromodulation for chronic cough and opens the door for future prospective studies on management. Are neuromodulators the rescue agent for those with chronic cough? Unfortunately, 42%‐47% of patients did not have complete improvement despite these interventions. Future predictive models will need to be designed to determine who will improve with neuromodulators and to identify those whose cough needs further investigation for alternative aetiologies and treatments.