Dr. Mandel Sher Had A Fit!

Dr. Mandel Sher had a fit! – A coughing fit similar to the experience of people with Chronic Cough and patients at Center for Cough.  He had an upper respiratory infection five weeks ago and is experiencing residual cough.  Since his is related to a post-viral acute cough, Dr. Sher quieted his cough by slowly dissolving a menthol lozenge in his mouth. A chronic cough, on the other hand, is soothed by lozenges with pectin as the main ingredient because they are lubricating.  Different cough causes and triggers have different treatments.  It is important to know your specific cough profile.

Hard-Wired to Cough and Chronic Cough

Are you hard-wired to cough?  And if you are hard-wired to cough, then normal cough that everyone experiences and needs becomes exaggerated.  That means your cough mechanism is easily irritated and sets-off coughing spells. People who are hard-wired to cough suffer from Chronic Cough.  Dr. Mandel Sher is a Cough Specialist and one of the very few doctors in the Tampa Bay area who is specially trained to use an advanced diagnostic tool during an office visit to determine if you are hard-wired to cough.  Accurate diagnosis of cause is the key to developing an effective cough treatment plan.

A current school of scientific research and thought around Chronic Cough points to an overly sensitive cough mechanism, also known as Hypersensitive Cough Reflex, as the underlying cause of Chronic Cough.  A relevant discussion was presented by Eva Millgvist, M.D., Ph.D. in “The Problems of Treating Unexplained Chronic Cough” in the March 2016 issue of the journal Chest.  The article reports that chronic cough, similar to chronic pain and itch, is neurogenic mediated. In the case of Chronic Cough, this means that the nerve endings at the back of the throat become irritated and set-off a coughing episode. 

Dr. Mandel Sher is one of the nation’s leading doctors investigating neurogenic mediated cough.  Dr. Sher’s diagnostic approach concludes by identifying the underlying cause of your unique cough.  People who are hard-wired to cough may follow a cough treatment plan that includes speech therapy and a combination of prescription drugs such as chlorpheniramine extendtabs and gabapentin to cool down the cough.

If you have a cough that won’t go away, contact Dr. Mandel Sher today at Center for Cough:  727-393-8067.

Dr. Mandel Sher Presents Advanced Diagnostic Tool to National Physician Audience

Dr. Mandel Sher recently presented a seminar on Rhinolaryngoscopy  at the American Academy of Allergy, Asthma & Immunology in Los Angeles, California. Rhinolaryngoscopy is an advanced diagnostic tool used to identify the underlying cause of Chronic Cough.  Dr. Mandel Sher is specially trained in Rhinolaryngoscopy and one of the few doctors in the Tampa Bay area who uses rhinolaryngoscopy in the office to make a firm diagnosis of Chronic Cough or Upper Airway Disease. 

Rhinolaryngoscopy is in invaluable diagnostic tool for identifying the triggers and causes of chronic cough and upper airway disease” stated Dr. Sher.  Dr. Sher has performed thousands of rhinoscopies in Center for Cough and regularly teaches other physicians how to perform rhinolaryngoscopy.  Endoscopy or rhinolaryngoscopy of the nasal and sinus structures, back of throat and the voicebox (larynx and vocal cords) is an advanced diagnostic tool that enables Dr. Sher to clearly see sinusitis, allergic rhinitis, nasal polyps, deviated septum, infected or enlarged adenoids, layrngopharyngeal reflux (stomach acid attacking the voice box), vocal cord nodules and polyps, and “dancing” vocal cords – a sign of neurogenic cause of chronic cough. 

This simple and relatively non-invasive procedure is a cornerstone of the diagnostic approach used by the Center for Cough.  Diagnostic precision of underlying cause of Chronic Cough is the first step to Dr. Sher developing an effective cough treatment plan for each patient. 

Dr. Sher and his colleague, Dr. Gary Stadtmauer of CityAllergy in New York, New York collaborated on this program. 

Dr. Mandel Sher In North Carolina: New Concepts in Chronic Cough

Dr. Sher in North Carolina: Emerging Concepts in Chronic Cough “New Concepts in Chronic Cough”  presented by Dr. Sher to his North Carolina colleagues was just the invitation he needed to return to beautiful North Carolina.  Dr. Sher began his specialty training at Duke Health System in Durham, North Carolina, after graduating from Northwestern University’s medical school in Chicago, Illinois.  The scientific and medical community’s understanding of Chronic Cough causes and treatments are evolving rapidly and it was Dr. Sher’s pleasure to share these new concepts.     

Mandel Sher, MD, Medical Director of Center for Cough, spoke to the North Carolina Allergy, Asthma and Immunology Society’s annual meeting on Saturday, February 6, 2016 on “New Concepts in Chronic Cough”.  Dr. Sher is one of the nation’s leading investigators studying new scientific and clinical findings about the causes of Chronic Cough and effective cough treatments.  These new concepts in Chronic Cough have the promise of expanding our understanding of this debilitating medical condition and treating it effectively.

Chronic cough affects 12 to 15% of the population and has debilitating consequences:  Depression, Social Isolation, Fatigue, and Urinary Incontinence to name a few.  Dr. Sher spoke about the current unmet need in cough treatment and the promising cough treatments in the future.  Dr. Sher addressed the paradigm shift in the diagnostic and cough treatment approach to now focus on overly sensitive cough mechanism particularly in people who are hard-wired to cough. 

“The hypersensitive cough reflex is the primary cause of chronic cough triggered by multiple factors including viral respiratory infections, allergies, asthma and acid reflux”, Dr Sher told the group of North Carolina allergists.”





Positive Results in Chronic Cough Trial

Afferent Pharmaceuticals Announces Positive Results in Phase 2b Chronic Cough Trial

AF-219 Treatment Significantly Reduces Cough Frequency in Patients

SAN MATEO, Calif.–(BUSINESS WIRE)–Afferent Pharmaceuticals, a leader in the development of small molecule compounds targeting P2X3 for the treatment of poorly managed and common neurogenic disorders, such as chronic cough, today announced positive top-line results from its Phase 2b dose escalation clinical trial of AF-219 in chronic cough patients. AF-219 is a selective, non-narcotic and orally administered P2X3 antagonist that targets the mechanism by which certain nerve fibers become hyper-sensitized and can lead to chronic and debilitating symptoms. The results of this clinical trial will be presented at a scientific meeting in the future.

“Our promising Phase 2b results demonstrate AF-219’s potential to be a first-in-class therapy, with the potential to replace the current, often ad hoc treatments that have little impact on cough frequency or result in possibly serious side effects or carry abuse potential,” said Kathleen Sereda Glaub, Afferent’s chief executive officer. “With the robust reductions in cough frequency following AF-219 treatment confirmed in this second study, we are committed to a full development program to advance this non-narcotic treatment for the benefit of the many patients suffering from chronic cough.”

Jaclyn Smith, M.B., Ch.B., MRCP, Ph.D. and professor and honorary consultant in Respiratory Medicine, University of Manchester and University Hospital Manchester NHS Foundation Trust, a leading investigator in the field of chronic cough, said “Chronic cough has widespread effects on patients’ quality of life, and a new therapy with increased efficacy and substantially reduced adverse events will have a meaningful impact and address a significant unmet need. I am excited by the consistency of the findings demonstrated in the AF-219 program, and I look forward to the continuing progress of these efforts.”

Significant Efficacy and Improved Tolerability Shown With Lower Doses

The study randomized 29 chronic cough patients. Doses of 50 mg, 100 mg, 150 mg and 200 mg twice daily for 4 days demonstrated significant reduction in cough frequency, including at the lowest dose of 50 mg twice daily. Cough frequency was measured objectively utilizing a cough recording device, with periodic measurements following AF-219 treatment compared to a baseline recording.

All AF-219 doses, including the lowest dose of 50 mg twice daily, demonstrated a statistically significant reduction in awake cough frequency compared to placebo (p≤0.002).

AF-219 was generally well tolerated. The incidence of decreased taste acuity, as observed in the first study at 600 mg twice daily, was much less at the 50 mg dose. Only one patient discontinued treatment at any dose in the current study, due to the taste effect.

Afferent’s previous high-dose proof-of-concept trial demonstrated a 75% reduction in cough frequency (Intent-to-Treat population) in 24 refractory chronic cough patients with AF-219 treatment 600 mg twice daily for two weeks. In the first study, six of 24 patients discontinued treatment due to a change in taste acuity (published in the Lancet, March 2015; online November 2014).

About the Phase 2b Trial

The 29-patient randomized, double-blind, placebo controlled, Phase 2b crossover study was conducted at 10 clinical sites in the U.S. Patients were randomized to either AF-219 or placebo arms. Those in the treatment group received AF-219 50 mg, followed by a titration up to 100 mg, 150 mg and 200 mg, with each dose given twice daily for four days. Treatment period one was followed by a 3-5 day washout period. Patients were then crossed over to the alternate arm of the study and treated with either AF-219 or placebo for 16 more days.

Pathologic Cough – Debilitating & Potentially Chronic Neurogenic Disorder Affecting Millions

Cough is the symptom for which patients most often seek medical attention. Pathologic cough or non-productive cough serves no functional purpose, and can occur following an upper respiratory infection. In most patients, this cough manifests itself as an acute cough lasting a few weeks. However, in some patients, sensitized nerve fibers fail to return to a normal quiescent state, resulting in sub-acute or chronic cough lasting months to years. The prevalence of chronic cough is estimated to be over 10% of adults in the U.S. While an underlying etiology may contribute to cough in some of these patients (such as GERD, asthma, COPD, etc.), many patients are not well-controlled for their cough even with treatment for such underlying etiology, or with the addition of currently available cough medications.

P2X3 Receptors Role in Hyper-sensitization and Pathology

The P2X3 receptor, the target for Afferent’s lead AF-219, is predominantly expressed in nociceptive C-fiber primary afferent nerves that innervate most tissues and organs, including the skin, joints, and the hollow organs such as the airways and bladder. These primary afferent neurons are not important in normal physiological or defensive sensing processes, but rather become activated and sensitized under pathological conditions by a common cellular signal, ATP, such as following nerve injury, infection or inflammation.

P2X3 receptor-mediated sensitization has been implicated in inflammatory, visceral and neuropathic pain states, as well as airways hyper-reactivity, migraine, itch and cancer pain.

Afferent’s first-in-class compounds selectively target P2X3 channels in order to block the activation of these afferents by ATP.

About Afferent Pharmaceuticals

Afferent Pharmaceuticals is a clinical-stage biotechnology company and leader in the development of novel drugs for the treatment of a range of debilitating neurogenic disorders. These disorders affect millions of patients who suffer from chronic respiratory and urologic sensory pathologies as well as chronic pain and cardiovascular disorders, and who have limited, if any, treatment options. These chronic pathologies arise when certain nerve fibers become hyper-sensitized as a result of inflammation, distress, infection or tissue injury, and sometimes remain chronically sensitized for months and even years.

Afferent is developing molecules that selectively block P2X3, a purinergic receptor, which plays a key role in the sensitization of these nerves. Afferent’s lead molecule, AF-219, is a first-in-class P2X3 antagonist, and is being developed for the treatment of chronic cough. For more information on the company, please visit Afferent’s website atwww.afferentpharma.com.


Afferent Pharmaceuticals Amy Pfeiffer, 650-286-1276 info@afferentpharma.com or Media: Burns McClellan, Inc. Justin Jackson, 212-213-0006, Ext. 327 jjackson@burnsmc.com


What’s Causing You to Cough?

We all cough.  Cough is an important function.  But like many things, too much of a good thing is no good.  The first and most important step toward effective cough treatment is understanding what’s causing cough.  And there’s a meaningful difference between identifying the underlying cause of your cough and the triggers or irritants or stimuli that tickle your body’s cough mechanism and produce  cough.  Real and lasting success relies on addressing what’s causing cough rather than the symptom.

Dr. Mandel Sher and Center for Cough team accurately diagnose the cause and triggers of your unique cough. Accurate diagnosis is the foundation of an individualized and effective cough treatment plan.

Cough evaluation includes a thorough medical history and physical exam exploring your cough symptoms and their effects on your daily activities. Previous physician visits, laboratory testing, X-rays, and diagnostic procedures will be reviewed. Based on this evaluation, further testing may be performed at the initial visit using advanced diagnostic tools. These tools include:

  • Rhinolaryngoscopy
  • Pulmonary function studies
  • Pulmonary inflammatory testing (expired nitric oxide)
  • Allergy testing
  • Oropharyngeal pH (acid) probe

Precision cough diagnosis avoids a trial and error approach with cough treatments that prove to be ineffective.  Accurate diagnosis and targeted cough treatment also shortens the time it takes for people suffering with Chronic Cough to feel better.  More than 8 out of 10 Center for Cough patients demonstrate measurable improvement in their cough and life. 

Dr. Sher is a Cough Specialist.  He is the only doctor in the southeastern United States, and one of only a few in the nation, who focuses on being a cough doctor.  Dr. Sher and Center for Cough team have a comprehensive approach to cough diagnosis and cough treatment.  In almost all cases, cough evaluation and recommendation of cough treatment occurs during a single outpatient visit to the Center for Cough  office.

If you or someone you know suffers with Chronic Cough, contact Dr. Mandel Sher at Center for Cough: 727-393-8067.



Cough Treatment

Did you know that not all coughs are created equal? Different types of cough require different diagnostic approaches and different cough treatments.  So, when it comes to cough treatment, there is no universal solution.

To be effective, cough treatment must target the specific cause(s) and trigger(s) of your unique cough.  Do not waste time and money and expose yourself to risks or side effects with the wrong cough treatment.

Dr. Mandel Sher is a Cough Doctor.  He understands the debilitating impact of Chronic Cough on living life to the fullest.  As a Chronic Cough specialist, he and the Center for Cough team offer people suffering with Chronic Cough a comprehensive diagnostic and cough treatment approach.  At Center for Cough, Dr. Sher balances innovation with evidence-based medicine.  All his services are recognized by Medicare and other major insurance companies and are covered medical services.  Contact Dr. Mandel Sher if you or someone you know has a cough that won’t go away:  727-393-8067. 

Chronic Cough is a complex medical condition with multiple contributing factors.  Cough treatment for Chronic Cough involves medical detective work upfront to establish an individualized profile of your unique cough.  Then, a choreography of prescription and over-the-counter medications and voice exercises and therapy can begin.

A common cause of Chronic Cough is an overly sensitive cough mechanism that is easily irritated to produce cough.  This syndrome is called “hypersensitive cough reflex” in the medical literature.  The cough reflex has three components: neurogenic, inflammatory, and behavioral. Generally, medication aimed at cooling down the cough reflex is part of the cough treatment plan.

The importance of beginning with a precise diagnosis of the cause(s) and trigger(s) of your cough cannot be overstated.  A sequential, trial and error approach to cough treatment is often ineffective, wastes time and money, and includes unnecessary risks and side effects of the medication.  A comprehensive cough treatment approach expedites relief from cough and is based on each unique patient’s situation.