Some Laryngopharyngeal Reflux Resists PPI Treatment

There are consequences of reflux in the esophagus, he added. “Pepsin, acid, stomach contents—they all have effects on the lining of the esophagus and the throat, such as swelling or other changes. Look in the esophagus for those things,” he said. “LPR is a continuum of reflux disease in my opinion, although there is some debate on this.”

If reflux is suspected, either based on physical evidence or partial response to medicine, some otolaryngologists advise doubling the dose of PPIs. “I do think that some people do better, but there’s no convincing evidence base behind that,” said Dr. Krouse. “Anecdotally, yes.”

Otolaryngologists sometimes add an H2 blocker at bedtime, such as famotidine (Pepcid) or ranitidine (Zantac), to boost the pharmacologic effect.

Another factor to consider, said Dr. Krouse, is that patients have often had the problem for a long time. “You can’t expect to fix it right away. It might need several months to see signs of improvement,” he said. Doctors need to be patient and use good clinical judgment. Dr. DelGaudio asks his patients to be patient. “I tell them they may notice improvement in the first few weeks, but really it takes two to three months to see effect.”

While PPIs are the standard of care, results from clinical trials with these drugs do not reliably support their use. A systematic review of PPIs in LPR found that combined data from the best designed studies—randomized, placebo-controlled trials—found no overall benefit from using the drugs (Laryngoscope. 2006;116:144-148). Severity and frequency of symptoms after treatment were not statistically different between the placebo and drug treatment groups.

Additionally, given the fact that LPR is a symptom-based, descriptive diagnosis, misdiagnosis may dilute any positive effects of PPIs. Still, the fact remains that no one’s ever shown a cost-effective benefit to PPI medications, said Mark Courey, MD, an otolaryngologist at the University of California San Francisco School of Medicine. “Physicians need to be responsible about cost-effective treatments,” he said. “LPR is difficult to confirm, and is often overdiagnosed.”

If Not LPR, Then What?

“LPR is a diagnosis that otolaryngologists love,” said Dr. Krouse, but other things can cause the symptom profile of LPR, including allergies, sinusitis, asthma or any chronic inflammatory airway disease. “LPR is common, but allergy affects 25 percent of the population. Patients with allergies frequently have very similar symptoms,” he added. “Patients could have both problems: LPR and allergic airway disease. I advise my residents: Don’t close your mind that LPR is the correct and only diagnosis.”