Drug treatments in laryngeal reflux disease Part 1

Posted by Doctor Mai Vien Phuong - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital.

Laryngeal reflux is defined as the reflux of gastric contents into the larynx and pharynx. There are limited results to evaluate the effectiveness of reflux treatments (including diet and lifestyle changes, medical therapy, anti-reflux surgery) for laryngeal reflux.

Dietary and lifestyle modifications are effective interventions for GERD, despite the fact that there are few robust published data. According to the treatment used in a UK county general hospital, dietary and behavioral modifications are also found to be very effective in managing laryngeal reflux.

Considering the poor sensitivity and specificity of all available diagnostic tests, an empiric treatment trial is the first step in confirming laryngopharyngeal reflux and treating it accordingly. However, there is no accepted regimen for the most effective treatment of patients with laryngeal reflux.
Since their introduction in the 1980s, PPIs have demonstrated the most potent inhibition of gastric acid secretion, showing a distinct advantage (for cure and symptom relief) compared with H2 receptor antagonists. Thus, H2-receptor antagonists have limited their role primarily to patients with nocturnal acidosis despite twice-daily PPI treatment, or for long-term management of symptoms. reflux on an 'as needed' basis. Prokinetic agents, although little evaluated, are generally considered not useful in laryngeal reflux.

Summary of various medical therapies in laryngopharyngeal reflux disease with proven or uncertain efficacy.

Abbreviations: GERD, gastroesophageal reflux disease; H2RA, a histamine-2 receptor antagonist; PPIs, proton pump inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCA, tricyclic antidepressant.

PPI therapy is considered the mainstay of care in patients with GERD; however, its effectiveness in the treatment of laryngeal reflux remains questionable.
In clinical practice, consistent with the assumption that the upper gastrointestinal tract is more sensitive to acid reflux than the esophagus, it is believed that patients with reflux-associated laryngitis require higher doses and trials. PPIs took longer to achieve improvement in laryngeal symptoms than those with typical GERD symptoms. On the other hand, placebo-controlled trials have not demonstrated any therapeutic benefit of PPIs. In 2006, a prospective multicentre randomized study, involving 145 patients with endoscopic symptoms and signs of laryngopharyngeal reflux, showed no benefit in patients treated with esomeprazole 40. mg x 2 times/day for 4 months versus placebo.
In addition, the Cochrane systematic review of 302 studies did not find any high-quality trials that met the inclusion criteria to evaluate the effectiveness of antireflux therapy for hoarseness. A systematic review and meta-analysis of randomized controlled trials failed to demonstrate superiority of PPIs over placebo in the treatment of suspected laryngeal reflux.
See also: Drug treatments in laryngeal reflux disease Part 2