Drug treatments in laryngeal reflux disease Part 2

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 dietary and lifestyle changes, medical therapy, anti-reflux surgery) for laryngeal reflux.

Drug treatments in laryngospasm Part 1

On the contrary, many recent studies have demonstrated effectiveness in treating reflux symptoms and improving laryngitis. Reichel et al reported a randomized, double-blind, placebo-controlled trial of esomeprazole 20 mg twice daily for 3 months in patients with endoscopic symptoms and signs of reflux. larynx, which showed significant improvement in both symptoms and laryngeal examination. Similarly, Lam et al performed a prospective, randomized, double-blind, placebo-controlled study with rabeprazole 20 mg twice daily for 3 months in symptomatic patients and endoscopic findings of laryngeal reflux, leading to a significant improvement in symptoms, but not in the larynx. However, on the basis of a closer look at these two studies, Vaezi suggested that the significant improvement was indeed for heartburn symptoms and not for chronic throat symptoms.

Some observational and uncontrolled data recommend twice-daily PPIs for laryngeal reflux. Furthermore, several studies have shown that a higher percentage of patients improve their laryngeal symptoms after PPI therapy in patients with GERD than in patients without GERD. esophageal thickening. On the other hand, several studies evaluated that the presence of abnormal acid reflux on pH monitoring did not predict response to therapy.
Overall, considering that most of the evidence for treatment is based solely on uncontrolled open-label studies and the lack of high-quality evidence supporting treatment efficacy, the evaluation of optimal treatment for laryngeal reflux remains challenging. Furthermore, the dosage and duration of PPI treatment in laryngeal reflux represent current issues of debate. To date, whenever typical GERD symptoms are present in addition to extraesophageal symptoms and/or there is objective evidence of GERD by endoscopic or Reflux monitoring is a pragmatic clinical strategy when starting with 2 months of empiric therapy with twice daily PPIs.

If there is improvement in symptoms, it is recommended to gradually reduce the PPI once daily, then reduce the dose or decrease the duration of acid suppression. On the other hand, if such an empiric PPI test is not available, causes other than GERD should be explored through concurrent evaluation by ENT, pulmonologist, and allergist.
Treated patients with objective evidence of ongoing reflux as the cause of symptoms should be considered for additional treatment with anti-reflux therapies that may include esophageal sphincter inhibitors. under transient or surgical.

Traditional antacids are often used as an adjunct therapy to neutralize stomach acidity and help manage heartburn in patients with GERD. They are polysaccharides found in algae and transform into a gel when they combine with cations. In particular, they form a physical barrier to gastrointestinal substances, and have the advantage of being a non-systemic drug.
In a prospective, randomized controlled study, liquid alginate preparations (taken four times daily) were shown to be effective in the treatment of symptoms and signs of laryngeal reflux. It should be noted, considering that oropharyngeal and laryngeal cancers may represent laryngeal reflux complications, a statistically significant reduction in squamous cell carcinoma volume was observed in these subjects. hamsters receiving alginate before known carcinogen [7,12-dimethylbenzanthracene (DMBA)] and human pepsin application, compared with guinea pigs plotted with DMBA and human pepsin alone. Thus, alginate suspension provides protection from pepsin-enhanced tumor growth.
Alginate should be given after each meal and the last meal at night, and nothing should be taken after the nocturnal dose.

Heat-tolerant PPI patients with persistent reflux (nonacid or weak acid), as assessed by ambulatory 24-hour MII-pH monitoring, may benefit from reflux reducers or internal pain modifiers organs. Reflux reducers, including GABA B agonists and metatropic glutamate receptor antagonists, are believed to decrease the frequency of the lower esophageal sphincter, representing the main pathophysiological mechanism underlying reflux disease. gastroesophageal reflux.
In particular, a GABA B receptor agonist (i.e. baclofen) has been shown to reduce acid reflux occurrence, esophageal acid exposure, and improve reflux-related symptoms. However, their use in clinical practice is limited due to poor tolerability. Some researchers have tried to develop more effective and better tolerated compounds (eg, lesogaberan, ADX10059, arbaclofen) with no such results.
Visceral pain modifiers [i.e. tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs)] decrease perception of reflux episodes increasing the threshold of true perception administration, thus may exert beneficial effects in patients with esophageal hypersensitivity, as diagnosed through reflux monitoring in the case of normal acid exposure time and a positive correlation between symptoms and reflux. These observations, although preliminary, encourage the conduct of studies to evaluate the efficacy of visceral pain modifiers in patients with laryngeal reflux who tolerate optimal treatment. with PPIs.

The management of laryngeal reflux can be divided into lifestyle modification, medical treatment and/or surgery. Behavioral changes and lifestyle modifications are considered first-line treatments with the lowest chance of side effects. Weight loss, smoking cessation, alcohol avoidance, changes in eating habits, and elevation of the head during sleep should be recommended for the patient.
As for medical therapy, currently, treatment is focused on increasing the pH of the reflux substance, therefore, it is recommended to start with PPIs twice daily for a period of 8-12 weeks. Tolerant patients with objective evidence (reflux monitoring) of ongoing reflux as the cause of symptoms should be considered for alternative therapies, such as visceral pain modifiers or endoscopic anti-reflux surgery.

The surgical approach needs to be tailored to the individual patient and carefully considered. Upcoming results are available with speech therapy, but these results need to be evaluated in future trials. Surgery should be indicated in a select number of patients in whom massive regurgitation and ineffectiveness of the lower esophageal sphincter are demonstrated by esophageal pathophysiological assessments.

References
Irene Martinucci, Nicola de Bortoli, Optimal treatment of laryngopharyngeal reflux disease, Ther Adv Chronic Dis. 2013 Nov; 4(6): 287–301. Altman K., Prufer N., Vaezi M. (2011) A review of clinical practice guidelines for reflux disease: towards creating a clinical protocol for the otolaryngologist. Laryngoscope 121: 717–723 [PubMed] [Google Scholar]