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BackTable / ENT / Article
Laryngopharyngeal Reflux (LPR) Treatment
Taylor Spurgeon-Hess • Sep 19, 2023 • 1.2k hits
Laryngopharyngeal reflux (LPR) treatment and management is evolving, broadening its scope beyond just medications. Dr. Inna Husain, an otolaryngologist specializing in LPR, delves into the intertwined relationship between lifestyle and LPR, highlighting the nuanced role of individual triggers and the need for personalized interventions. While proton pump inhibitors (PPIs), like omeprazole, continue to be a cornerstone in treatment, concerns about their long-term use emerge. On the horizon, alginate therapies for LPR present an intriguing alternative, offering relief in a distinct manner with a natural treatment. As the field advances, so does the promise of novel and more effective treatments for LPR.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Lifestyle factors like diet, smoking habits, and timing of consumption play a pivotal role in LPR symptoms and management.
• Individual triggers for LPR symptoms can vary, making tailored recommendations crucial. Coffee, acidic foods, carbonated beverages, and late-night eating are common irritants linked to LPR.
• PPIs are beneficial for LPR treatment, especially in patients with classic GERD symptoms. Although, the efficacy of PPIs in treating LPR is variable and prolonged use can lead to dependency issues.
• A typical empirical treatment strategy involves a two-month trial with PPIs. To witness tangible benefits, an omeprazole dosage for LPR of 40mg is recommended.
• Tapering is crucial after the initial phase to minimize potential side effects. Abrupt discontinuation of PPIs can cause rebound heartburn due to an increased secretion of acid.
• Omeprazole's efficacy is maximized when taken on an empty stomach, ideally 45 minutes before a protein-rich meal. The administration of Pepcid is recommended during the night, given its potential anti-dysmotility properties.
• Alginate therapies, an LPR natural treatment unlike PPIs, work with the body's natural acid production to manage LPR symptoms. Upon interaction with stomach acid, alginates form a barrier, reducing reflux movement without suppressing digestive acid.
• It's recommended to administer alginate suspensions after meals, with an optional bedtime dosage for those with morning symptoms. Combining alginate therapies with other acid suppression medications is not advised, as alginates require acid for activation. There is no significant interaction of alginates with other medications, nor do they affect absorption.
Table of Contents
(1) LPR Treatment: Lifestyle Adjustments
(2) LPR Treatment: Proton Pump Inhibitors
(3) Alginate Therapies for LPR Treatment
LPR Treatment: Lifestyle Adjustments
The modern approach to LPR treatment goes beyond mere medication, delving deep into the significance of lifestyle modifications. Dr. Inna Husain highlights the necessity to discuss potential irritants to the larynx, such as diet choices, smoking, vaping, and even the timing of food and drink consumption. While certain foods and beverages—like coffee, acidic dishes, and late-night eating—are linked with LPR symptoms, the key lies in individual triggers. Thus, a blanket restriction is not always the answer. It's about balancing symptom alleviation with quality of life. If symptoms are bothersome, patients should consider what they might be willing to modify or give up.
[Dr. Ashley Agan]
Getting into empiric medical therapy, when I was in residency, it was PPI. The main thing would be okay, the good thing is your scope exam is pretty normal. We're not seeing anything that looks like cancer. This is probably LPR, because that's the waste basket diagnosis, so we're going to try PPI, you need to make sure you take it on an empty stomach at the beginning of the day. Here's some dietary modifications, yada yada yada. What's the latest paradigm? What are you doing for patients if they decide they want to hold off on that pH probe?
[Dr. Inna Husain]
Definitely, we talk about the effects of lifestyle on the throat. Lifestyle meaning what you're eating, drinking, when you're eating and drinking, and then smoking. Smoking, vaping, marijuana, all of those things. Symptoms are generally describing symptoms of laryngeal irritation. What irritates our larynx? Are there ways in your own personal lifestyle that you can make some of those adjustments? Coffee is usually a big one. Late night eating for a while. Especially in the summer, carbonated water is a huge issue, especially with the lovely flavors that exist and stuff.
That usually we talk about where in your own personal diet you can maybe make a few adjustments because everybody's triggers can be a little bit different. The decision to add on an antacid, again, I support it when it's needed. These are great medications. These have saved lives and improved the quality of life for many people. It's just the discussion should be why am I giving you an antacid or why am I recommending it? Definitely, if patients describe traditional GERD symptoms, like yes, I have heartburn a lot, feeling a lot of burning, that sort of thing. Then I say, "Yes, we should add on an antacid." I talk to patients about the idea that 50% of patients with LPR don't improve with an antacid or PPI. Again, the problem with part of this is how was the LPR initially diagnosed, but I'm very upfront with patients that, "Hey, there are these medications called proton pump inhibitors. I can't tell you that they will do anything for you, but it's definitely an option. Once we talk about the potential risk factors of taking them." For short-term course LPR treatments, most patients are open to giving it a try.
If they have any acid reflex symptoms, I definitely recommend it. If they don't have acid reflux symptoms, then I offer it, say we can try it, or your alternative would be something known as an alginate suspension which tries to address more of the mechanical reflux component of it. Everybody gets the recommendations for the diet behavior, smoking, vaping, all of that stuff.
[Dr. Ashley Agan]
Yes. For the lifestyle modifications, when you talk to people about taking away coffee, sometimes I get that look like don't take away my coffee. Is it completely zero coffee or no caffeine at all, or can it be like, okay let's just limit it to one cup in the morning, or is everybody different?
[Dr. Inna Husain]
What I say with that is, when I've scoped you and I've ruled out any big bad things we have a really heart-to-heart conversation here about this is quality of life which means the ball is in your court. Raise your hand if you've ever had LPR symptoms, and I raise my hand like I get LPR all the time, and that's why I feel very comfortable talking to patients about this in a realistic manner. If you enjoy something and it brings you joy whether that's your morning coffee, if that's Friday night barbecue whatever it is, put it into context of what you're feeling. You clearly came to see me, because something was bothering you. I'm trying to provide you reassurance, help be a guide here for your journey, but this is all quality of life.
We have our worrisome characteristics when we talk about reflux which our GI colleagues are great at handling. We've scoped the larynx, we've taken a look at it. This is all quality of life now, so if you want to give yourself the best chance of not having these symptoms, then yes, that coffee has to go, but I also understand that quality of life comes in many different forms, and so if that morning cup of coffee, reading The New York Times is what gets you through your day, it's okay. We're not trying to take away everything here. We're just trying to guide you.
[Dr. Ashley Agan]
Just kind of equip them with that information that like, "Oh, if you feel a little bit more phlegm after your coffee the morning, just be like, 'It was worth it.'" [laughs] Or it wasn't.
[Dr. Inna Husain]
Exactly.
[Dr. Ashley Agan]
When you think about the lifestyle modifications, the biggest offenders from a diet standpoint, would it be the same things we think about as we do things that cause heartburn; coffee, acidic beverages, tomato-based, think of Italian food like pizzas and stuff like that.
[Dr. Inna Husain]
Definitely. I mean, it's definitely the acidity in the food. So citrus is a big one, cooked tomatoes. I try to explain to patients it still irritates your throat on the way down. That's why you still have to do that even if you're doing something like an acid suppression trial because the PPI doesn't work on the way down. It only helps once it hits the stomach, so that all has to go hand in hand.
[Dr. Ashley Agan]
You mentioned the late-night eating, is there a particular number that you give patients to shoot for as far as I want you to stop eating two hours before you lay down or is there a guideline around that?
[Dr. Inna Husain]
Yes, I generally tell them about two to three hours. Now, this gets more complex with some of our more medically complex patients or diabetics or elderly who probably have a little bit more slowing in the GI track, but generally the initial [unintelligible 00:29:15] is two to three hours.
[Dr. Ashley Agan]
As far as the PPI therapies, I will frequently have patients ask me about the safety of being on that for long term. I think short trials are helpful because if it does help, it allows us to say, okay, that is what's going on. Then if it does help, does that mean we're going to continue that therapy indefinitely, and is that safe?
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LPR Treatment: Proton Pump Inhibitors
PPIs remain a valuable tool for LPR treatment, targeting acid suppression to alleviate symptoms. They are especially helpful for those exhibiting classic GERD symptoms. For tangible benefits, an omeprazole dosage for LPR treatment of 40mg is recommended. However, the efficacy of PPIs varies, and up to half of LPR patients might not benefit. While they do offer notable benefits, their long-term use raises concerns, particularly when extended beyond a decade, leading to potential chronic dependency. Striking a balance in treatment involves a two-month empirical trial with PPIs, followed by a carefully tailored tapering strategy. Such an approach ensures optimal symptom management, while mitigating side effects, notably rebound heartburn from abrupt cessation.
[Dr. Inna Husain]
Big concern over acid suppression over the last couple of years and it's made its way into popular culture and media and stuff as well. Very honest with patients, I'm like, "Listen, proton pump inhibitors are awesome drugs for what they do." They really suppress acid and there's a whole population of patients that benefit from this. When we're doing something empirically trying, there's going to be the potential for some side effect, all drugs, every drug out there will cause some potential side effect. My initial trial is usually one to two months and the reason I say one to two months is it really depends on the severity of the symptoms patients are having, so if they're really severe, I want to see them in a month as opposed to more general things and I space it out to about two months. I tell patients that we would expect something to be different by that one to two-month mark. Now everything is probably not going to be gone, but you would expect to see some result. If there is no result, then I do not think you need acid suppression. That's a fair trial. If there is some response, then we really talk about, am I concerned about you being on this longer or can we push it a little bit?
That's really based on underlying medical conditions and that sort of thing. When we talk about the side effects of proton pump inhibitors, we're really talking about the side effects of acid suppression and we know that our bodies need acid. Acid is really good. It just needs to stay where it needs to stay, so as long as it stays where it's in the stomach, it helps with digestion, absorption of calcium, magnesium B12, that's all fantastic. Now, the tricky part of all this is what does long-term mean? When is it long-term? Is that like a year? Is that two years? We mentioned the medical records and having patients on proton pump inhibitors, people don't even know they're like 10 years, 15 years. That's really a problem because 10 to 15 years of chronic suppression, you can't get those patients even off of PPIs at that point. When I talk to patients about long-term, again, I'm very upfront being like the literature says that there's potential for these side effects, but it does not tell us what long-term means. I would say for you, we would talk about doing this course of LPR treatment or this type of follow-up with the idea being that we should try to get people off of these medications almost 100% of the time.
[Dr. Ashley Agan]
At what point are we talking like, months or years, or when do you say like, "Okay, we need to get you off of this."
[Dr. Inna Husain]
Usually what I do is when at that two-month follow-up with patients, we talk about it. So we actually talk about should we try tapering you off? Because often when I first start and I'm doing an empiric trial I'll put them on a high dose because I'm like, "If we're going to do this, let's do this." Let's go 100% into this acid suppression for a short period to really see if there's any effect. At that two-month mark, I definitely want to start bringing you down. When I mean high dose of omeprazole, I mean like 40 milligrams. Usually, I do Omeprazole. I've transitioned away from the BID twice a day and instead doing a high dose of Pepcid at night to get that dual coverage, so definitely at the first follow up we talk about coming down on the dose now. We start tapering right off the bat and then we talk about-- we can do this slowly over a few months if you really, a lot of patients come to me and they're like, "I want to get off of the medication now." Then we go a little faster with the idea being that you may need to restart it again and then we would bring you off again. When we talk about chronic disease or illness, you talk a lot about it's unlikely to be a one time and then you'll never feel it again, but if you do notice again, we can restart it.
[Dr. Ashley Agan]
What is your dosage for your Pepcid?
[Dr. Inna Husain]
I do 40 as well. 40 for the initial trial. I'm like, "If we're going to do it, let's make sure it's not, the dose is too low." I see lots of patients being put on things like 20 milligrams that's too low, that's fine for heartburn, but if we're trying to talk about extraesophageal symptoms and we want to just do an empiric trial for short term, let's put you on a higher dose and then bring me down.
[Dr. Ashley Agan]
40 omeprazole in the morning, 40 Pepcid in the evening for one to two months. Does it matter as far as taking the omeprazole on an empty stomach? Is that important?
[Dr. Inna Husain]
Yes. You want to definitely take it empty stomach. I usually tell patients about 45 minutes before they eat. Usually, breakfast and ideally the breakfast would have something like protein in it to help activate the pumps that the PPI is then turning off. Again, if we're going to take it, we want to do a decent dose and we want to take it properly to give the drug the best chance of helping. Pepcid works best at night, actually, so after meals and there are some studies that show that it actually has some anti-dysmotility properties, a mild effect on that as well, so I usually do the Pepcid at night.
[Dr. Ashley Agan]
Got you. For patients wanting to get off these medications or let's say you've done your trial and it's time to come off. Correct me if I'm wrong, but it's important to taper because if you decided one day, I'm not going to take any of these medications anymore, you didn't get a rebound hypersecretion of acid. Is that still correct?
[Dr. Inna Husain]
Yes, that's correct. The longer that you've been on it, the more prominent that effect will be and that's why patients will say, "I tried to stop it but I need it because I got heartburn." I'm like, "Well, I don't really know that that's true, but you definitely felt heartburn because of the rebound." I usually tell patients you might have up to five days of rebound heartburn, so to help prevent that rebound heartburn, which can be very uncomfortable, let's taper you down. We generally do half, so we'll go from 40 to 20 and then I'll do 20 and every other day maybe add an extra Pepcid if they need it, customize that part for patients, give them some options. We definitely want to taper so that you don't get rebound heartburn symptoms.
[Dr. Ashley Agan]
If during the taper, if they start to experience their laryngeal symptoms, again, whether it be the mucus or the throat clearing or whatever at some point you say like, "Okay, we're going to hold this dose for a little while and then maybe again, try to taper down a little bit later." How does that work?
[Dr. Inna Husain]
Exactly. That's how we do it. Again, as your tapering symptoms start to come back, I talk to them about your options are to either go back to the dose that was taking care of your symptoms with the understanding that we're doing this with acid suppression or see how you feel. If they're back but they're not that bothersome and you feel comfortable, then let's continue the tapering, so definitely customize it at that point.
Alginate Therapies for LPR Treatment
Alginate therapies offer an innovative solution to LPR treatment and management. Unlike PPIs that suppress acid production, alginates utilize the body's natural acid presence. Upon ingestion, the alginate interacts with the stomach's acid, forming a protective barrier. This barrier acts to minimize reflux movement, thereby potentially alleviating throat symptoms, without inhibiting digestive acid. For people seeking an LPR natural treatment option, alginate suspension may be a good option. It is typically administered post-meal to counteract acid production spikes, they can also prove beneficial when taken before bedtime for patients experiencing morning symptoms. Clinicians should note that while alginates are generally well-tolerated, the original Gaviscon contains significant sodium, and potential GI side effects exist. Furthermore, in the evolving landscape of LPR treatment, upcoming developments like anti-pepsin treatments, leveraging specific HIV medications, signify promising advancements.
[Dr. Ashley Agan]
With the alginate therapies, I think I was introduced to the alginate maybe a few years ago, which I really like. I've noticed more and more that patients are having more of a negative feel about being on PPIs and with the alginate therapies it's meaning like Gaviscon, and there may be others, but it's a different type of medication, different mechanism of action that I think people are a little bit more open to. Can we switch gears and talk about those and how they work?
[Dr. Inna Husain]
Yes. Natural is the way most people trend towards now, natural is considered better. So the alginate suspensions offer a good option for wanting to take something more than not drinking coffee but trying to lean towards the more natural aspects of it. I think it also makes sense to patients when you talk about how an alginate suspension works because again, I'm saying reflux is contributing to your symptoms. I didn't say acid is contributing to your symptoms. I said reflux.
With these alginate suspensions, they use the mechanism of normal acid production to be activated. Your normal acid is in your stomach, you take an alginate suspension, it hits that normal acid that's meant to be there and creates a raft or a barrier to help reduce the amount of movement or reflux that's happening. Again, I'm not suppressing your acid for digestion and all of that but we're trying to limit the amount of movement that's happening to hopefully help your throat symptoms.
[Dr. Ashley Agan]
How do you dose that? What do you recommend for patients? Just taking it after they eat or in the evenings or?
[Dr. Inna Husain]
Usually after meals because the acid production gets revved up during mealtime and that's what we're really trying to limit the movement of. So usually after meals, sometimes they'll throw in a bedtime, especially if they have a lot of morning symptoms like the morning mucus, morning throat clearing, or if they're waking up at night because of symptoms.
[Dr. Ashley Agan]
Are there any contraindications or interactions that we need to be aware of or careful with when using those medications?
[Dr. Inna Husain]
Yes, generally, I don't use them with other forms of acid suppression because again, they need acid to go into suspension. When I first started, I would give them hand in hand, but I stopped doing that. It's kind of you pick which pathway you want to be on, acid suppression or alginate suspension. Not too many contraindications. Some of them, like the original Gaviscon does have a lot of sodium in it, so that's one thing to be mindful of. I've had a few people have some lower GI issues with it. I think with any GI medication that's possibility for the lower GI issues exist like diarrhea and colitis and things like that, so I tell patients to look out for that sort of stuff, but generally, they're well tolerated.
[Dr. Ashley Agan]
They shouldn't interact with any other medications that they're taking or affect the absorption of them really. Right?
[Dr. Inna Husain]
Yes, they really shouldn't. No.
Podcast Contributors
Dr. Inna Husain
Dr. Inna Husain is the medical director of laryngology with the CCNI Network and Community Hospital in Munster, Indiana.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, January 3). Ep. 83 – Laryngopharyngeal Reflux [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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