Is Empirical Treatment a Reasonable Strategy for Laryngopharyngeal Reflux? A Contemporary Review.

Is Empirical Treatment a Reasonable Strategy for Laryngopharyngeal Reflux? A Contemporary Review.:

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Is Empirical Treatment a Reasonable Strategy for Laryngopharyngeal Reflux? A Contemporary Review.

Clin Otolaryngol. 2020 Feb 25;:

Authors: Lechien JR, Bock JM, Carroll TL, Akst LM

Abstract

BACKGROUND: Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remains controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing.

OBJECTIVES: To review contemporary evidence that does and does not support empiric medication trials for presumed LPR.

METHODS: PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations, and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices.

RESULTS: The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non-specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one-third of patients remain non-responders. The use of hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) has benefits and limitations in objective diagnosis of LPR.

CONCLUSIONS: Use of PPIs for single-agent empiric medication trial does not account for possible non-responders with nonacid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII-pH testing up front is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.

PMID: 32097534 [PubMed - as supplied by publisher]