Treatment of chronic posterior laryngitis with esomeprazole

Treatment of postnasal drip with proton pump inhibitors: a prospective, randomized, placebo-controlled study

BACKGROUND

Patients commonly present with complaints of postnasal drainage (PND) without objective evidence to support a sinonasal or infectious etiology. PND has been attributed to extra-esophageal reflux (EER), and an empiric trial of antireflux medication often is used to treat PND and associated symptoms. This study was performed to (1) evaluate the relationship between symptoms of EER and PND and (2) assess the efficacy of proton pump inhibitors (PPIs) in the management of PND.

METHODS

Patients with a chief complaint of PND without objective evidence of sinonasal inflammatory disease were enrolled in a prospective, double-blinded, randomized placebo-controlled trial using rabeprazole, 20 mg, orally twice daily or placebo for 90 days. Subjects completed two-site 24-hour pharyngeal pH probe monitoring before treatment. Outcome measures included pre- and posttreatment visual analog scales for PND symptoms, reflux symptom index, and reflux finding score (RFS).

RESULTS

Forty-seven patients were enrolled (mean age, 55 years)-21 patients in the PPI group and 26 in the placebo group. Fifty-six percent of subjects had pH probe confirmed EER using a cutoff of pH < 5.0. Baseline symptom measures between subjects with and without EER were not different. Compared with placebo, subjects receiving rabeprazole reported significant reduction in PND frequency (p = 0.0180), hoarseness (p = 0.0164), and chronic cough (p = 0.0204). The RFS decreased slightly in the placebo group (p = 0.1490) whereas it increased slightly in the PPI group (p = 0.5235). This difference between groups was significant (p = 0.0272).

CONCLUSION

Although 50% of subjects had evidence of EER, there was no difference in baseline symptoms between subjects with and without. Our findings support the potential benefit of PPI therapy for reducing PND frequency, hoarseness, and chronic cough, and confirm a placebo effect for other laryngopharyngeal reflux symptoms. The effect on laryngeal findings is mixed and patients may experience symptomatic improvement before changes in laryngoscopic appearance.

Gene expression changes of inflammatory mediators in posterior laryngitis due to laryngopharyngeal reflux and evolution with PPI treatment: a preliminary study

HYPOTHESIS

Standard of care in laryngopharyngeal reflux (LPR) is acid suppression therapy. Its treatment efficacy and mechanism of action are not well documented. No objective study investigating the molecular patterns of inflammation in LPR or in response to proton pump inhibitor (PPI) treatment has been accomplished. We hypothesized that gene expression levels of mediators of inflammation -- interleukin 6 (IL6), interleukin 8 (IL8), interleukin 1a (IL1a), interleukin 1b (IL1b), transforming growth factor beta 1 (TGFbeta1), vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF2), and tumor necrosis factor alpha (TNFalpha) -- in posterior larynx tissue would be increased in those with diagnosed LPR and would be then reduced with PPI treatment.

STUDY DESIGN

Prospective uncontrolled trial.

METHODS

Biopsies from the posterior larynx were taken from 25 participants with LPR before and after a 10-week period with rabeprazole (40 mg). RNA isolation and real-time PCR was used to measure gene expression levels.

RESULTS

No significant differences were measured for any of the cytokines, either for the entire participant group (n = 25) or for the subset of participants who did not have a previous history of PPI usage (n = 15). In those participants who had a history of PPI usage (n = 10), a significant increase in gene expression levels post medication was measured for TGFbeta1 (P = .0396), VEGF (P = .0216), IL8 (P = .0297), after adjusting for compliance, subjective improvement, and reflux severity.

CONCLUSIONS

Our findings are provocative and speak to the unresolved understanding of the pathophysiology of LPR, its diagnosis, and its differences from gastroesophageal reflux disease.

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update

BACKGROUND AND AIMS

Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed.

METHODS

A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded.

RESULTS

GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials.

CONCLUSIONS

Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.

Review article: The laryngological manifestations of reflux disease; why the scepticism?

BACKGROUND

Despite increasing clinical and experimental evidence of its existence, otolaryngological manifestations of reflux disease remain controversial, concerning diagnosis as well as treatment.

AIM

Proper understanding of laryngopharyngeal reflux disease (LPRD).

METHOD

Review of literature.

RESULTS

Scepticism concerning LPRD is based upon differences between gastro-oesophageal reflux disease and LPRD; lack of specificity and sensitivity of diagnostic tests to confirm LPRD; non-specificity of laryngological symptoms, which are difficult to distinguish from other causes of upper respiratory tract inflammation; non-specificity of laryngological signs in laryngoscopy, with high intra- and inter-observer variability in evaluation; diagnosis of LPRD is essentially only based on a combination of diagnostic signs and symptoms, which cannot be attributed to other pathology; slow, or sometimes lack of, response of LPRD symptoms to proton pump inhibitor (PPI) medication and lack of evidence concerning efficacy of PPIs in placebo-controlled trials.

CONCLUSIONS

LPRD remains a diagnosis by exclusion and resolution of symptoms following 4-month trial of 40 mg PPI twice daily is, for all practical purposes, considered proof of the initial diagnosis. However, non-response does not exclude LPRD as PPIs have no influence on noxious non-acid components of the refluxate.

Lipid laden macrophage indices and reflux finding score in canine gastroesophageal reflux model

Laryngeal exposure to acid and aspiration of gastric contents may lead to severe respiratory disorders. This study utilizes the canine model of Gastroesophageal reflux (GER) to identify whether lower esophageal dysfunction is associated with upper and lower airway pathology.

MATERIALS AND METHODS

Five mongrel dogs underwent GER-creating surgery (partial cardiomyectomy). Laryngeal reflux finding score (RFS), lipid-laden macrophage index (LLMI) and BAL fluid cell differential were obtained before and after surgery.

RESULTS

Partial cardiomyectomy in dogs significantly increased the Reflux index (RI) from 0.38 +/- 0.21% to 7.56 +/- 2.89% (P = 0.048), the duration of the longest reflux episode (DLRE) from 1.22 +/- 1.19 min to 66.2 +/- 42.03 min postoperatively (P = 0.049) and the total number of episodes in 24 hr from 2.06 +/- 1.03 to a postoperative value of 19.24 +/- 4.79. There was no statistically significant change in values for RFS, LLMI, and BAL fluid cell differential after the induction of GER.

CONCLUSIONS

Acid reflux to the proximal esophagus of this animal model did not cause laryngeal exposure to acid or aspiration of gastric content. The results of this study suggest that presence of GER, secondary to lower esophageal dysfunction is not necessarily associated with upper and lower airway pathology.

Monitoring of gastric acid suppression in patients with extraesophageal reflux disease

OBJECTIVE

Response to acid suppressive therapy varies in patients with extraesophageal esophageal reflux disease (EERD). Inadequate suppression of gastric acid may contribute to the observed differences in the response to the treatment. The aim of this study was to evaluate suppression of gastric acid in EERD patients being treated with acid suppressive therapy.

METHODS

Charts of patients with EERD who underwent dual channel 24h esophageal pH monitoring while receiving acid suppressive therapy between January 2002 and June 2004 were reviewed. Suppression of gastric acid was determined based on the number of acid reflux episodes, esophageal acid exposure, and acid clearance time.

RESULTS

Twenty patients (12 male, 8 female, age range: 2-19 years) were identified. Esophageal pH monitoring was within normal limits, documenting complete acid suppression in nine patients (45%). Increased numbers of acid reflux episodes were observed in seven patients. In four patients, the number of acid reflux episodes was normal in spite of incomplete acid suppression. However, other abnormal pH monitoring parameters included delayed acid clearance in three patients and increased acid exposure time in three. The majority of patients also showed alkaline reflux.

CONCLUSION

Esophageal pH monitoring documented incomplete acid suppression in this group of infants, children, adolescents and teens with EERD. Monitoring of gastric acid suppression can be useful in guiding the follow-up of EERD patients who receive acid suppressive therapy.

Effects of esomeprazole on acid output in patients with Zollinger-Ellison syndrome or idiopathic gastric acid hypersecretion

OBJECTIVES

To evaluate the efficacy and safety of oral esomeprazole in the control of gastric acid hypersecretion in patients with hypersecretory states.

METHODS

In this 12-month, open-label, multicenter study, acid output (AO) was evaluated at baseline, day 10, and months 3, 6, and 12. The starting dose of esomeprazole was 40 mg or 80 mg twice daily. On day 10, patients with controlled AO were maintained on the same dose, while those with uncontrolled AO had their doses increased (maximum dose 240 mg/day) until control was attained. Esophagogastroduodenoscopy (EGD) was performed at baseline and at 6 and 12 months. Safety and tolerability were assessed throughout the study by EGD, gastric analysis, and adverse events.

RESULTS

Twenty-one patients (19 with Zollinger-Ellison syndrome [ZES], 2 with idiopathic gastric acid hypersecretion [IGH]) completed the study. Of the 20 patients with controlled AO at day 10, 18 (90%) had sustained AO control for the rest of the study. At 12 months, AO was controlled in 14 of 16 patients receiving esomeprazole 40 mg twice daily, in all 4 patients receiving esomeprazole 80 mg twice daily, and in the 1 patient receiving esomeprazole 80 mg 3 times daily. At 6 and 12 months, no patient had endoscopic evidence of mucosal disease. Esomeprazole was well tolerated; 1 patient had a serious adverse event (hypomagnesemia) attributed to treatment that resolved with magnesium supplementation during continued treatment.

CONCLUSION

Esomeprazole in appropriately titrated doses controls AO over 12 months in patients with hypersecretory states and is well tolerated.

Extra-esophageal manifestations of gastroesophageal reflux

Gastroesophageal reflux disease (GERD) is a common medical condition affecting approximately 35-40% of the adult population in the western world. The role of GERD in causing extra-esophageal symptoms including laryngitis, asthma, cough, chest pain, and dental erosions is increasingly recognized with renewed interest among gastroenterologists and other specialists. Direct injury by mucosal contact, and vagally mediated reflex from distal esophageal acid exposure are the two possible mechanisms by which reflux-related extra-esophageal tissue injuries may occur. Several investigational techniques may be used to diagnose gastroesophageal reflux; however, because of the poor sensitivity of endoscopy and pH monitoring, and the poor specificity of laryngoscopy, empiric therapy with proton-pump inhibitors (PPI) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. In those who improve with such therapy, it is likely that GERD may be the cause of the extra-esophageal presentation. In those who are unresponsive to such therapy, other diagnostic testing such as impedance/pH monitoring may be reasonable in order to exclude continued acid or weakly acid reflux. However, PPI-unresponsive patients usually have causes other than GERD for the extra-esophageal symptoms and signs.

Extra-esophageal GERD: clinical dilemma of epidemiology versus clinical practice

Gastroesophageal reflux disease (GERD) is a common disorder. A significant percentage of patients with GERD may experience extra-esophageal manifestations, such as asthma, cough, and laryngitis. Epidemiologic studies consistently demonstrate strong associations between GERD and potential extra-esophageal manifestations. However, randomized controlled studies evaluating the use of proton-pump inhibitors for treatment of extra-esophageal GERD have inconsistent results. In asthma, few randomized controlled studies have shown improvement in objective measures, such as forced expiratory volume or peak flow. For chronic cough, studies are all small and have not demonstrated consistent improvement with acid suppression. Even a recent well-designed large randomized controlled study in laryngitis demonstrated no difference in resolution of symptoms with acid suppression. Given the examples from the literature, the current treatment of extra-esophageal symptoms with acid suppression is controversial. Although improvement in symptoms has been shown in case series, it has not been consistent in randomized controlled studies. We offer potential explanations for the discrepancy between the epidemiologic associations and the lack of response to therapy in clinical trials.

Impact of different pH thresholds for 24-hour dual probe pH monitoring in patients with suspected laryngopharyngeal reflux

OBJECTIVES

The gold standard test for laryngopharyngeal reflux is 24-hour pH monitoring, which determines the reflux area index with a pH threshold of less than four (i.e. the reflux area index four). However, refluxed pepsin is able to cause laryngeal injury at pH levels above five.

STUDY DESIGN

Prospective study.

MATERIALS AND METHODS

In order to establish normative values for a reflux area index with a pH threshold of less than five (i.e. the reflux area index five), 29 healthy volunteers underwent pH monitoring. In 45 patients with suspected laryngopharyngeal reflux, reflux area index four and reflux area index five were determined by pH study.

RESULTS

In healthy volunteers, the reflux area index five was 72.6 (95th percentile). In 29 of 44 patients, laryngopharyngeal reflux was diagnosed due to a reflux area index four of greater than 6.3. However, the reflux area index five revealed laryngopharyngeal reflux in six more patients.

CONCLUSIONS

For exact analysis of pH monitoring results, two pH thresholds (less than four and less than five) must be considered. Further studies with a larger number of healthy volunteers are necessary in order to reveal normative values for the reflux area index five parameter.

Exclusion of pH artifacts is essential for hypopharyngeal pH monitoring

BACKGROUND

Published yields of pH monitoring for suspected laryngopharyngeal reflux (LPR) vary greatly. Hypopharyngeal pH artifacts may be responsible for these inconsistencies.

OBJECTIVE

To determine the impact of potential artifacts on pH monitoring of the hypopharynx and esophagus.

METHODS

Patients with suspected LPR were prospectively studied. Single-catheter, triple-sensor pH monitoring was performed off antireflux therapy. Subjects recorded meal times and marked liquid swallows outside of meals on the data recorder. Results were analyzed by excluding six potential pH artifacts individually and all together. Positive pH test was defined as three or more reflux episodes in hypopharynx, total percent of time pH less than 4 was 1.0% or greater in the proximal esophagus, and total percent of time pH less than 4 was 4.2% or greater in the distal esophagus. Wilcoxon rank sum and chi-square tests were used.

RESULTS

Thirty-eight subjects (24 females; median age, 47 yr) completed the study. A total of 2,225 hypopharyngeal pH drops less than 4 were identified; 48% were short pH drops at less than 5 seconds, 17% within meal periods, 16% liquid swallows outside of meals, 16% isolated proximal pH drops, 12% pH out of range, and 5% pH drift. Eighty percent of the hypopharyngeal pH drops were at least one of the potential pH artifacts. The yield of the hypopharyngeal sensor was reduced by 45% (from 92% to 47%) after all potential pH artifacts were excluded. Yields of proximal and distal esophageal pH sensors were reduced by 19% and 8%, respectively, significantly less than the hypopharyngeal sensor (P < .01).

CONCLUSIONS

Patients should record all liquid swallows outside of meals. It is essential to exclude all potential artifacts for hypopharyngeal pH monitoring in patients with suspected LPR.

Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy

BACKGROUND AND AIMS

There is growing evidence that gastroesophageal reflux disease (GERD) may cause typical laryngeal/pharyngeal lesions secondary to tissue irritation. The prevalence of those lesions in GERD patients is not well established. The aim of this study was to evaluate the prevalence of GERD signs in the laryngopharyngeal area during routine upper gastrointestinal endoscopy.

METHODS

Between July 2000 and July 2001, 1,209 patients underwent 1,311 upper gastrointestinal endoscopies and were enrolled in this study. The structured examination of the laryngopharyngeal area during upper gastrointestinal endoscopy was videotaped for review by three gastroenterologists and one otorhinolaryngologist, blinded to the endoscopic esophageal findings. From the 1,209 patients enrolled in this prospective study, all patients (group I, N = 132) with typical endoscopical esophageal findings of GERD (Savary-Miller I-IV) were selected. The sex- and age-matched control group II (N = 132) underwent upper gastrointestinal endoscopy for different reasons, had no reflux symptoms, and had normal esophagoscopy.

RESULTS

In the two groups of patients, we found no difference in the prevalence of abnormal interarytenoid bar findings (32%vs 32%), arytenoid medial wall erythema (47%vs 43%), posterior commissure changes (36%vs 34%), or posterior cricoid wall edema (1%vs 3%). The only difference was noted in the posterior pharyngeal wall cobblestoning (66%vs 50%, P= 0.004).

CONCLUSION

The results of this large systematic investigation challenge the diagnostic specificity of laryngopharyngeal findings attributed to gastroesophageal reflux.

Defining the relationship between gastroesophageal reflux and cough: probabilities, possibilities and limitations

The common co-existence of cough and gastroesophageal reflux disease (GORD) is well established. However, ascertaining cause and effect is more difficult for many reasons that include occurrence by chance of two common symptoms, the changing definition of GORD, equipment limitations and the lack of randomised controlled trials. Given these difficulties, it is not surprising that there is disparity of opinion between respiratory and gastroenterology society guidelines on the link between GORD and chronic cough. This commentary explores of these issues.

ACG practice guidelines: esophageal reflux testing

Investigations and technical advances have enhanced our understanding and management of gastroesophageal reflux disease. The recognition of the prevalence and importance of patients with endoscopy-negative reflux disease as well as those refractory to proton pump inhibitor therapy have led to an increasing need for objective tests of esophageal reflux. Guidelines for esophageal reflux testing are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Issues regarding the utilization of conventional, catheter-based pH monitoring are discussed. Improvements in the interpretation of esophageal pH recordings through the use of symptom-reflux association analyses as well as limitations gleaned from recent studies are reviewed. The clinical utility of pH recordings in the proximal esophagus and stomach is examined. Newly introduced techniques of duodenogastroesophageal reflux, wireless pH capsule monitoring and esophageal impedance testing are assessed and put into the context of traditional methodology. Finally, recommendations on the clinical applications of esophageal reflux testing are presented.

Meta-analysis: the efficacy of proton pump inhibitors for laryngeal symptoms attributed to gastro-oesophageal reflux disease

BACKGROUND

Many investigators have proposed an association between gastro-oesophageal reflux disease and laryngo-pharyngeal symptoms, suggesting that medical or surgical therapy for reflux may be useful.

AIM

To perform a meta-analysis assessing the effectiveness of medical or surgical therapy for reflux disease in adult patients with laryngeal or pharyngeal symptoms presumed to be due to gastro-oesophageal reflux disease.

METHODS

Randomized controlled trials comparing medical or surgical treatments for gastro-oesophageal reflux disease against placebo were identified by searching MEDLINE (1966-September 2005), EMBASE (1974-September 2005), the CCRCT (until September 2005) and abstracts from gastroenterology and ENT meetings. The relative risks of reporting symptomatic improvement or resolution of symptoms was evaluated using a random-effects model.

RESULTS

Five studies using high-dose proton pump inhibitor as intervention met the inclusion criteria and were included in the meta-analysis. No surgical studies met inclusion criteria. The pooled relative risk was 1.18 (95% confidence interval: 0.81-1.74). There was no heterogeneity between studies but evidence of significant publication bias. Sub-group analysis performed evaluating Jadad scores and symptom type, did not change the relative risk.

CONCLUSIONS

Therapy with a high-dose proton pump inhibitor is no more effective than placebo in producing symptomatic improvement or resolution of laryngo-pharyngeal symptoms. Further studies are necessary to identify the characteristics of patients that may respond to proton pump inhibitor therapy.

Gastro-oesophageal reflux disease in chronic laryngitis: prevalence and response to acid-suppressive therapy

BACKGROUND

Gastro-oesophageal reflux is thought to cause chronic laryngitis through laryngopharyngeal reflux. Response of laryngitis to treatment with acid-suppressive therapy supports this causal link.

AIM

To determine the prevalence of gastro-oesophageal reflux disease in patients with chronic laryngitis and response to proton-pump inhibitor therapy.

METHODS

Patients with chronic laryngitis were recruited. The frequency and severity of reflux and laryngeal symptoms were scored and laryngitis graded by laryngoscopy. All patients underwent esophagogastroduodenoscopy and 24-h ambulatory pH monitoring before receiving lansoprazole 30 mg b.d. for 8 weeks.

RESULTS

The prevalence of gastro-oesophageal reflux disease was 65.6% (21 of 32). Based on positive pH test, the prevalence was 25% (eight of 32). The change in laryngeal symptom score and laryngitis grade was significantly higher in GERD compared with non-GERD patients (P = 0.010 for both). The proportion of patients with marked/moderate improvement in laryngeal symptoms were significantly higher in patients with reflux (14 of 21, 67%) compared to those without reflux (two of 11, 18%; P = 0.026).

CONCLUSIONS

The prevalence of gastro-oesophageal reflux disease amongst our patients with chronic laryngitis was high. The response to treatment with proton-pump inhibitors in patients with reflux disease compared to those without underlined the critical role of acid reflux in a subset of patients with chronic laryngitis.

Relationship between time of exposure of laryngopharyngeal reflux and gene expression in laryngeal fibroblasts

OBJECTIVES

Acid reflux is damaging to the laryngeal mucosa; however, the significance of the duration of reflux episodes has not been evaluated. The purpose of this study was to determine whether varying the exposure times at low pH with or without pepsin alters gene expression in laryngeal fibroblasts.

METHODS

Human false vocal fold and postcricoidal cultures were exposed to pH 4 or pH 5 media with and without pepsin for 10, 30, 60, and 240 seconds. Using a real-time polymerase chain reaction, we determined the messenger RNA expression of TGFbeta-1, VEGF, FGF-2, EGR-1, ATF-3, CTGF, MMP-1, MMP-2, and decorin.

RESULTS

Molecular responses were initiated at pH 5. Postcricoidal fibroblasts were more sensitive than false vocal fold fibroblasts to the presence of pepsin. Changes in transcript levels were dependent on acid exposure time, and the most significant changes were measured during the first 60 seconds after exposure.

CONCLUSIONS

Time of exposure to acid and pepsin needs to be taken into consideration when determining limit of pathology in pharyngeal reflux. Genes are identified that are induced by low pH and that may be of potential importance in the pathogenesis of reflux laryngitis.

Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta-analysis of randomized controlled trials

OBJECTIVE

The role of proton pump inhibitors (PPIs) in suspected GERD-related chronic laryngitis (CL) is controversial. Hence, we performed a meta-analysis of the existing randomized controlled trials (RCTs) to evaluate the efficacy of PPIs in this disorder.

METHODS

Data extracted from MEDLINE (1966 to August 2005), Cochrane Controlled Trials Register (1997 to August 2005), EMBASE (1980 to August 2005), ClinicalTrials.gov website, and meetings presentations (1999-2005). Published and unpublished randomized placebo-controlled trials of PPIs in suspected GERD-related CL were selected by consensus. Random effects model was utilized with standard approaches to quality assessment, sensitivity analysis, and an exploration of heterogeneity and publication bias. The primary outcome measure was defined as the proportion of patients with >or=50% reduction in self-reported laryngeal symptoms.

RESULTS

Pooled data from 8 studies (N = 344, PPI 195, placebo 149; mean age 51 yr; males 55%; study duration 8-16 wk) were analyzed. No significant quantitative heterogeneity was found among the studies (chi2= 11.22, P= 0.13). Overall, PPI therapy resulted in a nonsignificant symptom reduction compared to placebo (relative risk 1.28, 95% confidence interval 0.94-1.74). No clinical predictors of PPI response were identified on meta-regression analysis done at study level.

CONCLUSIONS

PPI therapy may offer a modest, but nonsignificant, clinical benefit over placebo in suspected GERD-related CL. Validated diagnostic guidelines may facilitate the recognition of those patients most likely to respond favorably to PPI treatment.

Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults

BACKGROUND

Cough is a very common symptom presenting to medical practitioners. Gastroesophageal reflux disease (GORD) is said to be the causative factor in up to 41% of adults with chronic cough. However cough and GORD are common ailments and their co-existence by chance is high. Also cough can induce reflux episodes. Treatment for GORD includes conservative measures (diet manipulation), pharmaceutical therapy (motility or prokinetic agents, H(2) antagonist and proton pump inhibitors (PPI)) and fundoplication.

OBJECTIVES

To evaluate the efficacy of GORD treatment on chronic cough in children and adults with GORD and prolonged cough that is not related to an underlying respiratory disease i.e. non-specific chronic cough.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register Collaboration and Cochrane Airways Group, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles were searched. The date of last search was 7th April 2006.

SELECTION CRITERIA

All randomised controlled trials on GORD treatment for cough in children and adults without primary lung disease.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. Two independent reviewers selected, extracted and assessed data for inclusion. Authors were contacted for further information. Data was analysed as "intention to treat" as well as "treatment received". Paediatric and adults data were considered separately. Sensitivity analyses were performed.

MAIN RESULTS

Thirteen studies (3 paediatric, 10 adults) were included. Data from six were available for analysis. None of the paediatric studies could be included in meta-analysis. In adults, analysis on use of H(2) antagonist, motility agents and conservative treatment for GORD were not possible (from lack of data) and there were no controlled studies on fundoplication as an intervention. Six adult studies comparing PPI (2-3 months) to placebo were analysed for various outcomes in the meta-analysis. Enrolment of subjects for two studies were primarily from medical clinics and another 4 studies were otolaryngology clinic patients or patients with laryngitis. Using "intention to treat", pooled data from 4 studies resulted in no significant difference between treatment and placebo in total resolution of cough, Odds Ratio 0.46 (95% CI 0.19 to 1.15). Pooled data revealed no overall significant improvement in cough outcomes (end of trial or change in cough scores). Significant differences were only found in sensitivity analyses. A significant improvement in change of cough scores was found in end of intervention (2-3 months) in those receiving PPI with a standardised mean difference of -0.41 (95%CI -0.75, -0.07) using GIV analysis on cross over trials. Two studies reported improvement in cough after 5 days to 2 weeks of treatment.

AUTHORS' CONCLUSIONS

There is insufficient evidence to definitely conclude that GORD treatment with PPI is universally beneficial for cough associated with GORD in adults. The beneficial effect was only seen in sub-analysis and its effect was small. The optimal duration of such a trial of therapy to evaluate response could not be ascertained in the meta-analysis although two RCTs reported significant change by 2 weeks of therapy. Clinicians should be cognisant of a period (natural resolution with time) and placebo effect in studies that utilise cough as an outcome measure. Data in children are inconclusive. Future paediatric and adult studies are needed whereby studies should be double blind, randomised controlled, parallel design, using treatments for at least two months, with validated subjective and objective cough outcomes and include ascertainment of time to respond as well as assessment of acid and/or non acid reflux whilst on therapy.

Double-blind, placebo-controlled trial with single-dose pantoprazole for laryngopharyngeal reflux

OBJECTIVES

Results of randomized treatment trials for laryngopharyngeal reflux (LPR) are mixed. The cause and effect between gastroesophageal reflux and laryngeal symptoms remain elusive.

AIMS

To determine the efficacy of single-dose pantoprazole in newly diagnosed LPR and to correlate hypopharyngeal reflux with symptom improvement.

METHODS

Randomized, double-blind, placebo-controlled trial was performed with a 2-wk run-in, 12-wk treatment period (pantoprazole 40 mg q.a.m. or placebo), and 4-wk follow-up. Study criteria were laryngeal complaints >3 days/wk and a positive triple-sensor pH test. Laryngeal exam was graded using a reflux finding score before and after treatment. Repeat pH test was performed on study drug at week 12. Weekly diaries were kept on symptom severity and global assessment. Total laryngeal symptom score was defined as the sum of six laryngeal symptoms. Mann-Whitney U, Wilcoxon, and Pearson tests were used.

RESULTS

Thirty-nine subjects (13 M/26 F, median age 39 yr) were randomized; 35 completed the study. During the treatment period, total laryngeal symptom scores significantly improved compared with pretreatment scores in both study groups, but there were no significant differences between them. Forty percent of pantoprazole group reported adequate relief at week 12, compared with 42% of placebo group (p= 0.89). No significant improvement in hypopharyngeal reflux was found in either study group. There were no significant correlations between laryngeal reflux finding scores and hypopharyngeal reflux episodes with symptom improvement.

CONCLUSIONS

Response was similar between single-dose pantoprazole and placebo in newly diagnosed LPR. Our results suggested that laryngeal exam was not useful in following treatment response. Hypopharyngeal reflux may represent acid reflux or artifacts, but is not likely the underlying cause.