LPR treatment by diet

 Laryngopharyngeal reflux (LPR) is quite common, has protean manifestations (eg, chronic dysphonia, excessive throat clearing, persistent cough, globus pharyngeus, dysphasia, and others) and historically has been treated with long-term high-dose PPIs. There may be a relationship between LPR and laryngeal and esophageal carcinomas, as well as with Barrett's. A new retrospective analysis suggests that alkaline water and a Mediterranean diet works at least as well as PPIs (see doi:10.1001/jamaoto.2017.1454).

Details:
-- retrospective chart review of 2 treatment cohorts:
    -- 85 patients from 2010-12 treated with PPI (either esomeprazole or dexlansoprazole) and standard reflux precautions (prohibiting coffee, tea, chocolate, soda, greasy/fried/fatty/spicy foods, and alcohol)
    -- 99 patients from 2013-15 were treated with alkaline water (pH >8.0), a 90% plant-based Mediterranean-style diet, and standard reflux precautions
-- mean age of each cohort was 60 years, 60% women, primary symptom was cough in 33%, dysphasia in 33%, and dysphonia in 34%
-- primary outcome was a change in reflux symptom index (RSI), where baseline score was <11 in 8%, 11-20 in 51%, 21-30 in 28%, >30 in 12%.
-- there are many exclusion criteria, in order to match these 2 samples, but included other pharyngeal diagnoses (e.g. muscle tension dysphonia), those with neuropathic cough (including taking medications which might be used to treat that, such as amitriptyline, gabapentin, tramadol), concurrent diagnoses of allergic rhinitis/sinusitis/URI, current smokers.

Results:
-- there was no difference in pretreatment RSI between the groups, both being around 20
-- percentage of patients achieving a clinically meaningful (at least 6 point) reduction in RSI:
    -- 54.1% in the PPI treated group, with mean reduction of 27.2%
    -- 62.6% in the dietary group, with mean reduction of 39.8%
    -- although the percent of people achieving a meaningful 6-point reduction in RSI did not achieve statistical significance, the mean % reduction in RSI did

Commentary:
-- mechanistically, LPR is considered to be related to the combination of acid and pepsin reflux. Pepsin is active up to a pH of 8.0, so in theory the alkaline water would decrease its biological activity. In addition, a lower gastric load of amino acids, as through a plant-based diet, should decrease pepsinogen secretion and pepsin generation. And, PPIs decrease the acid reflux. Hence the combo
-- it is not entirely clear what a clinically meaningful reduction in RSI is. The RSI is a 9-item self-administered validated questionnaire, though its utility has been questioned. However, even in accepting it, a 6-point reduction (stated as being meaningful)  may in fact be less meaningful in those with a baseline score of <20 (found that in almost 60% of the population studied above) vs those with a significantly higher score. So, the percent reduction in RSI, which was significantly better in the dietary group, may be more useful as an indicator of effectiveness.
-- Other studies have shown that just doing standard reflux precautions does not really help LPR. Also, the medical approach to treatment is not consistently accepted: the American Gastroenterological Association recommends against using PPIs unless there is concomitant GERD. But the American Academy of Otolaryngology – Head and Neck Surgery recommends a trial of twice-daily PPIs for at least 6 months.
-- And, perhaps the most important difference between these 2 treatments is that the dietary one has positive collateral effects (decreasing diabetes, heart disease, cancer, strokes, perhaps dementia, etc.), whereas PPIs may well have significant collateral damage on the microbiome, and perhaps an array of serious adverse consequences (see links below).
--There are several commercially available alkaline waters with pH of 8, including Ethos and Evamor (though I have never tried any of them, my search suggests there are lots out there, though many are fraudulent. These 2 seem to have been checked out)
--There are clearly limitations to this type of study above: it is retrospective and there may be many uncontrolled biases, the diagnosis of LPR may not have been objective in many cases (lacking pH testing), we have no data on the adherence to either medications or diet in the groups, we also did not know about weight changes (perhaps those on the Mediterranean diet lost more weight, which might help LPR symptoms), and even the RSI tool has been questioned in terms of its clinical validity.

So, unlike GERD, which responds to acid suppressive therapy relatively quickly, LPR requires high-dose PPI use over a long time to assess effectiveness. (and the Am Gastroent Assn does not even suggest it).  In my own limited experience with LPR in the past, PPI therapy has not worked well. So, a study like this, which despite its not being a well-designed RCT, provides a further impetus for recommending the globally more healthful high plant-based, Mediterranean-type diet over meds….

See:
http://bit.ly/2xmZy7u for an overview of the risks and benefits of PPIs
http://bit.ly/2h3kQ3y for the relationship between PPIs and the microbiome
http://bit.ly/2f9mCQd for the relationship between PPI and MIs

http://bit.ly/2h5LYPz for the relationship between PPI and CKD