Heartburn and regurgitation are easily identifiable symptoms of gastroesophageal reflux disease (GERD) and tend to be easier to treat with PPI therapy. However, symptoms of laryngopharyngeal reflux (LPR) or atypical reflux have become very prevalent in the population since they are difficult to spot and are often unresponsive to PPI therapy.
Here are FOUR possible reasons why your patient’s LPR symptoms aren’t improving:
1. Their symptoms aren’t caused by reflux.
Common chronic conditions like cough, throat clearing, and laryngeal erythema are examples of LPR symptoms. However, these symptoms can also result from several other etiologies.1
2. Empiric treatment is ineffective at confirming LPR.
The absence of specific LPR symptoms and treatment methods make LPR a difficult condition to assess. Acid can cause LPR symptoms even in the absence of GERD. Although PPIs are extremely effective in controlling symptoms of GERD, PPI therapy has proven unreliable in managing LPR symptoms and confirming reflux as the etiology of patient complaints.
A systematic review of six randomized, controlled studies reveals that the majority of LPR symptoms improved similarly in the PPI and control groups.2 This data demonstrates that empiric PPI treatment of suspected LPR is not superior to treatment by placebo.
3. Laryngopharyngeal pH fails to normalize for most individuals following PPI therapy.
A study led by Jonathan Waxman, MD at the University of Illinois at Chicago, tested patients pre- and post-treatment after at least 4 weeks of PPI therapy. Only 39.5% of patients with positive RYAN Scores achieved both pH and symptom normalization while on PPIs. The remaining 60.5% of patients had persistent positive RYAN Scores with no pH normalization when retested on medication.3 (The RYAN Score was created by Dr. Tom DeMeester with high specificity for severe reflux patients using thresholds of pH 5.5 for upright and pH 5.0 for supine positions.)
Over 30% of patients presenting with LPR symptoms do not have excessive acid exposure; thus, LPR symptoms won’t improve in over 30% of patients on PPI therapy.3
4. Symptom normalization does not equate to pH normalization.
Only significant improvement (not normalization) of the upright RYAN Score was necessary for symptom normalization. This further illustrates why symptoms are unreliable in the diagnosis of LPR. Acid exposure in the larynx in the absence of symptoms may lead to detrimental damage in sensitive epithelial tissue.
The chart above illustrates that symptom normalization while on PPIs does not correlate with a healthy patient. Testing on therapy at 8-12 weeks will either confirm pH normalization or identify patients who require escalated therapy or surgical intervention.
Visit our Restech blog to learn more about evidence-based pharyngeal pH testing.
… AND … download a copy of “Atypical Reflux: An Ever-Present Enigma in the Physician’s Office” for a concise overview of the current literature on laryngopharyngeal reflux, PPI response, and objective testing.
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References
- Hoarseness. American Academy of Otolaryngology-Head and Neck Surgery. http://www.entnet.org/content/hoarseness. Published April 22, 2014.
- Karkos PD, Wilson JA. Empiric Treatment of Laryngopharyngeal Reflux with Proton Pump Inhibitors: A Systematic Review. Laryngoscope. 2006;116(1):144-8.
- Waxman J, Yalamanchali S, Valle ES, Pott T, Friedman M. Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg. 2014;150(6):1010-1017.
Bree has been an integral part of Restech from the very beginning. She holds a Masters in Public Health from George Washington University, a BFA from The University of Kansas in Visual Communications, and is a National Board Certified Health & Wellness Coach. Her command of marketing, public health/health delivery systems, and human health behavior change gives her a unique perspective in developing effective marketing strategies for the company.
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Thomas previously worked as a polysomnographic technologist in the Virginia Mason system, before moving into sales with Restech in 2007. After spending 9 years working with distributors across Europe, he was moved into an organizational role at the head office in Houston. In this capacity he works closely with sales and marketing to provide clinical support, manages clinical studies, and provides clinical perspectives on business development. In his spare time Thomas plays rugby for Houston Athletic Rugby Club.
Jeff has over 30 years of experience in the medical device industry and previously worked in sales at companies such as Encision Inc., Interventional Therapies, LLC, Boston Scientific, and United States Surgical Corporation. He has been working as the VP of Sales for Mederi Therapeutics since 2009 and now brings his extensive expertise to Restech. Jeff was part of the team that bridged the Mederi asset sale to Restech. His clinical knowledge of the Stretta and Secca technologies is invaluable. Jeff has three decades of physician relations experience that he brings to Restech as part of the leadership team.
Ray joined Restech in May 2018 as the Vice President for Sales. He has been in the medical device, and specifically in the GERD space for more than 18 years. Starting in sales at Sandhill Scientific pH diagnostics, he moved on to Curon Medical when Stretta and Secca were first introduced to the market. He then worked for Given Imaging when Curon closed operations. When Stretta was relaunced he joined Mederi as VP of Sales. Ray was instrumental in keeping Stretta alive and the customer based informed when Mederi ceased operation and assets were purchased by Restech. He is part of the leadership team directing all product sales for Restech. Ray graduated from Old Dominion University in Norfolk with a BS in Marketing and Business Administration.
Mark is a seasoned professional and Certified Public Accountant in Texas who brings a unique blend of creative vision and financial expertise to any leadership team. He worked as a Senior Executive for 15 years on a leadership team which grew a private equity backed cash logistics company performing at negative EBITDA on $100 million revenue into an international industry leader with superior profitability on revenue exceeding $1.5 billion. In addition, he spent 10 years as a Senior Manager at Price Waterhouse delivering results-oriented merger & acquisition, audit and strategic consulting services to middle market clientele including over 40 manufacturing, distribution, service, nonprofit and technology clients. Mark currently serves as a Chief Financial Officer and consulting CFO (seven years) providing in-house and outsourced CFO and transactional services to the middle market.
Larry is the CTO for Restech and holds a B.S. in Computer Science. He is a software architect specializing in remote patient monitoring, medical sensors, and clinical trial software. Larry holds a patent on massively distributed computing and has worked for a number of major software startup companies including Sybase, Oracle, and Teradata. Larry was also the co-founder of a startup to deliver advanced clinical pathways to patients using mobile devices and medical sensors. Larry is truly a pioneer and now a veteran in the deployment.
Jeff has a breadth of experience with over 25 years in engineering and executive positions within major fortune 100 healthcare companies. He also has proven success in startup medical technology companies. Jeff provides leadership in securing and managing Restech’s patent portfolio. He also built Restech’s compliance platform that established regulatory acceptance in 25+ countries worldwide. Jeff’s scientific support and in-depth understanding of the device industry set the foundation for current and future commercial innovations at Restech.
With nearly 30 years of working with physician thought leaders developing novel and emerging technologies, Leo has played a key role in the development and evolution of balloon angioplasty and stent technologies that revolutionized the therapy of cardiac disease. His experience was instrumental in the development of the patented platform technology which drives the Restech sensor. Leo provides a vision and passion for effecting change in the diagnosis and management of atypical reflux.
With over 20 years of executive experience in both the private and public sector, Debra brings a broad understanding of healthcare delivery system. With experience managing products aimed at wide scale disease and population management for 20 million subscribers, Debra has extensive experience in effectively and efficiently developing models of delivery that address specific health issues. Debra has also been involved in the legislative process and served as the elected President of the Independent Physician Association of California. Debra is dedicated to bringing tools to the healthcare market that improve and support the clinical process.