PPIs for Laryngeal Symptoms: Two More Negative Trials

Summary and Comment |
September 28, 2006

PPIs for Laryngeal Symptoms: Two More Negative Trials

  1. Allan S. Brett, MD

PPIs weren't beneficial for chronic laryngeal symptoms, laryngoscopic findings appeared to be nonspecific, and pH abnormalities didn’t predict treatment response.

  1. Allan S. Brett, MD

Patients with unexplained laryngeal symptoms often receive proton-pump inhibitors (PPIs) for presumed laryngopharyngeal reflux (LPR). However, PPI therapy was ineffective in several small previously published randomized trials.

One new industry-supported randomized trial included 39 patients with at least 2 months of LPR symptoms (e.g., hoarseness, sore throat, throat clearing, voice loss), laryngoscopic findings thought to represent reflux, abnormal results on 24-hour esophageal pH monitoring, and no previous diagnosis of gastroesophageal reflux. Patients received pantoprazole (40 mg daily) or placebo. After 12 weeks, the proportions of patients with adequate symptom relief were similar in the two groups (40% vs. 42%). Laryngeal examinations improved in the placebo group but not in the pantoprazole group.

In another industry-supported randomized trial published earlier this year, 145 patients with LPR symptoms received either esomeprazole (40 mg twice daily) or placebo. All patients had laryngoscopic findings thought to represent reflux, but patients with moderate-to-severe heartburn were excluded, and more than half the patients had normal 24-hour esophageal pH results. After 16 weeks, primary symptoms had resolved in only 15% of esomeprazole recipients and 16% of placebo recipients. Abnormal 24-hour esophageal pH did not predict treatment response.

Comment

These trials add to previous evidence that PPI therapy is not beneficial for most patients with chronic unexplained laryngeal symptoms. Moreover, the results suggest that laryngoscopic findings, such as erythema and edema, are nonspecific (i.e., they cannot confidently be ascribed to acid reflux), and that 24-hour ambulatory pH abnormalities do not predict laryngeal symptom response to PPIs. These findings do not apply to patients with severe heartburn, but such patients usually receive PPIs anyway.

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