[Dysphagia] LPR and PPIs

[eripley at yahoo.com (Irene Campbell-Taylor)]

Not Much Support for PPIs in Treating Respiratory Symptoms 
  Several studies challenge the use of PPIs to treat asthma, cough, or hoarseness. 
  Gastroesophageal reflux disease (GERD) is thought to cause or exacerbate respiratory tract symptoms in some patients. Postulated mechanisms include both direct effects (e.g., aspiration) and indirect neurally mediated effects of acid reflux on upper and lower airway function. Many clinicians thus treat asthma, chronic cough, or chronic hoarseness with proton-pump inhibitors (PPIs), even in patients with minimal or no heartburn or reflux. However, several studies published in 2006 challenge this practice. 
  In one randomized trial, 700 adults with stable asthma ? nearly all of whom used inhaled steroids ? received either esomeprazole (40 mg twice daily) or placebo for 16 weeks (Journal Watch Jun 6 2006). Mean morning peak expiratory flow (PEF) from baseline to end of study (the primary outcome) increased by 9% in the esomeprazole group and by 7% in the placebo group, a difference that did not quite achieve significance. Most secondary outcomes (e.g., use of rescue inhalers, asthma symptoms, and quality of life) also were not better with esomeprazole than with placebo. Even in subgroups with symptomatic GERD, small improvements in morning PEF with esomeprazole did not reach significance. 
  Two randomized trials examined the effect of PPIs on patients with laryngeal symptoms and laryngoscopic findings attributed to GERD (Journal Watch Sep 28 2006). In one trial, 145 such patients received either esomeprazole (40 mg twice daily) or placebo. After 16 weeks, the proportions of patients with a good response were virtually identical in the two groups. In another trial, 39 patients -- all of whom had abnormal 24-hour esophageal pH monitoring in addition to laryngeal symptoms -- received pantoprazole (40 mg daily) or placebo. Again, clinical responses at 12 weeks were the same in the pantoprazole and placebo groups. 
  These studies do not preclude the possibility that occasional patients with asthma or chronic laryngeal symptoms might benefit from PPI therapy. However, recent systematic reviews suggest that the evidence is insufficient to support PPI therapy for asthma, prolonged cough, or hoarseness. For now, clinicians should temper their enthusiasm for PPI therapy for these conditions. 
  ? Allan S. Brett, MD 
Published in Journal Watch General Medicine December 28, 2006 

Dr I Campbell-Taylor
Clinical Neuroscientist
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