[Dysphagia] LPR and PPIs

[joanneaton at charter.net (JoAnn Eaton)]

Irene,
Am I recalling correctly that those studies were supportive of other 
approaches such as small meals and elevating the HOB for treatment?  I also 
read recently that diet change was not an effective treatment for GERD. 
(Yeah! Still get chocolate.) However, weight loss was still a good strategy 
(Darn, there goes the chocolate.)
JoAnn
----- Original Message ----- 
From: "Irene Campbell-Taylor" <eripley at yahoo.com>
To: <dysphagia at b9.com>
Sent: Monday, January 22, 2007 9:23 AM
Subject: [Dysphagia] LPR and PPIs


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
Exclusive Distributor:
www.interactivetherapy.com
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