A 2012 study of 100 patients diagnosed with LPR, half of whom were treated with PPI alone and the rest with PPI and voice therapy, found that significantly more patients in the voice therapy with PPI group showed significant improvements in RSI, RFS, and voice handicap index, as well as on the grade, roughness, breathiness, asthenia, and strain scale (Otolaryngol Head Neck Surg. 2012;146:92-97). Many parameters improved in both groups, but greater improvement was seen in several areas among those who had taken voice therapy. “The patients who had voice therapy in addition to the PPI treatment got better faster,” Dr. Jamal said.
Explore This IssueDecember 2016
Non-Pharmaceutical and Alternative Medicine Options
There are many non-pharmaceutical options that might allow LPR patients to avoid the use of PPIs, said Agnes Czibulka, MD, clinical instructor of otolaryngology at Yale University in New Haven, Conn. Potential long-term complications associated with PPIs include a two-fold increase in the rate of Clostridium difficile, a heightened risk of community-acquired pneumonia, drug-induced acute interstitial nephritis, possible cardiovascular events, bacterial overgrowth of the stomach and small intestine, increased risk of hip fracture, and development of food allergies, Dr. Czibulka said.
One alternative option is probiotics, which she said can help optimize gut flora so that it can better break down complex carbohydrates, defend against “foreign invaders,” and help “train” the immune system. Dosing can range up to 10 billion colony-forming units (CFU) a day for infants and from 10 to 20 billion CFU for adults. Probiotics have a good safety record but should be used with extra caution in individuals with compromised immune systems.
Plants that can help ease inflammation include aloe, marshmallow, slippery elm (FDA approved as a safe demulcent plant), plantains, coltsfoot, and Irish moss. Dr. Czibulka drew particular attention to deglycyrrhizinated licorice, which is recommended for long-term use and avoids the potential side effects of hypertension, hypernatremia, and hypokalemia seen with standard licorice. A 700 mg to 1200 mg chewable tablet before meals and at bedtime is the suggested use, with a maximum daily dose of 5 grams, Dr. Czibulka said.
I can’t emphasize enough that it’s worth those extra few minutes to really talk to the patient about their diet and their lifestyle. —Michele Morrison, DO
Iberogast, available over the counter in the U.S., has been found, in in vitro studies, to reduce acid secretion and increase mucous production. Clinical studies have found it increases gastric motility. Dr. Czibulka added that melatonin has been found to protect gastric mucosa from free radicals in stress-induced ulcers by increasing blood flow and anti-inflammatory molecules in the esophageal mucous.