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Reflux Laryngitis Medication

  • Author: Bardia Amirlak, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Dec 01, 2015
 

Medication Summary

A variety of pharmacologic agents are available for suppressing gastric acid secretion. These include H2RAs such as famotidine, ranitidine, nizatidine, and cimetidine; proton pump inhibitors (PPIs) such as omeprazole; prokinetic agents such as cisapride and tegaserod; and mucosal cytoprotectants such as sucralfate. Evidence that supports the efficacy of the H2RAs is questionable. PPIs are significantly more potent and reliably achieve a greater magnitude of gastric acid inhibition. In addition, compared with esophageal symptoms, significantly greater acid inhibition is required to relieve supraesophageal symptoms and, especially, to achieve mucosal healing. Hence, the choice of PPIs over H2RAs is clear as a first-line pharmacologic intervention.

Omeprazole has been studied most extensively and is the only agent used in the clinical trials evaluating efficacy of PPIs in supraesophageal disorders. However, experience with lansoprazole is increasing, and newer agents (rabeprazole, pantoprazole) promising sustained and more potent gastric acid suppression with once daily dosing have recently arrived.

Prokinetic agents accelerate esophageal clearance and increase lower esophageal sphincter (LES) tone. The prokinetic agent cisapride has been discontinued because of serious adverse effects or ventricular arrhythmia. Tegaserod decreases reflux and LES relaxation events and is useful for treating laryngopharyngeal reflux (LPR) associated with esophageal dyskinesia.

Tegaserod was temporarily withdrawn from the US market in March 2007; however, as of July 27, 2007, restricted use of tegaserod is now permitted via a treatment IND protocol. The treatment IND will allow tegaserod treatment of irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease.

Earlier this year, tegaserod marketing was suspended because of a meta-analysis of safety data pooled from 29 clinical trials that involved more than 18,000 patients. The results showed an excess number of serious cardiovascular adverse events, including angina, myocardial infarction, and stroke, in those taking tegaserod compared with placebo. In each study, patients were assigned at random to either tegaserod or placebo. Tegaserod was taken by 11,614 patients, and placebo was taken by 7,031 patients. The average age of patients in these studies was 43 years, and most patients (ie, 88%) were women. Serious and life-threatening cardiovascular adverse effects occurred in 13 patients (0.1%) treated with tegaserod; among these, 4 patients had a heart attack (1 died), 6 had unstable angina, and 3 had a stroke. Among the patients taking placebo, only 1 (0.01%) had symptoms suggesting the beginning of a stroke that went away without complication. For more information, see the FDA MedWatch Product Safety Alert.

Sucralfate is a polysulfated salt of sucrose that may be helpful as an adjunct in protecting injured mucosa from the harmful effects of acid and pepsin.

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Proton pump inhibitors

Class Summary

Inhibit gastric acid secretion by inhibition of the H+/K+ -ATPase enzyme system in the gastric parietal cells.

Omeprazole (Prilosec)

 

Specifically suppress gastric acid secretion by potent inhibition of the H+/K+ -ATPase enzyme system at secretory surface of gastric parietal cell. This blocks the final step in gastric acid production. Effect is dose related and inhibits both basal and meal-stimulated acid secretion. Omeprazole has been studied most extensively and is the only agent used in the clinical trials evaluating efficacy in supraesophageal disorders.

Lansoprazole (Prevacid)

 

Suppresses gastric acid secretion by specific inhibition of the H+/K+ -ATPase enzyme system (ie, proton pump) at the secretory surface of the gastric parietal cell. It blocks the final step of acid production. The effect is dose related and inhibits both basal and stimulated gastric acid secretion, thus increasing gastric pH levels.

Pantoprazole (Pantoloc, Protonix)

 

Suppresses gastric acid secretion by specifically inhibiting H+/K+ -ATPase enzyme system at the secretory surface of gastric parietal cells. Use of the IV preparation has only been studied for short-term use (ie, 7-10 d).

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Prokinetic agents

Class Summary

These agents may stimulate peristaltic reflex.

Tegaserod hydrogen maleate (Zelnorm)

 

Available in US by restricted treatment IND for irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Used for the short-term treatment of women with irritable bowel syndrome in whom constipation is the predominant symptom. Serotonin type 4 receptor partial agonist with no affinity for 5-HT3 receptors. May trigger peristaltic reflex via 5-HT4 activation, which enhances basal motor activity and normalizes impaired GI motility. Research studies have shown inhibitory activity of the drug on visceral activity in the GI tract.

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Gastrointestinal agents

Class Summary

These agents may protect the GI lining against peptic acids.

Sucralfate (Carafate)

 

Binds to positively charged proteins in exudates and forms a viscous, adhesive substance that protects GI lining against pepsin, peptic acid, and bile salts. Used for short-term ulcer management.

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Contributor Information and Disclosures
Author

Bardia Amirlak, MD Assistant Professor of Plastic Surgery, Director of Residency Cosmetic Clinic, Director of Plastic Surgery Global Health Program, University of Texas Southwestern Medical Center at Dallas; Chief of Hand and Peripheral Nerve Surgery, Dallas Veterans Affairs Medical Center

Bardia Amirlak, MD is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, American Society of Reconstructive Transplantation, Kleinert Society

Disclosure: Nothing to disclose.

Coauthor(s)

Reza Shaker, MD 

Reza Shaker, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Federation for Medical Research, American Gastroenterological Association, American Neurogastroenterology and Motility Society, American Physiological Society, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Pamela A Mudd, MD Attending Physician in Pediatric Otolaryngology, Children's National Medical Center

Pamela A Mudd, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians

Disclosure: Nothing to disclose.

Ramin Soraya, MD Chair, Department of Science, West Coast University, Dallas

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, American Rhinologic Society, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Clark A Rosen, MD Director, University of Pittsburgh Voice Center; Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine

Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Pennsylvania Medical Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merz North America Inc<br/>Received consulting fee from Merz North America Inc for consulting; Received consulting fee from Merz North America Inc for speaking and teaching.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Ann L Edmunds, MD, PharmD, to the development and writing of this article.

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The RSI documents the presence and degree of nine laryngopharyngeal reflux (LPR) symptoms both before and after treatment; maximum score: 45.
The reflux finding score (RFS) documents the presence and degree of eight laryngopharyngeal reflux (LPR) findings during fiberoptic laryngoscopy; maximum score: 26.
Table 2. shows key features of the 7 studies that evaluated efficacy of antireflux medical treatment. These studies were published from 1991-1997 and reported on 346 adult patients with otherwise unexplained posterior laryngitis suspected to be caused by GERD who received antireflux medical treatment in an uncontrolled nonblinded clinical trial. Outcomes Reported by Trials of Antireflux Medical Treatment of Reflux Laryngitis
Author n Pharmacologic Intervention Treatment Duration



wk



Symptom Improvement Laryngoscopic Improvement Follow-up



wk



Repeat Treatment
Laryngeal Esophageal
Koufman 33 Ranitidine 300-600 mg/d or



Famotidine 80 mg/d



24 85% 85% 44 50%
Kamel 16 Omeprazole 40 mg/d 6-24 79% 96% 56% 6 Majority
Hanson 182 Step-wise treatment



Famotidine 20 mg/d,



Omeprazole 20-40 mg/d



6-12 96% 96% >6-12 79%
Shaw 68 Omeprazole 20 mg bid 12 Significantly improved 40% Significantly improved None
Wo 21 Omeprazole 40 mg/d 8 40% 48% 50% 8 38%
Metz 10 Omeprazole 20 mg bid 4 60% 100%
Hanson 16 Omeprazole 20 mg/d 6-9 Significantly improved acoustic parameters
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