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Diet vs. Proton-Pump Inhibitors in Laryngopharyngeal Reflux Disease

12/26/2017 10:23:57 AM
Laryngopharyngeal reflux (LPR) disease is a condition characterized by reflux of gastric contents beyond the esophagus (as in GERD) and into the throat. There is no gold standard diagnostic test for LPR. Patients can present with a cough, dysphagia, dysphonia, or other vague symptoms. Proton-pump inhibitors (PPIs) have been the pharmacologic treatment of choice for LPR for the last 3 decades, but PPIs can cause numerous adverse effects. The pathophysiology of LPR suggests dietary interventions may be a viable alternative to PPIs.

There is a general consensus that LPR is mediated by the presence of pepsin in an acidic environment in the throat. Because pepsin is inactivated when exposed to a pH greater than 8.0, alkaline water has been proposed as a possible intervention. Also, because pepsin secretion is regulated by gastrin in the presence of amino acids in the stomach, a plant-based diet with a lower amino acid load might decrease the activity of pepsin. It is therefore plausible that a plant-based diet in combination with alkaline water might improve symptoms of LPR.
Clinicians and researchers at New York Medical College conducted a retrospective medical chart review to compare the effects of PPI treatment to a diet-based approach in patients diagnosed with LPR from 2010 to 2015. The patient cohort from 2010 to 2012 (n=85) was treated with PPI therapy and standard reflux precautions, which prohibited coffee, tea, chocolate, soda, alcohol, and greasy, fried, fatty, and spicy foods. The patient cohort from 2013 to 2015 (n=99) was treated with alkaline water (pH>8.0), a plant-based Mediterranean-style diet, and standard reflux precautions. Patients were instructed to replace all beverages with alkaline water and to eat 90% to 95% plant-based diet consisting of vegetables, fruits, whole grains, and nuts.
The tool to assess the severity of LPR was the Reflux Symptom Index (RSI). A clinically meaningful response was defined as a reduction of ≥6 points on the RSI. Percent decrease in RSI was calculated as a secondary measurement. Patients were evaluated at baseline and after 6 weeks. 
The percentage of patients in the PPI cohort that achieved a 6-point reduction in RSI score was 54%, compared with 62.6% in the diet cohort (difference between groups, 8.51; 95% CI, -5.74 to 22.76). According to this calculation, the difference between groups was not statistically significant. However, when the percent reduction in RSI symptoms was compared between groups, the difference was statistically significant: the mean reduction in RSI in the PPI group was 27.2%, compared with 39.8% in the diet group (difference, 12.10; 95% CI, 1.53 to 22.68).
The authors of this study, published in the journal of JAMA Otolaryngology-Head & Neck Surgery, conclude with the following statement: “our data suggest that the plant based approach is at least as good, if not better, than PPI therapy. Thus, we recommend that a patient with suspected LPR at least attempt a dietary approach prior to any pharmacological intervention.”        
Reference: Zalvan CH, Hu S, Greenberg B, Geliebter J. A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1023-1029.