Laryngopharyngeal reflux (LPR) is a complex disease that is difficult to treat. Diagnosis is very challenging because the symptoms are unspecific. Once LPR has been identified as the cause of the symptoms, only then does the search for a successful treatment begin. Affected patients soon realize that medications specifically against silent reflux do not exist and that doctors often do not know how to treat the condition.
Why is this the case?
LPR has only recently moved into the focus of research.
Recent studies suggest that LPR is a common disease. Until recently, though, only a few scientists and doctors knew about this condition. There were no tests to detect silent reflux. For this reason, a statement that a patient had LPR was rather a hypothesis than a diagnosed fact.
To get straight to the point, the pharma industry only develops medications for diseases that are known to exist. Because silent reflux became a scientifically established condition only recently, there has not been enough time for the development of drugs specifically for LPR. You have to consider that to develop a new drug and bring it to market, it is not unusual to take 10 years or more.
Acid is often thought to be the only culprit.
In classic reflux (GERD), acidic gastric juice irritates the esophagus. While gaseous reflux is also acidic, acid is not the primary problem with silent reflux. It is the pepsin that is carried along with the reflux into the airways that causes the actual damage.[1]
Nevertheless, many doctors prescribe proton pump inhibitors (PPIs) for LPR and expect the problem to be solved.[2] As studies have shown, PPIs do very little to improve LPR as they only target the acidity. The fact that acid-suppressing medications are not sufficient, and that specific medications are needed, has not been widely understood yet.
Pepsin is a challenging target.
Pepsin causes the actual damage in LPR. Pepsin is an enzyme from the stomach that is vital for digestion. In silent reflux, it ends up in the throat and airways, where it attacks the cells of the mucous membranes.
An effective medication would therefore have to target pepsin. A general inhibition of pepsin is not a suitable approach, though, because it is essential for digestion – without it, it is not possible to digest proteins. Inhibition of pepsin would likely cause many side effects and lead to digestive problems. Acid, on the other hand, is easier to inhibit because it merely facilitates digestion and sterilizes the food.
One possibility would be to target pepsin only in the airways, for instance, by blocking its uptake into those cells. Whether such an approach could be successful is as yet unknown. It is for sure more challenging than simply suppressing acid production. It will likely still take a long time until we see any interesting drug come on the market that can target pepsin to reduce LPR symptoms.
LPR can be treated without medication.
Even though there are no medications that specifically target silent reflux, treatment options still exist. They are, however, more laborious than merely taking a pill.
Dietary changes are very efficient because they target two root causes: They can minimize the reflux so that fewer pepsins end up in the airway. Moreover, avoidance of acidic foods prevents the activation of the remaining pepsins. This strategy is usually successful in keeping the LPR in check and preventing further damage.[3]
For my online course on the treatment of LPR, I did a lot of research and interviewed experts to find out which dietary approaches are most successful. The dietary protocol has already helped several thousand LPR patients to get rid of their silent reflux symptoms.
In extreme cases, though, dietary changes alone are not successful in keeping the reflux in check. For these patients, surgery might be a suitable option.
References
[1] Johnston N, Dettmar PW, Bishwokarma B, Lively MO, Koufman JA. Activity/stability of human pepsin: implications for reflux attributed laryngeal disease. Laryngoscope. 2007;117(6):1036-9.
[2] Reimer C, Bytzer P. Management of laryngopharyngeal reflux with proton pump inhibitors. Ther Clin Risk Manag. 2008;4(1):225-33.
[3] Koufman JA. Low-acid diet for recalcitrant laryngopharyngeal reflux: therapeutic benefits and their implications. Ann Otol Rhinol Laryngol. 2011;120(5):281-7.
