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Interactive Approaches Help Control Reflux Disease

Agnes Czibulka MD, a clinical instructor at Yale Medical School, explored the use of probiotics and herbal therapies for LPR.

Laryngopharyngeal reflux (LPR) is one of the most common complaints in the ENT world. Up to 10 percent of patients may suffer from LPR, but they can be treated successfully.

“Proton-pump inhibitor therapy is considered the standard for LPR,” said Marilene B. Wang, MD, moderator of the September 13 Miniseminar “Integrative Approaches to Reflux Disease: Beyond Proton-Pump Inhibitors.”

“But PPIs can have adverse effects, including malabsorption, which can lead to osteoporosis, an increase in cardiac events, increased incidence of enteric infections, and other problems. Those adverse effects have led to increasing resistance to using PPIs. Fortunately, we have options,” said Dr. Wang, professor of head and neck surgery at the David Geffen School of Medicine, University of California, Los Angeles

Potential options to PPIs include voice therapy, diet-based management, probiotics, acupuncture, stress reduction, and combination strategies.

One of the most obvious effects of LPR is vocal changes. Patients with LPR typically show hard glottal attack, glottal fry, restricted pitch range, a rough or hoarse sound, and other changes to the quality, loudness and clarity of their voice. PPI therapy often helps reduce vocal symptoms of LPR, but voice therapy can help even more.

Vocal techniques usually address hyperfunction through stretching exercises and identifying muscular over-achievers. Isolating and only using necessary muscles as well as neuromuscular re-education can break and replace habitual patterns that cause vocal symptoms. Multiple studies support the beneficial effects of voice therapy plus PPI treatment, and the use of voice therapy alone is currently under investigation.

Dietary changes, probiotics, and herbal therapies may be the most widely studied and used alternatives to PPIs.

“Diet can affect, in a positive way, the symptoms of reflux,” Dr. Wang said. “Avoidance of fatty and fried foods, spicy foods, and processed meats rich in nitrates can make a significant difference. So can incorporating more healthy fruits and vegetables and possibly probiotics.”

Probiotics act by restoring more normal gut flora to reduce acid production. The most commonly used probiotics include Bacteroides fragilis, various Bifidobacterium and Lactobacillus species, Escherichia, Enterococcus, Bacillus, Streptococcus thermophiles and Saccharomyces boulardii (yeast). Patients can take oral probiotics or simply eat more fermented foods, such as yogurt, kefir, kimchi, tofu, kombucha, sauerkraut, tempeh, natto, and pickles.

On the herbal side, demulcent plants repair irrigated GI mucosa and are generally ingested before meals to coat and protect the stomach. Common herbals include aloe, marshmallow, slippery elm, licorice and deglycyrrhizinated licorice (DGL), plantains, coltsfoot, and Irish moss.

Traditional Chinese medicine is another well-developed alternative. “Hot” foods such as fried and fatty foods, spicy foods, onions, garlic, cheese, chocolate, refined sugars, coffee, and citrus can trigger reflux. “Cooling” foods such as melons, leafy green vegetables, soy, and bitter melon can reduce reflux. Reducing hot foods in the diet and increasing cooling foods can improve LPR symptoms.

So can reducing stress, which triggers reflux via the brain-gut axis. Relaxation techniques can help, as can acupuncture that targets both GI symptoms and stress.

“The bottom line is that there are treatment options for patients who cannot or will not take PPIs,” Dr. Wang said. “By incorporating these alternatives, we can give patients new treatment options.”

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