Treatment for Laryngopharyngeal Reflux (LPR)
Lifestyle and dietary modifications combined with PPIs (when heartburn/regurgitation is present) form the evidence-based treatment for LPR, while PPIs alone without lifestyle changes are ineffective and should not be used as isolated therapy. 1
Initial Treatment Algorithm
For LPR with Heartburn/Regurgitation Present
Implement the following combination approach, as PPIs alone have failed to show benefit:
- Weight loss if BMI >25 1
- Elevate head of bed 1
- Avoid eating within 2-3 hours of bedtime 1
- Avoid trigger foods on an individualized basis 1
- Start twice-daily PPI therapy: esomeprazole 40 mg twice daily, omeprazole 40 mg twice daily, pantoprazole 40 mg twice daily, or rabeprazole 20 mg twice daily 1
This combination approach demonstrates superior outcomes compared to PPIs alone, with studies showing better cough outcomes when lifestyle modifications and weight loss were included. 1
For Isolated LPR Symptoms (No Heartburn/Regurgitation)
Do not prescribe antireflux medications without laryngoscopy first. 1 The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends against empiric PPI therapy for isolated dysphonia or LPR symptoms without laryngoscopic confirmation. 1
- Perform laryngoscopy to confirm laryngeal inflammation and exclude alternative diagnoses 1
- If laryngeal findings suggest LPR, consider objective reflux testing before empiric PPI therapy 1
- Implement lifestyle and dietary modifications as above 1
Expected Timeline and Response Rates
GI symptoms typically respond within 4-8 weeks, while LPR symptom improvement may take up to 3 months. 1 This delayed response is critical to understand, as premature discontinuation or escalation is common.
The evidence for PPIs in LPR is notably weak: of 9 placebo-controlled trials evaluating PPIs for LPR, only 3 showed improvement in voice symptoms, while the remainder found no difference from placebo. 1 Meta-analyses of 8 randomized controlled trials found no advantage for PPIs over placebo for GERD-related chronic laryngitis (relative risk 1.28; 95% CI 0.94-1.74). 1
Management of Treatment Failure
After one failed 3-month trial of appropriate therapy, perform objective testing rather than trying additional PPIs. 1
- Proceed to esophageal manometry and pH-metry 1
- Consider objective reflux testing before trying additional medications 1
- Evaluate for alternative diagnoses including laryngeal hypersensitivity, which may benefit from neuromodulators or behavioral interventions rather than acid suppression 1
Do not add nocturnal H2-receptor antagonists to twice-daily PPI therapy, as there is no evidence of improved efficacy. 1 H2-receptor antagonists are inferior to PPIs in acid suppression efficacy and develop tachyphylaxis with frequent use. 1
Critical Pitfalls to Avoid
Do not continue empiric therapy beyond 3 months without response—proceed to objective testing instead. 1 This is one of the most common errors in LPR management, leading to prolonged ineffective treatment and unnecessary PPI exposure.
Do not use PPIs as isolated therapy without lifestyle modifications. 1 The evidence clearly shows this approach is ineffective.
Be aware of PPI safety concerns with prolonged use: associations with impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease have been linked to long-term PPI therapy. 1 Short-term PPI benefits outweigh risks when there is a relevant indication (e.g., documented GERD), but prolonged empiric use without response should be avoided. 1
Special Considerations
Symptom improvement while on PPI therapy may result from mechanisms other than acid suppression and should not be regarded as confirmation of GERD as the underlying cause. 2 This placebo effect is substantial in LPR studies.
The presence of erosive reflux disease detected by endoscopy is predictive of a good treatment response of LPR symptoms to PPI treatment. 2 This supports the recommendation for objective testing in refractory cases.
For infants with laryngopharyngeal reflux, thickened feedings, positioning upright after feeding, and the use of histamine-2 receptor antagonists or proton pump inhibitors have become the mainstay of treatment. 3