Focus on gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR): new pragmatic insights in clinical practice.

Introduction: Gastroesophageal reflux (GER) is a common disease usually limited to the oesophagus. Laryngopharyngeal reflux (LPR) is an inflammatory reaction of the mucosa of pharynx, larynx, and other associated upper respiratory organs, caused by a reflux of stomach contents outside the oesophagus. LPR is considered to be a relatively new clinical entity with a vast number of clinical manifestations which are treated sometimes empirically and without a correct diagnosis. However, there is disagreement between specialists about its definition and management: gastroenterologists consider LPR to be a substantially rare manifestation of gastroesophageal reflux disease (GERD), whereas otolaryngologists believe that LPR is an independent, but common in their practice, disorder. Patients suffering from LPR firstly consult their general practitioners, but a multidisciplinary approach may be fruitful to define a unified strategy based on specific medications and behavioural changes. The present Supplement would review the topic, considering LPR and GER characteristics, pathophysiology, diagnostic work-up, and new therapeutic strategies also comparing different specialist points of view and patient populations. In particular, new insights derive from an interesting gel compound, containing magnesium alginate and E-Gastryal® (hyaluronic acid, hydrolysed keratin, Tara gum, and Xantana gum). In particular, two very large Italian surveys were conducted in real-world setting, such as outpatient clinics. The most relevant outcomes are presented and discussed in the current Issue. Actually, laryngopharyngeal reflux (LPR) is considered an extraesophageal manifestation of the gastroesophageal reflux disease (GERD). Both GERD and its extraesophageal manifestation are very common in clinical practice. Both disorders have a relevant burden for the society: about this topic most of pharmaco-economic studies were conducted in the United States. In population-based studies, 19.8% of North Americans complain of typical symptoms of GERD (heartburn and regurgitation) at least weekly (1). Also in the late 1990s, GERD accounted for $9.3 to $12.1 billion in direct annual healthcare costs in the United States, higher than any other digestive disease. As a result, acid-suppressive agents were the leading pharmaceutical expenditure in the United States. The prevalence of GERD in the primary care setting becomes even more evident when one considers that, in the United States, 4.6 million office encounters annually are primarily for GERD, whereas 9.1 million encounters include GERD in the top 3 diagnoses for the encounter. GERD is also the most frequently first-listed gastrointestinal diagnosis in ambulatory care visits (2, 3) Extraesophageal manifestations of reflux, including LPR, asthma, and chronic cough, have been estimated to cost $5438 per patient in direct medical expenses in the first year after presentation and $13,700 for 5 years.

Rethinking the laryngopharyngeal reflux treatment algorithm: Evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease.

OBJECTIVES/HYPOTHESIS: Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate once-daily, 40 mg omeprazole and once-nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up-front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high-resolution manometry (HRM) for potential cost minimization. STUDY DESIGN: Retrospective cohort review and cost minimization study. METHODS: A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up-front MII and HRM. RESULTS: Ninety-seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy-two subjects (74%) responded. Forty-eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty-nine (51%) subjects escalated to BID dosing. Twenty-four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty-five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up-front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS. CONCLUSIONS: An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high-dose PPI for 6 months. Overall per-patient cost appears less with up-front MII and HRM. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:S1-S13, 2017.