Laryngopharyngeal Reflux (LPR) and Treatment Options

What is LPR?
Most people have experienced acid reflux before. Eating a pizza with a beer is enough to trigger those
uncomfortable symptoms of chest pain, heartburn, and nausea.

While these symptoms clearly indicate gastroesophageal reflux disease (GERD), some people may not
develop any obvious signs of GERD. In this case, we call it silent reflux.

Laryngopharyngeal reflux (LPR), or silent reflux, doesn’t typically cause symptoms. Simply, the contents
of your stomach go up the esophagus, then find their way to your throat, nasal passages, and voice box.
In medicine, we refer to these structures as the larynx and pharynx, hence the name laryngopharyngeal
reflux.

The unusual thing about LPR is that you may have the condition without ever noticing it. This is, of
course, until some serious complications begin to emerge.

From a prevalence point of view, GERD is extremely common. According to studies, GERD affects 20% of
all Americans. LPR, on the other hand, is less prominent. Still, millions of people have it.

Note that infants and children are more likely to develop LPR due to the weak esophageal muscles and
the prolonged time in the supine position.

In this article, we will cover everything there is to know about laryngopharyngeal reflux, including
how to treat it. We will also discuss a very important topic – Why proton pump inhibitors may be
harmful in the long-term.

What are the signs and symptoms of LPR?

As just mentioned, LPR patients may not experience the classic symptoms of GERD. In some cases, the
symptoms of LPR may be confused for GERD, and vice versa.

With that said, LPR has a unique clinical presentation, which includes:

• Chronic cough
• Sore throat
• Vocal hoarseness (i.e, dysphonia)
• Difficulty swallowing (i.e., dysphagia)
• Swollen and sore larynx aka “voice box”
• Feeling mucus at the back of your throat

LPR vs. GERD – Similarities and Differences

An abnormally relaxed lower esophageal sphincter (LES) can lead to the regurgitation of your stomach
content to the esophagus. The function of the LES is to keep gastric content in the stomach. When it
doesn’t work properly, both GERD and LPR develop.

While LPR and GERD are quite different from one another, they have a few similarities. For instance,
both conditions may affect healthy individuals.
They also share the same risk factors, including:

• Obesity
• Smoking
• Excessive drinking of alcohol
• Binge-eating
• Pregnancy

Moreover, you can have LPR and GERD at the same time. In fact, many healthcare professionals
consider LPR to be a symptom of GERD. On the other hand, others find it beneficial to treat the two
conditions separately.

Still, LPR and GERD do not always occur simultaneously. Some patients may have GERD without LPR and
vice versa. What’s concerning, however, is having asymptomatic LPR. Your larynx and pharynx will be
inflicted with chronic damage without you even knowing about it.

Note that researchers found a solid connection between high pepsin levels in the throat and airways and
LPR. This enzyme is responsible for breaking down protein. Therefore, it may play an important role in
the pathogenesis of LPR. With that said, the activity of pepsin significantly drops in areas with high pH. It
is thought that gaseous pepsin is deposited in the throat and is activated when either acid reflux or
acidic food or drink contacts the pepsin. Activated pepsin can break down the proteins in the mucous
membranes of the throat causing the inflammation and pain of LPR.

How to diagnose LPR and GERD

The diagnosis of LPR and GERD follows the usual routine of medicine:

Taking your medical history

Your doctor will ask you about the symptoms you’ve been experiencing. He/she will also ask about your
symptoms duration, dietary habits, triggering factors, and relieving factors. The information gathered at
this step is the most important to make an accurate diagnosis. Therefore, do your best to be transparent
with your doctor.

Conducting a physical examination

A physical examination to diagnose LPR and GERD is typically normal. However, it could reveal
complications of GERD, including pneumonia. In this case, your doctor will listen to your lungs using a
stethoscope.

Ordering some follow-up tests

Follow-up tests are important to diagnose both conditions. However, they are not always necessary.
Tests become indispensable when your symptoms have been going on for too long. For example,
Barrett’s esophagus is one key complication of GERD. Unfortunately, it is a precancerous state. In other
words, if not treated swiftly, it may develop into esophageal cancer. To assess the damage inflicted on
your esophagus, your doctor will order an upper endoscopy (i.e., fibroscopy).

We have written an article on Barrett’s esophagus. Learn more about Barrett’s esophagus and the
tests used to diagnose it by clicking here.

Another test that your doctor may order is an ambulatory acid (pH) probe test. To conduct this test, a
monitor probe is placed in your esophagus. To attach the monitor, your doctor will use an endoscope.
This test provides the following data:

• The frequency of acid reflux episodes (i.e., when the acid leaks back to the esophagus)
• The quantity of acid that reaches the esophagus
• The duration that the acid remains in your esophagus

If a diagnosis of LPR is determined, you may need to see a specialist. The expert in this field is an
otolaryngologist. We colloquially refer to these specialists as ear, nose, and throat (ENT) doctors.

The current standard of care for LPR is empiric trial of a PPI, but is that truly the best way to treat LPR?

The dangers of long-term PPI use

Proton pump inhibitors (PPIs) are drugs that interfere with the release of acid in the stomach. This
increases the pH of stomach content, which lowers the risk of having symptoms. Common PPIs include
omeprazole (Prilosec), lansoprazole (Prevacid), dexlansoprazole (Dexilant), esomeprazole (Nexium),
pantoprazole (Protonix), and rabeprazole (Aciphex).

Before the invention of PPIs, people who experienced severe GERD, gastritis, and other acid-related
disorders had to undergo a procedure where the stomach was surgically removed. Therefore, when PPIs
became available for public use it was like a revolutionary drug.

For many years, PPIs were considered safe and well-tolerated. However, recent research suggests there
is more to the story.

PPIs and C. difficile infection

One study found that using PPIs in the long term disrupts the normal flora of the gut. As a result, your
risk of infections, nutritional deficiencies, and osteoporosis increases dramatically. The bacteria in your
gut have many roles, including the digestion of food, mood stabilization, and production of certain
nutrients. Remove them from the equation, and a whole bunch of disorders emerge.

Another study noted a relationship between PPIs and the proliferation of Clostridioides difficile
(formerly known as Clostridium difficile) spores, increasing the risk of severe infection.

What’s more, PPIs disrupt the function of leukocytes (i.e., white blood cells) by preventing them from
phagocytosing germs. This also increases the risk of C. difficile infection.

Symptoms of C. difficile infection include:

• Dehydration
• Fever
• Nausea
• Watery diarrhea
• Abdominal cramping
• Tachycardia (i.e., rapid heart rate)
• Increased white blood cell count
• Kidney failure
PPIs and magnesium deficiency
The United States Food and Drug Administration (FDA) even released a public safety announcement,
warning people of the long-term use of PPIs. Agents at the FDA found that this drug lowers magnesium
(Mg) levels, which is a severe complication that disrupts:

• Cardiac function
• Muscle contraction and relaxation
• Electrical heart rhythms
• Brain signaling pathways

According to the FDA, a quarter of cases related to PPIs and magnesium deficiency did not improve after
Mg supplementation. As a result, doctors had to discontinue PPIs in these patients.

For transparency’s sake, the FDA noted that the risks associated with PPIs are more likely to occur with
prescription drugs. This is because over-the-counter (OTC) PPIs usually come in lower doses. With that
said, abusing the intake of OTC PPIs can still cause magnesium deficiency and other side effects. PPIs
were originally intended only to be used for a two week treatment period up to three times per year,
not indefinitely.

PPIs and community-acquired pneumonia

In a 2018 study, scientists attempted to analyze the risk of community-acquired pneumonia after long-
term use of PPI. The study included more than 75,000 individuals aged 60 years and more. These
participants had a medical reason to take prescription PPIs for one year or longer.

During the second year of treatment, the risk of community-acquired pneumonia increased significantly.
The results were contrasted with pretreatment pneumonia incidence.

The mechanism behind this predisposition is multifactorial. However, researchers think that PPIs lower
the acidity of the stomach, allowing bacteria that usually wouldn’t survive in an acidic environment to
grow and reach the lungs via aspiration.

PPIs and dementia

Another complication of long-term use of PPIs is the increased risk of dementia. This primarily occurs in
elderly people.

One prospective study followed participants who took PPIs for at least 3 months in an 18-month
window. Not all participants used PPIs. Some were used as a control group.

After the 8th-year follow-up, researchers found that people who used PPIs had a 44% increase in the risk
of developing dementia compared to the control group. The PPIs in question were omeprazole
(Prilosec), pantoprazole (Protonix), and esomeprazole (Nexium). The researchers concluded that the
avoidance of PPI medication may prevent the development of dementia. This finding was supported by
recent epidemiological analyses on primary data and is in line with mouse models in which the use of
PPIs increased the levels of β-amyloid in the brains of mice.

PPIs and the risk of kidney disease

Shortly after the introduction of PPIs, case reports emerged suggesting an association between PPI use
and damage to kidneys, specifically the development of acute interstitial nephritis (AIN). The first large-
scale study examining the relationship between PPI use and Chronic Kidney Disease (CKD) included two
individual patient cohorts intended to represent the general population. In each group both the
adjusted and unadjusted analysis found a significant positive relationship between PPI use and the
development of CKD. A 2016 study found that PPI use was associated with a higher incidence of CKD,
kidney disease progression, and end-stage renal disease (ESRD). The mechanism responsible for the
association between PPI use and CKD is not well understood. It is postulated that acute interstitial
nephritis (AIN) caused by PPI use can lead to the development of CKD.

Why are PPIs not the best option for LPR?

Conventionally, general practitioners treat LPR with PPIs to relieve persistent throat symptoms. The
logic is lowering the acidity of the stomach to minimize throat damage. While this treatment may
provide temporary relief, it is not a long-term solution. As we detailed above, the chronic intake of PPIs
may cause severe complications. To make things worse, there is little evidence to support the
effectiveness of PPIs in the treatment of LPR.

One study attempted to study the effects of lansoprazole on LPR. This study recruited 346 participants
who had unexplained throat symptoms. These symptoms were present for 6 months or more at the
time of the study.

The authors of the study divided participants into two groups:

The first group – They took lansoprazole.

The second group – They took an identical-looking pill without any effects (a placebo).

Of course, participants from both groups didn’t know whether they were taking the real pill or a
placebo. The frequency of pill intake was two pills per day for 16 weeks.

The study found that PPI doesn’t improve throat symptoms. The authors emphasized that routine
prescription of lansoprazole and other PPIs for unexplained throat symptoms is not evidence-based and
should stop. They also insisted on the benefits of finding alternative therapies for throat symptoms.

Analyzing the questionnaires revealed that both groups reported the same symptom improvements.
Therefore, there was no evidence that lansoprazole was effective.

Also, new research shows that alkaline and weakly acidic LPR are more prevalent than previously
presumed because they concern more than 50% of patients. These patients often do not respond at all
to PPI therapy and require alginate therapy to control the alkaline component of reflux.

How alginate therapy works

Alginate is an anionic polysaccharide occurring naturally in brown algae, aka seaweed. Alginate therapy
works by creating a low-density viscous gel raft, that can last up to four hours, when alginate and
bicarbonate contact stomach acid. This raft acts as a physical barrier at the opening of the stomach to
prevent the leakage of acid as well as gaseous pepsin. Since it is a physical barrier even a gas can’t get
through!

Unlike PPIs and other conventional treatments of LPR, alginate therapy takes action immediately.
Therefore, once you take an alginate-bicarbonate preparation, the damage that’s being done to your
throat and voice box will stop at that moment. Unlike PPIs, alginate therapy is non-systemic. This means
that alginate therapy works by forming a physical foam barrier at the lower esophageal junction and its’
effect stays there. As we have seen, the PPI mechanism of action of cutting off acid production has side
effects that affect multiple body systems (stomach, brain, kidneys) with long-term use. Alginate therapy
is also safe for use while pregnant.

The good news is that alginate therapy’s effectiveness has been extensively tested by researchers. The
vast majority of studies in this field confirmed the positive effects of these preparations without any
known side effects.

We covered some evidence-based findings regarding alginate therapy in this article.

Why is Nutritist’s Refluxly the best choice for LPR?

A recent 2021 study enrolled 100 outpatients with LPR. Alginate treatment was administered for two
months. Patients underwent four visits (at baseline and 15, 30, and 60 days after treatment). A visual
analog scale assessed the perception of dysphonia, dysphagia, and cough. Alginate significantly
(p<0.0001) reduced all parameters. Therefore, the study demonstrated that alginate was effective and
safe in LPR treatment.

Nutritist Refluxly is the best alginate-bicarbonate supplement on the market today.

Because Alginate preparations are sold in the form of supplements, there are no regulations that
instruct manufacturers on how to develop these products. Many manufacturers use a random
assortment of ingredients or a “proprietary alginate complex” so you don’t know what dosage of the
ingredients you are taking. Sometimes manufacturers include ingredients that you don’t want like
aluminum and saccharin. Nutritist’s founder is an MD who studied clinical research papers such as the
ones mentioned in this article and used the ingredients mentioned in the papers in their correct
effective dosages when he created Refluxly. In addition to the ingredients necessary to form a strong
alginate raft, Refluxly also contains strawberry powder. Research has shown that strawberry powder can
help prevent esophageal cancer.

Anyone with LPR should be taking Refluxly by Nutritist. Why? Because of three reasons:

First, LPR is a chronic condition that requires long-term therapy. Opting for a PPI for long-term use is not
a good choice due to all the factors listed earlier.

Next, LPR is mostly asymptomatic. Hence, you might not know about it even though it’s damaging your
throat. In this case, would you prefer to take a natural supplement without any reported side effects or
a PPI?

Lastly, more than 50% of people with LPR have alkaline LPR or weakly acidic LPR. PPIs will not help
much, if at all, for these people. Because alginate works by forming an actual physical barrier when it
along with bicarbonate reacts with stomach acid, it doesn’t matter whether the LPR is alkaline or acidic.
Either way, its blocked!

These three reasons should be enough to make you choose Refluxly to solve LPR.

If you are ready to make the smart choice like many of our readers already have check out Refluxly by
going to https://amzn.to/3ThuFbg
Takeaway message
LPR, or silent reflux, is a mostly asymptomatic condition that wreaks havoc on the larynx and pharynx,
causing all sorts of complications. Unfortunately, these complications do not give us any warning signs,
meaning we only learn about them when it’s too late. So, how can you treat a condition if you don’t
know it’s there? One might think that PPIs are the answer. Unfortunately, the long-term complications
of these drugs are just too scary to take the risk. Also, the evidence that they actually work to treat LPR
is just not compelling enough.

For this reason, we recommend that people with GERD or suspected LPR should take Refluxly to address
their symptoms. It is a safe, natural supplement that uses basic chemical knowledge to protect your
esophagus from acidic damage. Pregnant women will be glad to hear that Refluxly is safe to take during
pregnancy.

We hope that this article managed to highlight the different aspects of LPR and how it’s different from
GERD.

If you have any questions, concerns, or personal experiences with LPR, please do not hesitate to share
your thoughts in the Comments section. You can also reach us on Twitter: @nutritist_real

#laryngopharyngealreflux #reflux #LPR #silentreflux #respiratoryreflux #healthcare #airwayreflux

#pepsin

Disclaimer: This article is not intended to provide medical advice. This article is intended for
informational and educational purposes only and is not intended to substitute for professional medical
advice, diagnosis, or treatment. Please consult your physician for medical advice.

Originally published at https://www.nutritist.us/post/laryngopharyngeal-reflux-what-is-it-and-how-do-

we-treat-it