Treatment of laryngopharyngeal reflux (LPR) with alkaline water and the Mediterranean diet may be as effective as treatment with proton-pump inhibitors (PPIs), according to research published online in JAMA Otolaryngology-Head & Neck Surgery in September.1 Like a similar condition, gastroesophageal reflux disease, LPR occurs when acidic gastric juices in the stomach back up into the esophagus, but in LPR, the gastric juices reach the throat, resulting in symptoms like hoarseness, sore throat, and excessive mucus.
In the study, researchers conducted a retrospective medical chart review comparing the change in Reflux Symptom Index (RSI) in two groups of patients, those treated between 2010 and 2012 with PPIs and standard reflux precautions and those treated between 2013 and 2015 with a plant-based Mediterranean diet and alkaline water that had a pH of at least 8. The team found that 54.1% of patients in the PPI group achieved a clinically meaningful reduction of at least 6 points, but 62.5% in the dietary group achieved similar results. Furthermore, those in the dietary group achieved a greater reduction in RSI, 39.8% compared with 27.2% in the PPI group.
“It’s pretty clear that this data suggests that we, as health care professionals, need to start getting patients educated so they understand how important a role diet plays,” said study lead author Craig H. Zalvan, MD, FACS, chief of otolaryngology and medical director at The Institute for Voice and Swallowing Disorders at Phelps Hospital in Sleepy Hollow, NY. “Certainly with reflux, diet should at least be attempted at initial onset of treatment, with the goal of getting off medication.”
Preventing pepsin
Zalvan said he thought to study dietary treatment for LPR after seeing that a sizable number of patients don’t get much relief with PPIs.
“The standard of care for LPR has always been PPIs, and many of my patients got better with them, but a bunch didn’t. At most it helps about 50% of patients,” Zalvan said. “I looked at chronic diseases like heart disease, diabetes, and stroke, and much of focuses on diet, so I thought there’s got to be a better way to treat LPR with diet [as well] and not have people constantly taking pills.”
The improvements patients saw with the plant-based Mediterranean diet make sense, Zalvan said. “LPR is really a disease of pepsin. You chomp chicken, and it makes amino acids in the stomach with gastric release and more pepsin. If you decrease animal protein, you decrease pepsin.”
Zalvan added that the idea to incorporate alkaline water into treatment stemmed from prior research conducted by Jaime Koufman, MD, at the Voice Institute of New York in New York City, which suggests that alkaline water may benefit patients with reflux because it deactivates pepsin and acts as an acid-buffer.
In an accompanying commentary in JAMA Otolaryngology-Head & Neck Surgery, Robert T. Kavitt, MD, MPH, assistant professor of medicine in the Section of Gastroenterology at the University of Chicago Department of Medicine noted that patients frequently have concerns about long-term PPI use, and that “the findings from this study are intriguing and suggest a possible change in future treatment paradigms in the management of LPR should the findings be confirmed.”2
Adding pharmacists’ voices
Zalvan said that as medication experts and readily accessible members of the health care team, pharmacists can help boost the signal about treatment options for LPR.
“Pharmacists can reinforce that PPIs are meant to be short-term medications for an acute problem, and that in order to get off them, diet will play a major part,” Zalvan said. “If patients come to me and I say they should try diet, and then they go to the pharmacy and the pharmacist says they should try diet, patients are more likely to try diet.”
This extends to written information, Zalvan added. “Pharmacists can provide literature and education about diet. It would be great if they put up a big poster of different fruits and vegetables and asked patients ‘Have you considered diet to help you with your chronic conditions?’ This goes not just for PPIs, but for other medications like statins and diabetes medications. There are so many conditions where patients can lower their medications through a healthy diet.”
