Saturday, November 13, 2010
PPI proton pump inhibitors
SUMMARY AND COMMENT
Pregabalin for Chronic Prostatitis/Pelvic Pain
October 14, 2010 | Thomas L. Schwenk, MD | General Medicine
Improvement, albeit modest, suggests a neuropathic mechanism.
Reviewing: Pontari MA et al. Arch Intern Med 2010 Sep 27; 170:1586
Free Full-Text Article
Summary and Comment
PPIs for Laryngopharyngeal Reflux?
A close look at findings from a randomized, placebo-controlled trial show that the proton-pump inhibitor rabeprazole provided benefit in treating gastroesophageal — but not laryngopharyngeal — symptoms.
Proton-pump inhibitors (PPIs) initially showed promise as a treatment for laryngopharyngeal reflux (LPR; JW Gastroenterol Aug 11 2006). However, small, randomized, placebo-controlled trials have not documented meaningful clinical benefit (e.g., Am J Gastroenterol 2006; 101:1972). Now, in a trial funded in part by the manufacturer of the PPI rabeprazole, researchers randomized 82 patients who had been referred to an ear, nose, and throat (ENT) center for clinical LPR to receive rabeprazole (20 mg twice daily) or placebo for 12 weeks.
Patients met these criteria: (1) ≥1 LPR symptom — hoarseness, globus, persistent throat discomfort, or frequent throat clearing — for ≥1 month during the preceding year; (2) evidence of LPR on video laryngostroboscopy (VLS), with a reflux finding score (RFS) >7; (3) absence of upper respiratory tract infection during the previous 4 weeks and absence of allergic causes for laryngitis; and (4) no use of acid-suppressive therapy during the previous 4 weeks.
All participants underwent manometry and 24-hour pH testing with a probe that had four pH sensors, spanning from a distal position 5 cm above the lower esophageal sphincter to a proximal placement just distal to the upper esophageal sphincter. LPR was documented if the pH for the proximal sensor registered <4.0 for >0.7% of total time, for >1.1% of time in the upright position, or for >0.5% of time in the supine position; gastroesophageal reflux disease (GERD) was documented for corresponding values of >4.6%, >7.0%, and >4.5%. A (blinded) laryngologist performed all ENT evaluations and assessed the VLS exams (intrarater reliability, 0.93). LPR symptoms were also assessed using a reflux symptom index (RSI) and sequential RFS scoring. Evaluations occurred during treatment and at 6 weeks after treatment ended (week 18).
The mean RSI score had improved significantly more with rabeprazole than with placebo at week 6 (P=0.003) and at week 12 (P=0.002), but not at week 18. The benefits of the drug at week 12 were significant improvements in the following: breathing difficulty or choking (P=0.009), troublesome cough (P=0.006), and sensation of something in the throat (P=0.007). RFS scores did not differ significantly between rabeprazole and placebo recipients.
Comment: At first glance, these data suggest that PPIs might be effective for treating LPR and challenge the present consensus that "silent GERD" should not be suspected. However, as an editorialist notes, the apparent positive effect on LPR was probably attributable to how outcomes were assessed. The on-treatment RSI improvements were in symptoms typical of GERD (which respond to PPI therapy), not in symptoms typical of chronic laryngitis. The lack of improvement on laryngeal examinations is consistent with findings from previous randomized trials. Clearly, laryngeal irritation on ENT examination is extremely nonspecific and, as a general rule, should not suggest a diagnosis of LPR, as it does to many of our ENT colleagues.
— David A. Johnson, MD
Published in Journal Watch Gastroenterology November 12, 2010
Pregabalin for Chronic Prostatitis/Pelvic Pain
October 14, 2010 | Thomas L. Schwenk, MD | General Medicine
Improvement, albeit modest, suggests a neuropathic mechanism.
Reviewing: Pontari MA et al. Arch Intern Med 2010 Sep 27; 170:1586
Free Full-Text Article
Summary and Comment
PPIs for Laryngopharyngeal Reflux?
A close look at findings from a randomized, placebo-controlled trial show that the proton-pump inhibitor rabeprazole provided benefit in treating gastroesophageal — but not laryngopharyngeal — symptoms.
Proton-pump inhibitors (PPIs) initially showed promise as a treatment for laryngopharyngeal reflux (LPR; JW Gastroenterol Aug 11 2006). However, small, randomized, placebo-controlled trials have not documented meaningful clinical benefit (e.g., Am J Gastroenterol 2006; 101:1972). Now, in a trial funded in part by the manufacturer of the PPI rabeprazole, researchers randomized 82 patients who had been referred to an ear, nose, and throat (ENT) center for clinical LPR to receive rabeprazole (20 mg twice daily) or placebo for 12 weeks.
Patients met these criteria: (1) ≥1 LPR symptom — hoarseness, globus, persistent throat discomfort, or frequent throat clearing — for ≥1 month during the preceding year; (2) evidence of LPR on video laryngostroboscopy (VLS), with a reflux finding score (RFS) >7; (3) absence of upper respiratory tract infection during the previous 4 weeks and absence of allergic causes for laryngitis; and (4) no use of acid-suppressive therapy during the previous 4 weeks.
All participants underwent manometry and 24-hour pH testing with a probe that had four pH sensors, spanning from a distal position 5 cm above the lower esophageal sphincter to a proximal placement just distal to the upper esophageal sphincter. LPR was documented if the pH for the proximal sensor registered <4.0 for >0.7% of total time, for >1.1% of time in the upright position, or for >0.5% of time in the supine position; gastroesophageal reflux disease (GERD) was documented for corresponding values of >4.6%, >7.0%, and >4.5%. A (blinded) laryngologist performed all ENT evaluations and assessed the VLS exams (intrarater reliability, 0.93). LPR symptoms were also assessed using a reflux symptom index (RSI) and sequential RFS scoring. Evaluations occurred during treatment and at 6 weeks after treatment ended (week 18).
The mean RSI score had improved significantly more with rabeprazole than with placebo at week 6 (P=0.003) and at week 12 (P=0.002), but not at week 18. The benefits of the drug at week 12 were significant improvements in the following: breathing difficulty or choking (P=0.009), troublesome cough (P=0.006), and sensation of something in the throat (P=0.007). RFS scores did not differ significantly between rabeprazole and placebo recipients.
Comment: At first glance, these data suggest that PPIs might be effective for treating LPR and challenge the present consensus that "silent GERD" should not be suspected. However, as an editorialist notes, the apparent positive effect on LPR was probably attributable to how outcomes were assessed. The on-treatment RSI improvements were in symptoms typical of GERD (which respond to PPI therapy), not in symptoms typical of chronic laryngitis. The lack of improvement on laryngeal examinations is consistent with findings from previous randomized trials. Clearly, laryngeal irritation on ENT examination is extremely nonspecific and, as a general rule, should not suggest a diagnosis of LPR, as it does to many of our ENT colleagues.
— David A. Johnson, MD
Published in Journal Watch Gastroenterology November 12, 2010
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