Why proton pump inhibitors aren’t always the answer for silent reflux

Mark Watson, Consultant ENT Surgeon at The Coriel Clinic

Jane Shaw, Consultant Speech & Language Therapist, Doncaster and Bassetlaw Teaching Hospitals NHS Trust

Laryngopharyngeal reflux (LPR) – also known as silent reflux – is estimated to be responsible for up to 10 per cent of otolaryngology consultations, but is unfortunately still frequently missed due to gaps in the diagnostic pathway and the lack of a specific symptom profile.¹ This has led to GPs often relying on prescribing proton pump inhibitors and antacids to patients presenting with non-specific reflux symptoms. However, there is no strong evidence supporting the effectiveness of proton pump inhibitors when prescribed as standalone treatments for silent reflux, and there are concerns about the effects of their long term use. In this blog, Jane Shaw, Consultant Speech and Language Therapist, and Mark Watson, Consultant Laryngologist at Doncaster and Bassetlaw Teaching Hospitals NHS Trust, explore the challenges in the diagnosis of silent reflux, and explains how Peptest^® can play a pivotal role in efficiently directing treatment plans and referrals to specialist services, avoiding unnecessary prescription of proton pump inhibitors.

The impact of silent reflux

Voice disorders impact around four per cent of the UK population and can significantly hamper an individual’s quality of life and even their ability to work, costing the British economy an estimated £200 million every year.¹ These conditions can result from inflammation of the larynx, which hinders the ability to speak normally, leading to hoarseness, vocal fatigue, dysphonia and discomfort when speaking. Silent reflux, characterised by the regurgitation of stomach contents into the throat, can be one contributor to this inflammation.² Bubbles carrying an aerosol of stomach contents ascend beyond the oesophagus to the laryngeal and pharyngeal regions, where digestive enzymes trigger inflammation.

Recognising silent reflux as the underlying cause of a voice disorder is essential for prompt and precise therapeutic intervention. However, symptoms linked with this condition can be varied and are not specific to laryngopharyngeal reflux, such as hoarseness, excessive throat mucus, swallowing and breathing issues. Patients are typically given a self-reported questionnaire – a reflux symptoms index (RSI) – where they are asked to rate their symptoms and the impact on their life over a month. However, the absence of a distinct unique symptom profile complicates the accurate identification or exclusion of silent reflux based on symptoms alone, leading to the misdiagnosis and subsequent delays in appropriate reflux treatment. It is therefore helpful if this questionnaire is accompanied by efficient and accurate testing and laryngeal visualisation.

Are proton pump inhibitors the solution for silent reflux?

As a result of the growing awareness of the presentation of silent reflux, there is a developing tendency to empirically prescribe proton pump inhibitors for patients exhibiting non-specific throat symptoms in primary care. However, there is a lack of robust evidence that demonstrates the efficacy of proton pump inhibitors as standalone laryngopharyngeal reflux treatment, but optimal results are typically achieved through their combination with liquid alginate preparations containing sodium alginate – such as Gaviscon Advance – and lifestyle modifications.³ The safety of long term use of proton pump inhibitors has also been called into question recently, as they have been associated with an increased likelihood to contract enteric infections or pneumonia, and can impair the absorption of certain nutrients³ such as calcium. Gastric acid plays a crucial role in digesting and absorbing various vitamins and minerals from food sources, so reducing gastric acidity may lead to deficiencies in vitamin B12, magnesium, and iron, which can have further knock-on effects for health, such as worsening anaemias and compromising bone density.³ These risks and the general lack of understanding as to the efficacy of proton pump inhibitors highlight the need to focus on correctly diagnosing silent reflux in order to prescribe the appropriate treatment at the outset.

Peptest^® for silent reflux

At Doncaster and Bassetlaw Hospitals NHS Trust, we have added Peptest – an innovative, non-invasive diagnostic tool that detects pepsin in clinical samples from the upper digestive and respiratory tracts – into our diagnostic portfolio for patients with certain vocal changes. Peptest employs a dual monoclonal antibody capture method integrated into a lateral flow device, quickly and efficiently assessing patients’ saliva and sputum samples for pepsin. This biomarker is not typically found in saliva, so a positive test indicates that stomach contents are being refluxed into the throat. This provides ENT surgeons and speech and language therapists with crucial insights for the creation of informed treatment plans for patients suspected of having silent reflux.

The process of testing is very straightforward; patients are given the test alongside detailed, step-by-step instructions on how to collect saliva samples themselves at home. They then send their samples in the secure packaging provided to the dedicated laboratory for analysis. We receive test results directly from the lab, usually within 24 hours of receipt, which enables us to make a fast diagnosis, and plan personalised treatment and follow-up. Peptest can also be applied in primary care to efficiently direct referrals to our ENT service and support our team in investigating patients’ vocal health. In doing so, Peptest is helping to address the longstanding diagnostic gap for patients with silent reflux, establishing itself as a valuable diagnostic tool to enhance the quality of care for individuals grappling with voice disorders.

Optimising silent reflux management with Peptest

The rapid turnaround time and high accuracy of the test offer significant advantages over more time-consuming and invasive diagnostic methods, and we can use it to better understand a patient’s symptoms. By testing their pepsin levels first thing in the morning, as well as at intervals throughout the day, we can understand whether reflux is triggered nocturnally, postprandially or both. These results motivate patients to make appropriate lifestyle changes to reduce their reflux symptoms and improve their health. Overall, this approach can help to combat the risk of potential misdiagnoses, overreliance on proton pump inhibitors, and suboptimal treatment plans, resulting in benefits for both patients and the NHS.

Read this white paper to find out more about how Peptest is helping ENT and speech and language therapists at Doncaster and Bassetlaw Teaching Hospitals NHS Trust.

Click here to learn more about Peptest.

References

1. Dettmar PW, Watson M, McGlashan J, et al. A Multicentre Study in UK Voice Clinics Evaluating the Non-invasive Reflux Diagnostic Peptest in LPR Patients. SN Compr Clin Med. 2020;2(1):57-65. doi:10.1007/s42399-019-00184-0
2. Silent reflux. Doncaster and Bassetlaw Teaching Hospitals. Accessed: 17th April 2024. Available at: https://www.dbth.nhs.uk/wp-content/uploads/2017/07/WPR26112-Silent-Reflux-update.pdf
3. Priston, J. et al. 2014. Laryngopharyngeal reflux: Diagnosis, treatment, and latest research. International Archives of Otorhinolaryngology, 18(02):184-191. doi:10.1055/s-0033-1352504.