Medical Therapy for Supraesophageal Complications of Gastroesophageal Reflux

Abstract

Gastroesophageal reflux (GER) has been implicated in the pathogenesis of a variety of pulmonary, laryngeal, pharyngeal, and oral disorders. In assessing the impact of medical therapies for GER in these conditions, it is important to appreciate some of the inherent difficulties. First, many of these conditions are multifactorial, for instance, asthma, cough, globus, laryngitis, and dental erosion. This introduces difficulties in assessing the effect of treatment of GER. Second, particularly for the pulmonary complications, it is clear that GER can be a consequence rather than a cause of the problem. Third, once the damage has been done, for instance in the case of dental erosion, it may be irreversible. Difficulties then arise in deciding how to assess whether treatment of acid reflux has a beneficial impact: how can slowing of the erosion of dental enamel be assessed? It is difficult to envisage a long-term study comparing effective medical therapy with no therapy in GER patients to assess the rate of de novo dental erosion. Fourth, such conditions as globus and asthma exhibit temporal variability, making it difficult to interpret the clinical value of interventions, particularly if a minor effect is found. Finally, evaluation of treatment outcomes is in some instances dependent on subjective ‘‘soft’’ data (e.g., globus and to some extent for pulmonary complications, such as cough). These last 2 considerations emphasize the crucial importance of good randomized blinded trials in these conditions. With these difficulties in mind, the studies available to assess the impact of medical therapy of GER in these conditions will be reviewed with an attempt to assess the clinical value and place of such interventions.