Objective:

Review evidence on H2-receptor antagonists for laryngopharyngeal reflux (LPR), including tolerance with continuous use and their role in current management.

Approach:

• Evidence reviewed: Investigators assessed gastroenterology and otolaryngology literature on sustained acid suppression, clinical use, and approaches to persistent symptoms.
• Clinical context: The review considered H2-receptor antagonists as alternatives or add-ons to proton pump inhibitors (PPIs) in suspected LPR.

Key Findings:

• Continuous H2-receptor antagonist use can produce tachyphylaxis, with reduced acid suppression within days and loss of effect reported by about day 5; dose escalation does not overcome this loss.
• A cited 2002 study found that the initial benefit of adding a bedtime H2-receptor antagonist to PPI therapy for nocturnal acid breakthrough was lost within 1 week, with no sustained gastric pH improvement after 28 days.
• The review describes H2-receptor antagonists as having a limited role in daily adjunctive therapy, with contemporary gastroenterology guidance favoring intermittent or as-needed use.
• LPR symptoms may persist for reasons other than inadequate acid suppression, including nonacid reflux components or mechanisms unrelated to reflux.
• For persistent symptoms, the authors favor reassessing adherence, dosing, and diagnosis, and considering objective reflux testing when appropriate.

Interpretation:

The authors state that tachyphylaxis evidence largely comes from gastroesophageal reflux disease studies, but consider the pharmacologic mechanism applicable to LPR. They note that LPR-specific guidance on the optimal role and duration of adjunctive H2-receptor antagonists remains lacking.

Limitations:

• Most evidence on H2-receptor antagonist tachyphylaxis was derived from patients with gastroesophageal reflux disease rather than LPR.
• Heterogeneous LPR mechanisms and variable responses to acid suppression complicate conclusions about prolonged dual therapy.

Conclusion:

The authors suggest intermittent rather than continuous H2-receptor antagonist use and phenotype-directed evaluation of persistent laryngopharyngeal symptoms.

Sources:

• OTO Open