Category Archives: Health Issues 2011

Why do Proton Pump Inhibitors get used for LPR?

Before the midnight service last week I was sat talking to a relation of one of one of the sides people who was staying over Christmas and had come along to the service. As is often the case we got onto my ongoing medical issues – it often comes up when they find out that I’m usually in the choir and ask why I’m not at whatever service it is we’re attending. This time the conversation was more interesting because the person I was speaking to was from a medical background.

First off she hadn’t heard of laryngopharyngeal reflux, so I explained what my symptoms were and what had been diagnosed, we then got onto the treatment I was on, in this case 30mg of Lansoprazole daily. Although she didn’t say it outright, she seemed somewhat concerned at the fact it had been prescribed, and also how long I had been taking it.

Anyway, after that I’ve had a bit of a look at some of the discussion about the use of Lansoprazole, and Proton Pump Inhibitors in general for the treatment of laryngopharyngeal reflux.

Probably the most interesting is one that comes up in Google pretty easily, a paper written by Christina Reimer and Peter Bytzer of the Department of Medical Gastroenterology, Køge University Hospital, Denmark entitled “Management of laryngopharyngeal reflux with proton pump inhibitors”. The interesting part is when it gets on to reviewing the number of medical trials, in particular the double blind studies, the first paragraph of their summary makes the point pretty clearly:

Data from controlled treatment trials convincingly show that PPI therapy is no more effective than placebo in producing symptom relief in patients suspected of laryngo-pharyngeal reflux disease. Furthermore, neither symptoms, nor laryngoscopic findings or abnormal findings on pH monitoring will predict response to PPI therapy. A reliable diagnostic test for LPR or one that might predict response to a PPI does not exist.

When you actually look at the figures, in some of the trials the placebo group had a greater symptom relief than those on the drugs, and of the studies reviewed only one showed a statistically significant higher rate for the group taking the drug. As the paper says, given these results, why do patients still get put on a PPI as a first course of action?

Certainly that was what happened in my case, and I’ve been on it since September, more than three months. Both my ENT and my GP have very matter-of-factly suggested that I could be on them long term if when I come off them symptoms return – this then was rather interesting when I pointed out to the GP that there is a well known (though not to him it seems) rebound effect from PPI use.

In my case, although it changed what was happening, the Lansoprazole certainly didn’t stop me refluxing, if anything I was refluxing more, and pretty consistently over the past couple of weeks within an hour or so of taking the pill. Since my throat has apparently healed the thought was that it changed the pH of what was refluxing, without actually addressing the underlying problem of what was causing me to reflux. Anyway, the latest run of pills finished over the holiday, and since my ENT has now declared that I am better I’ve tried coming off the Lansoprazole, and thus far I’ve not had any real problems, indeed although there have only been a couple of repeats of the nasty tasting reflux the pill used to induce they have been less than I was getting. It’s just a question now of waiting for my digestive system to recover from the long term effects of the PPI…

Health Update

Throat 1I’m just back from a follow up visit to my ENT specialist at the hospital having a check up and getting the results of the biopsy they took during my microlaryngoscopy.

The good news is that the biopsy came up all clear, i.e. benign and not cancerous. He’s also happy that the inflammation is continuing to go down so although I’m still refluxing stuff it’s not the acid that was causing the damage. Next on the agenda is some sessions with a speech therapist as I still get discomfort from my throat when I try to sing so I suspect I’m going to need to work back up to what I was doing before. As before he used an endoscope to check out the state of my throat, and since the speech therapist will need to see what is going on in my throat he took two pictures and gave me a copy, so what you can see here is one of two shots taken during the session. It’s worth noting that the original shots look a lot more pink than what the scanner has produced.

What is interesting is having asked me to sing a note whilst he was looking at my throat he said that I have an asymmetrical voice box – not uncommon apparently. Looking at the picture, front is at the bottom of the picture so the left side of my voice box is on the right of the picture and the right is on the left. Anyway, you can pretty clearly see my right vocal fold, but the left hand one is slightly hidden. When I sang a note the right side apparently moved a lot more than the left with the left remaining largely hidden. Now of course they can’t say whether it was like that before all this started, or whether it’s always been like that, but I guess we’ll find out when I start seeing the speech therapist next year. Aside from that I’m still on the Lansoprazole, although once things settle down that will be tapered down to the 15mg dose and then hopefully to none, but that will be under the care of my GP rather than keeping needing to go back to the hospital.

Beyond Zero Week Walking

This week at work is “Beyond Zero” week. Most large companies I’ve come across have something similar, basically it is a week focusing on health and safety, combine with personal health stuff too. The name refers to the aim to go beyond zero accidents by ensuring positive health and well being for the employees.

Anyway, during the week there have been various activities going on across the company including checking tyre tread depths on people’s cars on one site, free safety kit given out for us to use at home, and a number of different healthy activities to try. With my current health issues I’m rather limited in what exercise I’m allowed to take in order to avoid stomach acid sloshing about too much, however I did get some company on my lunchtime walk yesterday with a good crowd of people coming out to walk just over 4km from the office through Diamond Ridge Woods and up onto the edge of Old Dean Common, easily completed in about 45 minutes.

I’ve fed the track data from my GPS into Google Earth to get a nice picture for the Beyond Zero Week report, but I thought I’d post the picture here too.

20111103-102305 PM.jpg

Health Update

As I hadn’t written an update on my ongoing health problems, I thought I’d write an update.

Six weeks ago as things weren’t really clearing up I went back to see my ENT specialist. He did a full set of allergy tests and also used an endoscope to check out my throat.

The allergy tests confirmed that I was massively allergic to grass, which I knew about, but also allergic to house dust mites which I didn’t know about. However the endoscopy identified what has probably been the source of a lot of my problems over the past months.

Although I haven’t been getting any traditional heartburn symptoms the endoscope showed clear evidence of damage to my throat, and also a growth near my vocal cords, so the consultant diagnosed LPR or silent reflux, putting me on a course of daily Lansproprazole, a proton pump inhibitor that stops acid production in the stomach, along with doses of Gaviscon Advance after every meal, plus a stronger nasal steroid spray for the allergies.

Yesterday was the follow up appointment where although the granuloma had shrunk a little, my consultant wasn’t happy so I’m going into hospital next month for a microlaryngoscopy to remove the granuloma so they can biopsy it and ensure it’s not cancerous.

Of course it’s always rather scary when the ‘C’ word is mentioned, but he assured me he was 95% certain it was a benign growth, but he just wanted to be sure. He did offer to do some work on my nasal passages as well at the same time, as I’d be under a general anaesthetic for the microlaryngoscopy, but since my nose hasn’t really given me that much problem aside from running a lot during the summer I thought it was best not to have things done there if not strictly necessary.

Having been diagnosed with LPR there have been a number of changes. First off my diet has changed. We’re following the diet set out in a book called Dropping Acid, which is cowritten by one of the leaders in the field Jamie Koufman. I’m also now avoiding eating within 3-4 hours of bedtime, ensuring that there is minimal stuff in my stomach to reflux back during the night. To further ensure that I’m also now sleeping with a special wedge pillow that angles everything so my throat is above my stomach. I’m also not allowed to sing, which is most frustrating, and need to be careful of any activity that could cause stomach contents to back flow, so lots of bending and lifting is out too.

As to what caused the problem, nobody seems to know. There are a lot of online discussions with a remarkable number of people who had LPR develop after a heavy cold, which of course I had. The other option is that maybe I’ve got a hiatal hernia, which is when the top of the stomach comes through the hole in the middle of your diaphragm. In general since it’s a relatively newly identified condition doctors don’t seem quite sure. For the moment though it’s Lansproprazole and Gaviscon regularly and watching what I eat.

Diet and Lifestyle Changes

This post is one of a series about the ongoing health issues I have had recently beginning in February 2011.

Once the GP and Ear Nose and Throat specialist had established that there wasn’t really anything significant wrong, the general advice was that I needed to ride out the infections, but would benefit from some lifestyle changes.

Of course this is the same sort of general healthy living advice that I suspect most people get when they visit their GP – certainly a colleague at work said he gets much the same every visit to his GP, however like most people I wasn’t eating as healthily as I could, and certainly wasn’t getting enough exercise.

I’d already changed some things as a result of the effects of the post nasal drip. For two or three months I’d been getting morning nausea, which really wasn’t helped by having milk on cereal in the morning. For part of the time I’d just cut out the cereal, but that left me feeling decidedly hungry by lunchtime. Since the previous belief that too many eggs were bad for you had been changed recently I decided to try poached eggs for breakfast – Sam had already developed a bit of a liking for eggs for breakfast too, so it wasn’t too much of a problem to change. The change was also beneficial in cutting my sugar intake, as the muesli I was having had rather a lot of sugar I discovered when I was advised to cut down.

So why cut down on sugar? If you take a look at this WebMD list of immune system busters and boosters third on the list is sugar intake – apparently it can have a dramatic effect on the immune system and it’s ability to fight infection, indeed Sinus Survival, one of a number of deal with your sinus problem guides that are available recommends cutting refined sugar and dairy products totally when you are suffering from a sinus infection.

I’ve had not too much problem cutting out sugar as I’ve never been a great one for snacks, however when the birthday cakes come out at work I have to keep temptation under control. Having said that wanting to end months of being ill is a good way to keep it at bay!

Dairy wise again I’ve pretty well cut it out, but then I never had much dairy anyway, aside from milk on breakfast cereal I’ve just had to stop having cheese. Beth has also cut down on sugar and dairy, although going dairy free was something she was thinking about anyway having had a friend who had children who were lactose intolerant, and had gone dairy free as a family for convenience, and then ended up feeling better for it. In the case of sinus problems the reason for doing so is that dairy products are believed to cause an increase in mucus production, so by cutting it out it reduces the mucus.

The other recommendation from the GP was to start taking some multivitamins, so I’ve joined Beth and the children in taking my vitamins every morning – initially an immune building mix but subsequently myself and Beth are both having the same standard multivitamin.

Alongside this we’ve increased our fruit intake – so we’re certainly eating more than our five a day I’m sure. But the big change on my part is that I’m making time for a walk, often at lunchtime, but with a longer walk at weekends.

Although I work in a town centre, I’m lucky that five minutes drive up the road are the RMA Sandhurst training grounds. Although I have tried walking up there, in the limited time available in a lunchtime it means you end up spending 20-30 minutes walking alongside traffic choked roads, and only get a limited time out in the public parts of the training grounds. Driving up gives time for a 2-3km walk in the hour for lunch. There are plenty of paths to explore, and even a couple of geocaches that I’ve picked up. If I want a shorter walk, heading from the office up to the Camberley Obelisk is about 1km there and back, even if the Obelisk itself is in a bit of a sorry state nowadays and the view is mostly obscured by trees. (Saddleback Hill in the RMA Sandhurst training grounds gives a much better view.)

I’ve also done longer walks in and around Arborfield and Finchampstead. There is a nice circuit from St James’ down through the village and across to Fleet Hill and back, and there would be an equally nice circuit from home around to Arborfield village if it wasn’t for the fact that one key path from Langley Common Road to the village appears to end at a dead end at somebodies back fence! I’ve also picked up quite a few of the local geocaches over towards Farley Hill.

Certainly the diet changes and exercise are making me feel better, but until the hayfever season is over, it remains to be seen whether I’ll finally beat the sinus problems!