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.
