重新思考喉咽反流治疗方案：评估一种替代的经验性给药方案，并考虑采用预先的pH阻抗测试和测压测试，以尽量降低疑似喉咽反流疾病的治疗成本。
Rethinking the laryngopharyngeal reflux treatment algorithm: Evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease.
作者信息
Carroll Thomas L, Werner Astrid, Nahikian Kael, Dezube Aaron, Roth Douglas F
机构信息
Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A.
Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.
出版信息
Laryngoscope. 2017 Oct;127 Suppl 6:S1-S13. doi: 10.1002/lary.26806. Epub 2017 Aug 26.
OBJECTIVES/HYPOTHESIS: Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate once-daily, 40 mg omeprazole and once-nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up-front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high-resolution manometry (HRM) for potential cost minimization.
STUDY DESIGN
Retrospective cohort review and cost minimization study.
METHODS
A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up-front MII and HRM.
RESULTS
Ninety-seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy-two subjects (74%) responded. Forty-eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty-nine (51%) subjects escalated to BID dosing. Twenty-four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty-five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up-front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS.
CONCLUSIONS
An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high-dose PPI for 6 months. Overall per-patient cost appears less with up-front MII and HRM.
LEVEL OF EVIDENCE
- Laryngoscope, 127:S1-S13, 2017.
目的/假设：针对喉咽反流（LPR）进行经验性质子泵抑制剂（PPI）试验很常见。大多数患者对抑酸治疗有反应。本研究旨在评估每日一次40mg奥美拉唑和每晚一次300mg雷尼替丁（QD/QHS）的给药方案作为替代方案，并利用本研究队列评估针对LPR的经验性给药方案，与采用带有双pH探头的pH阻抗多通道腔内阻抗（MII）和高分辨率测压法（HRM）进行预先检测相比，以实现潜在的成本最小化。
研究设计
回顾性队列研究和成本最小化研究。
方法
通过病历审查确定被诊断为LPR的患者。所有受试者均接受序贯治疗并记录结果。如果3个月后无改善，初始QD/QHS给药剂量增加至每日两次（BID），如果每日两次给药失败，则最终进行MII和HRM检测。构建决策树图以确定两种经验性给药方案以及预先进行MII和HRM检测的成本。
结果
97名受试者符合标准。确定了经验性治疗的反应者和无反应者。72名受试者（74%）有反应。48名（占反应者的67%，占所有受试者的49%）通过QD/QHS给药得到改善。49名（51%）受试者升级为每日两次给药。24名受试者（占反应者的33%，占所有受试者的25%）在每日两次治疗中得到改善。25名受试者（26%）对抑酸治疗无反应。预先检测的平均加权成本为每位患者1897.00美元，初始每日两次给药为3033.00美元，初始QD/QHS给药为3366.00美元。
结论
替代的QD/QHS给药方案使大多数疑似LPR患者的病情得到改善。成本估算表明，QD/QHS给药方案在6个月内比初始每日两次高剂量PPI更昂贵。总体而言，预先进行MII和HRM检测时每位患者的成本似乎更低。
证据水平
4级。《喉镜》，2017年，第127卷：S1 - S13。
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