Can diltiazem be used to treat esophageal spasms?

Diltiazem for Esophageal Spasms

Diltiazem can be used to treat esophageal spasms, with recent evidence showing it is effective for symptom relief in patients with distal esophageal spasm. 1

Mechanism and Rationale

• Calcium channel blockers like diltiazem relax smooth muscle, which is the physiological basis for their use in esophageal spasm disorders
• Diltiazem works by reducing abnormally high and prolonged peristaltic and nonperistaltic contractions in the esophageal body 2

Evidence for Efficacy

• A 2024 randomized controlled trial demonstrated that diltiazem effectively relieved symptoms in patients with distal esophageal spasm, showing a significant decrease in mean Eckardt score (2.57 points) and heartburn score (0.89 points) 1
• This study also showed improved quality of life in patients treated with diltiazem (increase in mean SF-36 score of 3.95) 1
• Earlier studies have shown mixed results, with some patients experiencing individual relief of dysphagia and chest pain symptoms 3

Dosing Recommendations

• For esophageal spasms, diltiazem is typically used at doses similar to those for cardiovascular indications
• Standard dosing is 30-90 mg orally three to four times daily for immediate-release formulations 4
• Extended-release formulations can be used at 120-240 mg once daily 4

Precautions and Contraindications

• Diltiazem is contraindicated in patients with:
  • Left ventricular dysfunction (LVEF <40%)
  • Decompensated heart failure
  • AV block greater than first degree
  • Sick sinus syndrome
  • Cardiogenic shock 4
• Use with caution in patients with:
  • Significant LV dysfunction
  • PR interval >0.24 seconds
  • Second or third-degree heart block without pacemaker 4

Monitoring and Side Effects

• Monitor for:
  • Blood pressure response
  • Heart rate and cardiac conduction
  • Signs of fluid retention (edema)
  • Symptoms of hypotension or bradycardia 4
• Rare but serious side effect: paralytic ileus has been reported with diltiazem use 5

Alternative Treatments

• Other calcium channel blockers like nifedipine have also shown efficacy in esophageal motility disorders 2
• The 2024 study found that fluoxetine (an SSRI) was similarly effective to diltiazem for symptom relief in distal esophageal spasm 1
• Other treatment options include:
  • Nitrates
  • Anticholinergic agents
  • 5-phosphodiesterase inhibitors
  • Visceral analgesics (tricyclic agents)
  • Esophageal dilation
  • Botulinum toxin injection
  • Surgical options (Heller myotomy or POEM) for refractory cases 6

Treatment Algorithm

1. Confirm diagnosis of esophageal spasm through appropriate testing (endoscopy, barium esophagogram, manometry)
2. Start diltiazem at 30 mg three times daily
3. Titrate dose up to 60-90 mg three times daily based on symptom response
4. Evaluate response after 4-8 weeks of therapy
5. If inadequate response, consider alternative pharmacologic therapy (fluoxetine, nitrates) or procedural interventions

Diltiazem represents a reasonable first-line pharmacologic option for patients with esophageal spasms who do not have contraindications to calcium channel blockers.