What is the medical management of achalasia cardia?

Medical Management of Achalasia Cardia

Medical therapy with smooth muscle relaxants (nitrates and calcium channel blockers) is substantially less effective than invasive procedures and should only be reserved for patients who are poor candidates for definitive treatment due to significant side effects, drug tolerance, and inadequate symptom relief. 1, 2

Role of Pharmacologic Therapy

Medical management plays a limited role in achalasia cardia:

• Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals can improve dysphagia temporarily, but side effects and drug tolerance are common, making them unsuitable for long-term management 1
• These medications do not provide adequate relief of dysphagia and have substantial side effects, thus are rarely used as long-term therapy 2
• Medical therapy is much less effective than invasive procedures (pneumatic dilation, surgical myotomy, or POEM) 1

Botulinum Toxin Injection

Botulinum toxin injection (100-200 units) into the lower esophageal sphincter provides only short-term symptom relief and should be reserved exclusively for elderly patients or poor surgical candidates:

• Endoscopic injection gives short-term relief of symptoms and improves esophageal emptying 1
• Most effective in elderly patients, where symptom relief can last 1-2 years with a single injection 1
• Initially enjoyed enthusiasm but was shown to have only transient effect and is now recommended only for poor operative candidates 2
• Can be performed under endoscopic ultrasound guidance in patients with contraindications to other therapies (such as those with esophageal varices) 3

Proton Pump Inhibitor Therapy

All patients undergoing definitive treatment, particularly POEM, should receive proton pump inhibitor therapy:

• Prescribe 8 weeks of proton pump inhibitor therapy after POEM to decrease acid secretion and aid mucosal healing 4
• Pharmacologic acid suppression should be strongly considered in the immediate post-POEM setting given the increased risk of postprocedure reflux and esophagitis 5
• Post-POEM patients should be considered high risk to develop reflux esophagitis and may require potential indefinite proton pump inhibitor therapy 6

Clinical Pitfalls

Common mistakes to avoid:

• Do not rely on medical therapy as primary long-term treatment—it provides inadequate symptom control compared to invasive options 1, 2
• Do not use botulinum toxin in younger patients or those who are good surgical candidates, as it only provides transient benefit 2
• Do not forget to address gastroesophageal reflux prophylactically after any definitive treatment, especially POEM 6, 4

Treatment Algorithm

For patients requiring medical management specifically:

1. Poor surgical candidates or elderly patients: Botulinum toxin injection (100-200 units) as first-line palliative therapy 1
2. Temporary symptom control while awaiting definitive therapy: Calcium channel blockers or nitrates taken before meals 1
3. All patients post-definitive treatment: Proton pump inhibitor therapy for minimum 8 weeks, potentially indefinitely after POEM 4, 5

The definitive treatment options (pneumatic dilation, laparoscopic Heller myotomy, or POEM) provide excellent palliation in over 90% of patients and should be pursued whenever feasible rather than relying on medical management alone. 1, 7