What is the recommended dose of nifedipine (calcium channel blocker) for achalasia cardia?

Nifedipine Dosing for Achalasia Cardia

For achalasia cardia, the recommended dose is 10-20 mg of sublingual nifedipine taken 30-45 minutes before each meal (three times daily), which can provide symptomatic relief in selected patients, though it should be considered a second-line option reserved primarily for those at high surgical risk.

Dosing Regimen

• Standard dose: 10-20 mg sublingual nifedipine administered 30-45 minutes before each meal 1, 2, 3
• Alternative dosing: Some studies have used 20 mg sublingual doses with similar efficacy 4
• Total daily dose range: 30-60 mg per day divided before meals 5
• Initial trial period: A 2-week trial should be conducted to assess clinical response and tolerability before committing to long-term therapy 2

Mechanism and Expected Effects

• Nifedipine reduces lower esophageal sphincter (LES) pressure by approximately 28-30% in achalasia patients, which is roughly half the reduction achieved by pneumatic dilation or myotomy 1, 4
• The drug works through calcium channel blockade, causing relaxation of the hypertensive LES 1
• Plasma concentrations reach therapeutic levels (45-57 ng/mL) at 30-60 minutes after sublingual administration 4

Clinical Efficacy and Patient Selection

Who benefits most:

• Patients with mild to moderate achalasia (esophageal dilation <5 cm on X-ray) 2, 3
• Those demonstrating a good manometric response to initial nifedipine administration 2
• Patients at high surgical risk who cannot safely undergo pneumatic dilation or myotomy 1

Expected outcomes:

• Approximately 75-77% of appropriately selected patients achieve excellent or good clinical results 3
• Nifedipine significantly reduces dysphagia frequency, though some symptoms typically persist 1
• The drug does not improve esophageal emptying rates or reduce esophageal dilation 1, 5

Important Limitations and Caveats

• Nifedipine is NOT a standard first-line treatment for achalasia—pneumatic dilation and surgical myotomy remain superior options 1
• The reduction in LES pressure is suboptimal compared to definitive treatments, explaining why residual symptoms persist 1
• Long-term continuation rates are modest: in one series, only 13 of 39 patients (33%) remained on therapy long-term, with most eventually requiring dilation or myotomy after an average of 2.8 years 2
• Approximately 30% of patients will have insufficient clinical response or intolerable side effects during initial trial 2

Administration Technique

• Sublingual route is preferred because it bypasses the obstructed esophagogastric junction, ensuring reliable drug absorption 5
• Timing 30-45 minutes before meals allows peak effect to coincide with eating 2, 3

Side Effects

• Common adverse effects include flushing, hypotension, dizziness, headache, and peripheral edema 6, 5
• Most side effects are mild and related to vasodilation 5
• Severe side effects requiring discontinuation occur in a minority of patients 2

Monitoring and Follow-up

• Clinical evaluation should occur every 3 months 3
• X-ray controls every 6 months to monitor esophageal dilation 2
• Manometric examination after the first 6 months of therapy 2
• If clinical response is "excellent" or "good" without severe side effects after the 2-week trial, continue chronic therapy 2

Clinical Pearl

A small subset of patients with initial achalasia treated with nifedipine may experience disease regression, with manometry showing near-normal motor patterns after several years, though this is uncommon 2. This supports considering medical therapy in carefully selected patients with early disease, not just those who cannot tolerate invasive procedures.