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

Nifedipine Dosing for Achalasia Cardia

For achalasia cardia, the recommended dose is 10-20 mg of nifedipine taken sublingually 30-45 minutes before each meal, which can be titrated up to a total daily dose of 30-60 mg depending on symptom response and tolerability.

Dosing Regimen

• Initial dose: Start with 10-20 mg sublingual nifedipine administered 30-45 minutes before each meal 1, 2
• Titration: The dose can be increased to 10-30 mg before meals based on clinical response, with total daily doses ranging from 30-60 mg 2, 3
• Route: Sublingual administration is specifically preferred because it bypasses the esophagogastric junction, which has abnormally high pressure in achalasia patients 2

Patient Selection Criteria

Medical therapy with nifedipine should be reserved for carefully selected patients 1:

• Patients with mild esophageal dilation (<5 cm on X-ray) 1
• Those demonstrating a good manometric response to initial nifedipine administration 1
• Patients at high surgical risk who cannot undergo pneumatic dilatation or myotomy 3
• As a trial therapy before committing to invasive procedures 1, 4

Expected Clinical Outcomes

The evidence shows modest but meaningful benefits:

• Lower esophageal sphincter (LES) pressure reduction: Nifedipine decreases LES pressure by approximately 28-30%, which is roughly half the reduction achieved by pneumatic dilatation or myotomy 3, 5
• Symptom improvement: Good to excellent clinical response occurs in 75-77% of selected patients with mild to moderate achalasia 4
• Dysphagia reduction: Significant reduction in dysphagia frequency, though some residual symptoms typically persist 3
• No improvement in esophageal emptying: Radionuclide studies show nifedipine does not significantly improve esophageal emptying rates 3

Initial Trial Period

• Administer nifedipine for 2 weeks as an initial trial 1
• Continue chronic therapy only if patients achieve an 'excellent' or 'good' clinical response without severe side effects 1
• Perform X-ray controls every 6 months and manometric examination after the first 6 months of therapy 1

Common Side Effects and Tolerability

• Side effects are generally mild and include flushing of extremities, headache, and dizziness 2
• Most patients tolerate the medication well, with only rare discontinuation due to adverse effects 2, 4
• One study reported 1 out of 14 patients could not tolerate nifedipine 4

Critical Limitations

Nifedipine cannot be recommended as a standard alternative to pneumatic dilatation or surgical myotomy 3:

• The LES pressure reduction is suboptimal compared to definitive treatments 3
• Substantial symptoms often remain during therapy 3
• Long-term data shows that approximately 44% of patients initially responding to nifedipine eventually require pneumatic dilatation or myotomy after an average of 2.8 years 1

Clinical Pearls

• Some patients (approximately 13% in one series) may experience apparent disease regression with long-term medical therapy, with manometry showing near-normal motor patterns 1
• Nifedipine therapy is most appropriate as a temporizing measure or for patients who are poor candidates for invasive procedures 3
• The sublingual route ensures drug absorption without requiring passage through the dysfunctional esophagogastric junction 2