Medications for Achalasia Cardia
Pharmacological therapy has an extremely limited role in achalasia cardia and should only be used in patients who cannot undergo definitive treatment with pneumatic dilation, POEM, or laparoscopic Heller myotomy. 1, 2, 3
When Medications Are Appropriate
Medications should be reserved for:
- Patients who are not candidates for pneumatic dilation or surgery 2
- Elderly patients with significant comorbidities 3
- Early-stage disease as a temporizing measure 3
- Patients who have failed or are awaiting botulinum toxin injection 2
Available Pharmacological Options
Calcium Channel Blockers (Nifedipine)
- Nifedipine reduces lower esophageal sphincter (LES) pressure but provides only modest symptom relief 2, 4, 3
- Typical dosing is sublingual administration before meals 4
- Side effects include headache, peripheral edema, and hypotension, which limit tolerability 3
Nitrates (Isosorbide Dinitrate, Nitroglycerin)
- Sublingual nitrates transiently reduce LES pressure through smooth muscle relaxation 2, 4, 3
- Administered sublingually 10-15 minutes before meals 4
- Headache is the most common side effect and frequently leads to discontinuation 3
- Tolerance develops with chronic use, further limiting efficacy 3
Botulinum Toxin Injection
- Botulinum toxin injection into the LES is more effective than oral medications but still inferior to pneumatic dilation or myotomy 2, 5, 6
- Should be reserved for patients who cannot undergo balloon dilation and are not surgical candidates 2
- Can be administered under endoscopic ultrasound guidance in complex cases (e.g., patients with esophageal varices where pneumatic dilation is contraindicated) 5
- Provides temporary relief lasting 6-12 months in most patients 6
Critical Limitations of Pharmacological Therapy
Calcium channel blockers and nitrates are no longer used as initial treatment strategy and have been relegated to salvage therapy only 2. The efficacy is poor compared to definitive treatments:
- Pneumatic dilation achieves 90% symptom improvement at 1 year 1, 2
- Laparoscopic Heller myotomy achieves 94% success rates 2
- POEM achieves 92% response rates 1
- Medications provide inconsistent and temporary relief at best 3
Post-Procedural Pharmacotherapy
Proton pump inhibitor (PPI) therapy is strongly recommended after all definitive treatments (pneumatic dilation, POEM, or Heller myotomy) due to the 10-40% rate of symptomatic gastroesophageal reflux disease or ulcerative esophagitis 7, 1. This is particularly critical after POEM, which carries the highest reflux risk and may require indefinite PPI therapy 1.
Common Pitfall to Avoid
Do not rely on pharmacological therapy as primary treatment for achalasia. These medications were used historically but have been superseded by far more effective interventions 2, 3. Delaying definitive treatment with medications risks progression of disease, weight loss, aspiration pneumonia, and deterioration in quality of life 1.