Tailored Approach to Treating Achalasia Recommendations Either graded pneumatic dilation (PD) or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy for the treatment of achalasia in those fit and willing to undergo surgery (strong recommendation, moderate-quality evidence). PD and surgical myotomy should be performed in high-volume centers of excellence (strong recommendation, low-quality evidence). The choice of initial therapy should be guided by patients’ age, gender, preference, and local institutional expertise (weak recommendation, low-quality evidence). Botulinum toxin therapy is recommended in patients who are not good candidates for more defi nitive therapy with PD or surgical myotomy (strong recommendation, moderate-quality evidence). Pharmacologic therapy for achalasia is recommended for patients who are unwilling or cannot undergo definitive treatment with either PD or surgical myotomy and have failed botulinum toxin therapy (strong recommendation, low-quality evidence). Pharmacologic therapy Oral pharmacologic therapies are the least effective treatment options in achalasia (40). Calcium channel blockers and long-acting nitrates are the two most common medications used to treat achalasia. They transiently reduce LES pressure by smooth muscle relaxation, facilitating esophageal emptying. The phosphodiesterase-5-inhibitor, sildenafil, has also been shown to lower the LES tone and residual pressure in patients with achalasia (41). Other less commonly used medications include anticholinergics (atropine, dicyclomine, cimetropium bromide), β-adrenergic agonists (terbutaline), and theophylline. Overall, calcium channel blockers decrease LES pressure by 13–49% and improve patient symptoms by 0–75%. The most commonly employed calcium channel blocker is nifedipine, showing time to maximum effect after ingestion of 20–45 min with duration of effect ranging from 30 to 120 min. Thus, it should be used (10–30 mg) sublingually 30–45 min before meals for best response. Sublingual isosorbide dinitrate is also effective in decreasing LES pressure by 30–65%, resulting in symptomatic improvement ranging from 53 to 87%. It has a shorter time to maximum reduction in LES pressure (3–27 min) than sublingual nifedipine but also has a shorter duration of effect (30–90 min). Hence, sublingual isosorbide dinitrate (5 mg) is commonly administered only 10–15 min before meals. The only comparative study of sublingual nifedipine to sublingual isosorbide dinitrate showed a nonsignificant edge in LES pressure reduction with the latter (65%) than the former (49%) (42). The clinical response with pharmacologic agents is short acting and the side effects, such as headache, hypotension, and pedal edema, are common limiting factors in their use. Furthermore, they do not provide complete relief of symptoms. Thus, these agents are commonly reserved for patients with achalasia who cannot or refuse to undergo more definitive therapies (PD or surgical myotomy) and those who have failed botulinum toxin injections.
Posted on: Wed, 08 Oct 2014 01:24:41 +0000
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