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emptying (actions that are additional to their central action as antiemetics, see below).

Approaches to treatment. The 'step-up' approach involves starting with lifestyle modification (above) and an antacid, progressing as necessary to a H2 receptor antagonist and prokinetic drug, and a proton pump inhibitor only in those who fail to respond to less powerful measures. The converse ('step down') approach advocates rapid control of symptoms with a proton pump inhibitor followed by substitution with less potent treatments, which are titrated against symptoms. Evidence suggests that this latter approach may be more cost-effective.

Diffuse oesophageal spasm may be helped by isosorbide dinitrate 5 mg sublingually or 10 mg by mouth, or by nifedipine 10 mg sublingually or swallowed.

Achalasia, in which there is failure of relaxation of the lower oesophageal sphincter, may be relieved by balloon dilatation or by injection of botulinum toxin at the gastro-oesophageal junction.

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