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.
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