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Oesophageal spasm and glyceryl trinitrate

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  • Oesophageal spasm and glyceryl trinitrate

    Has anyone come across this situation before?

    Today a man came into the pharmacy (aged 40 to 45, non smoker, not overweight) and said he was suffering with oesophageal spasm due to acid reflux, and his GP has advised him to purchase some GTN tablets. His regular medication was amitryptilline and pantoprazole. His GP had just increased his pantoprazole dose from 20mg to 40mg daily.

    After speaking to him for a few minutes I dscovered that he had previously had tests for angina, had no idea of the dose he was supposed to take or if he was to take this drug on a regular basis or as he experienced symptoms (chest pain). He told me all his angina tests were negative.

    I was concerned that this was an unlicenced use of GTN tablets, but when he realised that their normal use was for angina, he immediately rejected the idea of using this drug, so opted to buy a bottle of gaviscon instead. He said he had an appointment with his consultant in February, and preferred to ask him about this. I felt this was a good idea, as he hadn't given the increase in pantoprazole chance to work, and I wondered why the GP had not prescribed him GTN tablets with a stated dose (I could only think of the cost).

    I found this on the British Heart Foundation website: -

    Oesophagael or Gastric pain
    This often occurs as a pain or burning sensation beneath your breast bone (sternum) and the sensation is quite similar to heart pain. It might happen after you have been eating and tends to last quite a while, although oesophageal spasm attacks can be brief. It isn’t usually associated with physical exertion, but can be brought on when you change posture, for example lying down or bending forward. Oesophageal spasms can be relieved with GTN spray or tablets.

    There are quite a few articles on the use of this GTN for this type of problem on the internet, but at first glance it seems to me that these drugs have been anecdotally successful in the management of oesophageal spasm.

    The obvious concern for anyone suffering chest pain is that it is cardiac in origin, and telling a patient to purchase a drug that is commonly used for angina would seem to possibly reinforce their fear that this is the true cause, however many tests they have previously found to be negative.

    Has anyone any experience of GTN being used in patients for this type of problem?

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  • #2
    Re: Oesophageal spasm and glyceryl trinitrate

    Esophageal spasm: MedlinePlus Medical Encyclopedia

    Kind of good learning if its licensed..

    Further more, this is the only reference I could locate
    Swamy N. Esophageal spasm: clinical and manometric response to nitroglycerine and long acting nitrites. Gastroenterology. Jan 1977;72(1):23-7. [Medline].
    Last edited by ghibtah; 5, May 2013, 07:57 PM.

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    • #3
      Re: Oesophageal spasm and glyceryl trinitrate

      Response to Nitro has No Predictive Value BUT use it to relieve symptoms | BMJ

      Test of Treatment or Therapeutic Challenge although imprecise is often used and is helpful in clinical practice. However, in their example of common tests of treatment, the authors gave an example of response to nitroglycerin as a test of Angina with 69-71% specificity. However, at least 2 studies [1-2] that evaluated the discriminatory value of nitroglycerin in patients presenting with chest pain, failed to show its usefulness in differentiating cardiac from non-cardiac chest pain, and response to nitroglycerin should not be used to guide the diagnosis. I think it is important to correct this myth that a chest pain relieved by nitroglycerin is angina and it incorrectly reinforces the patient and the physician. This unnecessarily results in further testing in most patients with atypical symptoms. I often tell patients that nitroglycerin is helpful in relieving symptoms by relaxing smooth muscles and discomfort causes by irritation or spasm of any smooth muscle in the body - whether in the heart (angina), oesopahgus (oesophageal spasm) or uterus (uterine contractions) would be relieved with nitroglycerin. In addition, there is always a possibility of placebo effect. It is important to advise patients to use nitroglycerin to relieve chest pain symptoms, keeping in mind that it doesn’t differentiate between the two common causes of chest pain.

      References:

      1. Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, Bushnell AC, Chandra-Strobos N. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med. 2003 Dec 16;139(12):979-86. PMID: 14678917
      2. Steele R, McNaughton T, McConahy M, Lam J. Chest pain in emergency department patients: if the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM. 2006 May;8(3):164-9. PMID: 17320010

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