Hot Off the Press: Antacid Monotherapy for Pain

Patients presenting to emergency departments (EDs) with epigastric pain are typically treated with an antacid, either alone or combined with other medications. Such medications include viscous lidocaine, an antihistamine, a proton pump inhibitor, or an anticholinergic.1, 2 There are mixed results from studies with varying methodologic quality examining acute dyspepsia management in the ED. One single-blind study comparing 30 mL of antacid with or without 15 mL of viscous lidocaine found that the addition of lidocaine significantly increased pain relief, decreasing the patient pain score by 40 mm compared to 9 mm with antacid monotherapy.3 Another single-blind randomized controlled trial (RCT) comparing antacid plus either benzocaine solution or viscous lidocaine found no statistical difference between the two interventions; however, there was no antacid monotherapy group.4 A larger, double-blind RCT of 113 patients compared 30 mL of antacid monotherapy, antacid with 10 mL of an anticholinergic, and antacid with anticholinergic and 10 mL of 2% viscous lidocaine. This study found that all treatments had clinical efficacy and there was no statistical difference in pain relief between the three treatment groups. The study’s conclusion was to recommend antacid monotherapy.5 This double-blind RCT evaluated adult patients presenting to the ED with epigastric pain or dyspepsia. There were three treatment arms; viscous lidocaine plus antacid mixture, lidocaine solution plus antacid mixture, and antacid given alone. Ultimately there was no difference in analgesic efficacy between antacid monotherapy and lidocaine antacid combinations. The antacid monotherapy was more palatable and acceptable to patients. This study was performed in the ED of a single tertiary-care urban hospital in Melbourne, Australia. It asks a clear and sensible question and study participants were adequately randomized with concealed allocation. Patients were enrolled prospectively based on the clinician providing an antacid therapy. Although this ultimately resulted in some patients having a nongastrointestinal cause of pain, it resulted in a more pragmatic study. Participants were analyzed in an intention-to-treat fashion and all groups were treated equally except for the intervention. Follow-up was complete and all patient important outcomes were considered. The primary limitations of this study are recruitment and participant awareness of group allocation. Participants and nursing staff were aware of group allocation because of the different taste and appearance of lidocaine containing solutions as compared with antacid monotherapy. However, physicians and data analysts were still blinded to group allocation. While nurses were unblinded to the drug being given, to test the secondary outcomes of taste, palatability, and overall acceptability, it was decided not to try and alter the treatments through food colorings or other methods. Study participants were not recruited overnight which may have also resulted in selection bias. The trial enrolled 94 patients and 89 could be analyzed (30 viscous, 31 solution, and 28 antacid group). The mean age was in the early 40s, and 80% of patients were discharged with a gastrointestinal diagnosis. All three treatments were effective and there was no statistical difference between groups. The primary outcome of clinically important analgesia with a >13-mm reduction in pain on a visual analog scale was achieved in the lidocaine solution with antacid and antacid monotherapy groups at 30 minutes (17 and 20 mm). Viscous lidocaine with antacid had a 9-mm reduction in pain, which was below the defined clinically important analgesia threshold, but there was not a statistically significant difference between treatments. Secondary outcomes included pain reduction at 60 minutes, which was achieved and clinically significant in all groups (21, 26, and 32 mm). The most frequent adverse effect was oral numbness (20% for viscous lidocaine and 26% for lidocaine solution). Two patients in the viscous arm reported dizziness and tiredness (7%), and four patients in the solution arm reported cough, nausea, and dizziness (13%). One patient in the antacid arm reported a dry mouth (4%). Participants found antacid monotherapy to be the most palatable solution, with statistically significant differences in taste, bitterness, and overall acceptability. Although a small single-center study cannot provide definitive answers, there does not appear to be any benefit from adding lidocaine to an antacid, and patients like it less. Based on these results, we generally prescribe antacid monotherapy but recognize that there may be room for more research in this area. Are you using GI cocktail for treating patients presenting with epigastric pain? Nope! Haven’t used it in years based on prior study https://pubmed.ncbi.nlm.nih.gov/14585449/ this study, despite limitations, strengthened this practice https://foamcast.org/2020/07/16/stop-giving-lidocaine-in-gi-cocktails/ Brilliant example of @UniMelbMDHS #medstudentresearch changing practice. No need to add a liquid anaesthetic for dyspepsia. #SGEMHOP I had heard of this study but couldn't find it! Dr. Milne, you're going to be fairly popular with a group of pharmacy technicians soon. Interesting study- but it should be noted that this may not be a case of medical reversal so much as it is changing disease states. In the 80s and 90s, the most common operation in America was for peptic ulcer disease, and such operations are now unheard of. In the modern era, when almost all patients with any epigastric pain are started on PPI therapy as outpatients already, and with true ulcers being less frequent, perhaps the classic teaching is no longer more effective in the modern population. Use antacid monotherapy, rather than mixtures with lidocaine, for dyspepsia in the ED.

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