Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial.

1. What is already known about this topic?
   i. There have been studies in the past which failed to show conclusive evidence that the addition of lidocaine to a “cocktail” was more effective at relieving symptoms associated with GERD.
2. What is the PICO question?
   i. Population: Adults presenting to emergency department with epigastric pain or dyspepsia
   ii. Intervention: antacid monotherapy (aluminum hydroxide/magnesium trisilicate/magnesium hydroxide)
   iii. Comparison: antacid/lidocaine 2% solution or antacid/lidocaine 2% viscous gel
   iv. Outcome: Primary outcome pain reduction on visual analog scale (VAS) at 30 minutes
   a. Secondary outcome pain reduction on VAS at 60 minutes, palatableness, side effects
3. What are the main findings?
   i. Both antacid and antacid+solution gave clinically significant pain reduction.
   ii. VAS reduction in pain was 20 (antacid), 17 (antacid+solution), and 9 (antacid+viscous).
   iii. The viscous group did not meet >13mm VAS decrease considered clinically important.
   iv. THERE WAS NO STATISTICAL DIFFERENCE BETWEEN THE THREE GROUPS.
   v. Antacid alone was (non-significantly) more effective than all the others.
   vi. Antacid alone was the most palatable. Both lidocaine preparations caused oral numbness.
   vii. All three provided pain relief >13mm at 60 minutes.
4. How will this article change practice?
   1. Take-home point: plain antacid is as effective, possibly more effective, it is also more palatable, and has fewer side effects compared to GI cocktails with lidocaine,
   2. It is quicker, easier, to prepare (i.e. doesn’t require mixing)
   3. Available over the counter
   4. Less side effects 
   5. Has very high maximum recommended daily dosage without risk of toxicity

Acad Emerg
Med. 2020 Jun 29. doi: 10.1111/acem.14069.

Written by: Taylor Brittan, MD

Peer reviewed and edited by: Dylan Kellogg, MD