What is the recommended anti-spasm (antispasmodic) medication for biliary colic?

Antispasmodic Medication for Biliary Colic

Hyoscine butylbromide (Buscopan) is the recommended first-line antispasmodic medication for biliary colic, but NSAIDs such as diclofenac are more effective and should be preferred when not contraindicated. 1, 2

First-Line Treatment Options

NSAIDs

• Diclofenac: 75mg intramuscular injection - provides faster and more effective pain relief than antispasmodics 2
  • Significantly reduces progression to acute cholecystitis (16.7% vs 52.8% with hyoscine) 2
  • Complete pain relief in 91.7% of patients within 4 hours 2
  • Additional benefit: anti-inflammatory effect that may prevent complications

Antispasmodics

• Hyoscine butylbromide (Buscopan): 20mg IV/IM 3
  • FDA-approved for symptomatic relief of biliary colic 1
  • Complete pain relief in 69.4% of patients within 4 hours 2
  • Less effective than NSAIDs in preventing progression to acute cholecystitis

Treatment Algorithm

1. For patients without NSAID contraindications:

   • Diclofenac 75mg IM as first choice
   • Alternative: Ketorolac 60mg IM (similar efficacy to opioids) 4

2. For patients with NSAID contraindications:

   • Hyoscine butylbromide 20mg IV/IM 3

3. For refractory pain:

   • Consider opioid analgesics:
     • Low-dose morphine (0.05-0.1 mg/kg IV) 5
     • Combination therapy: Paracetamol 1000mg IV + low-dose morphine may be effective 5

Evidence Comparison

Medication	Pain Relief	Prevention of Cholecystitis	Side Effects
Diclofenac	91.7% at 4h	Reduces by ~70%	GI bleeding, renal effects
Hyoscine	69.4% at 4h	Higher progression rate	Anticholinergic effects
Tenoxicam	Effective in 87.5%	May prevent progression	Similar to other NSAIDs

Important Clinical Considerations

• Timing matters: Early administration of NSAIDs significantly reduces the risk of progression to acute cholecystitis 6, 2
• Contraindications to NSAIDs: Peptic ulcer disease, renal impairment, bleeding disorders, pregnancy
• Monitoring: Assess pain relief at 30 minutes, 1 hour, and 4 hours after administration
• Warning signs: Persistent pain despite medication, fever, or increasing inflammatory markers may indicate progression to cholecystitis

Pitfalls to Avoid

• Relying solely on antispasmodics when NSAIDs are not contraindicated
• Delaying treatment, which increases risk of progression to cholecystitis
• Overuse of opioids as first-line therapy when NSAIDs or antispasmodics may be sufficient
• Failing to reassess patients who don't respond to initial therapy

For patients with confirmed biliary colic, a single 75mg intramuscular dose of diclofenac provides superior pain relief and significantly reduces progression to acute cholecystitis compared to antispasmodic medications, making it the preferred first-line treatment when not contraindicated.