What is the recommended treatment and dosage for gastrointestinal spasms using Dicycloverine?

Dicyclomine for Gastrointestinal Spasms

For gastrointestinal spasms and abdominal pain in irritable bowel syndrome (IBS), dicyclomine should be dosed at 40 mg orally four times daily (160 mg/day total), which has demonstrated superior efficacy compared to placebo in controlled trials. 1

Dosing and Administration

• Standard adult dose: 40 mg orally four times daily (160 mg/day total) 1
• In controlled trials, 82% of patients treated with dicyclomine 160 mg daily showed favorable clinical response versus 55% with placebo (p<0.05) 1
• Dose reduction to an average of 90 mg daily was required in 46% of patients experiencing side effects, while still maintaining therapeutic benefit 1

Clinical Efficacy

Dicyclomine is effective as a first-line antispasmodic for IBS-related abdominal pain and global symptom relief. 2, 3, 4

• The British Society of Gastroenterology guidelines recommend antispasmodics like dicyclomine for global symptoms and abdominal pain in IBS, though with weak recommendation strength due to very low quality evidence 2
• The American Gastroenterological Association suggests dicyclomine provides adequate global relief (RR 0.67; 95% CI 0.55-0.80) and improvement in abdominal pain (RR 0.74; 95% CI 0.59-0.93) compared to placebo 3
• Dicyclomine has less marked antimuscarinic action than atropine and may have direct smooth muscle relaxant effects 2

Mechanism of Action

• Dicyclomine is a tertiary amine antimuscarinic that inhibits gastrointestinal smooth muscle contraction 2, 4
• Unlike quaternary ammonium compounds (hyoscine butylbromide, propantheline), dicyclomine is more lipid-soluble and better absorbed orally 2
• It acts through muscarinic receptor blockade within the autonomic nervous system 1

Side Effects and Tolerability

Anticholinergic side effects occur in 61% of patients but are dose-related and reversible upon discontinuation. 1

The most common adverse effects in order of frequency are:

• Dry mouth: 33% (vs 5% placebo) 1
• Dizziness: 40% (vs 5% placebo) 1
• Blurred vision: 27% (vs 2% placebo) 1
• Nausea: 14% (vs 6% placebo) 1
• Somnolence: 9% (vs 1% placebo) 1

Only 9% of patients discontinued treatment due to side effects 1

Important Clinical Considerations

Avoid dicyclomine in constipation-predominant IBS, as anticholinergic effects may worsen constipation. 4

• In 41% of patients, side effects disappeared or were tolerated at the full 160 mg daily dose without reduction 1
• For diarrhea-predominant IBS, dicyclomine can be combined with loperamide 4
• Response varies between individuals; some patients respond better to dicyclomine than other antispasmodics 4

Serious Adverse Reactions (Rare)

• Cardiovascular: palpitations, tachyarrhythmias 1
• Central nervous system: delirium, confusion, hallucinations, syncope 1
• Ophthalmologic: cycloplegia, mydriasis, increased ocular tension 1
• Genitourinary: urinary retention in patients with prostatic hypertrophy 1
• Respiratory: apnea, dyspnea 1

Contraindications and Precautions

• Use with caution in patients taking diuretics (HCTZ), as drug interaction may cause contraction alkalosis 5
• May suppress lactation 1
• Decreased sweating may occur, increasing risk of heat-related illness 1
• Avoid in patients with increased intraocular pressure or prostatic hypertrophy 1

Comparison to Alternative Antispasmodics

• Hyoscine butylbromide is poorly absorbed orally; intramuscular preparations may be more effective for long-term use 2, 6
• Anticholinergic antispasmodics like dicyclomine are more effective than direct smooth muscle relaxants for pain relief 4
• Peppermint oil may be considered as an alternative or adjunct therapy 2