What is the treatment for stomach spasms?

Treatment for Stomach Spasms

Antispasmodics are the first-line pharmacological treatment for stomach spasms, with dicyclomine 10-20 mg before meals or hyoscyamine 0.125-0.25 mg sublingual as needed being the preferred agents in the United States. 1

First-Line Pharmacological Options

Anticholinergic Antispasmodics

• Dicyclomine 10-20 mg before meals is recommended for patients with predictable, daily postprandial cramping, as it provides sustained relief through anticholinergic blockade of gastrointestinal smooth muscle contraction 1, 2
• Hyoscyamine 0.125-0.25 mg sublingual as needed is preferred for intermittent, unpredictable severe episodes due to its rapid onset when taken sublingually 1, 3
• Dicyclomine works through dual mechanisms: antimuscarinic effects at acetylcholine receptors (approximately 1/8 the potency of atropine) and direct smooth muscle relaxation 2

Alternative First-Line Options

• Peppermint oil is an effective over-the-counter option that acts as a calcium channel blocker with direct smooth muscle relaxant properties 1, 4
• Outside the United States, hyoscine butylbromide 20 mg is the preferred agent due to strong efficacy evidence, though intramuscular preparations may be more effective than oral due to poor oral absorption 3, 4

Evidence Supporting Antispasmodics

• Meta-analysis of 22 RCTs (2,983 patients) demonstrates antispasmodics significantly improve abdominal pain (RR 0.74; 95% CI 0.59-0.93) and global symptom relief (RR 0.67; 95% CI 0.55-0.80) compared to placebo 3, 4
• A separate meta-analysis of 26 trials (2,811 patients) showed fewer patients treated with antispasmodics had persistent global symptoms or abdominal pain (RR 0.65; 95% CI 0.56 to 0.76) 5, 4
• The American Gastroenterological Association provides a conditional recommendation based on low-certainty evidence, but the clinical benefit is significant in practice 1

Treatment Duration and Escalation Algorithm

Initial Trial Period

• Use antispasmodics for 3-6 weeks, not indefinitely, with reassessment after this trial period 1
• If symptoms persist after 3-6 weeks, escalate to second-line therapy rather than continuing ineffective antispasmodic treatment 1

Second-Line Options for Refractory Cases

• Tricyclic antidepressants (TCAs) should be initiated if antispasmodics fail, as they have moderate-quality evidence for pain relief 1, 4
• Amitriptyline 25-100 mg/day or nortriptyline 25-100 mg/day are effective options, with nortriptyline preferred due to fewer sedating side effects 5
• TCAs work through multiple mechanisms: treating underlying depression, modifying gut motility, and altering visceral nerve responses 5

Additional Options for Specific Scenarios

• For visceral pain associated with gastroparesis, consider gabapentin >1200 mg/day in divided doses or pregabalin 100-300 mg/day 5
• Duloxetine 60-120 mg/day (serotonin-norepinephrine reuptake inhibitor) is another option for visceral pain 5

Common Side Effects and Management

Anticholinergic Effects

• The most common adverse effects are dry mouth (2.6-3.5%), thirst (7-7.8%), dizziness, and blurred vision 3, 4
• Quaternary ammonium compounds (hyoscine butylbromide, hyoscyamine) have fewer systemic anticholinergic effects than tertiary amines like dicyclomine 3, 4
• No serious adverse events have been reported in clinical trials 1

Tolerability Strategies

• Titrate the dose carefully to improve tolerability and minimize side effects 5
• Start with lower doses and increase gradually based on symptom response and side effect profile 1

Critical Pitfalls to Avoid

Contraindications and Cautions

• Avoid antispasmodics in patients with significant constipation, as anticholinergic effects will worsen this symptom 1, 3, 4
• Screen for eating disorders using simple questionnaires (e.g., SCOFF) before recommending restrictive dietary interventions that might accompany antispasmodic therapy 5

Red Flags Requiring Further Evaluation

• Screen for fever >38.5°C, bloody diarrhea, severe dehydration, or signs of peritonitis before attributing pain solely to benign stomach spasms 3
• These red flags suggest more serious pathology requiring immediate evaluation rather than symptomatic treatment 3

Treatment Errors to Avoid

• Do not delay escalation to TCAs if symptoms persist after 3-6 weeks of antispasmodic therapy 1
• Do not use antispasmodics indefinitely without reassessment of the underlying cause 1, 4
• In gastroparesis specifically, do not delay rehydration therapy, as antispasmodics treat symptoms but do not address underlying fluid and electrolyte losses 3

Special Considerations for Gastroparesis

If stomach spasms are related to gastroparesis, additional treatment options include:

• Metoclopramide 5-20 mg three to four times daily is the only FDA-approved medication for gastroparesis and accelerates gastric emptying 5
• For nausea and vomiting, ondansetron 4-8 mg twice or three times daily or granisetron 1 mg twice daily are effective options 5
• Erythromycin accelerates gastric emptying by binding to motilin receptors and stimulating cholinergic activity 5