From the Guidelines
Medications for non-cardiac chest pain typically include acid-reducing drugs, pain relievers, and antidepressants, with proton pump inhibitors like omeprazole (20-40mg daily) or pantoprazole (40mg daily) being first-line treatments for acid reflux-related pain, as recommended by recent guidelines 1.
Treatment Options
For acid reflux-related pain, the following medications can be used:
- Proton pump inhibitors like omeprazole (20-40mg daily) or pantoprazole (40mg daily) are first-line treatments, usually taken for 4-8 weeks initially.
- H2 blockers such as famotidine (20mg twice daily) may also help. For musculoskeletal pain, the following medications can be used:
- NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily) can provide relief. In cases where anxiety or stress contribute to pain, the following medications can be used:
- Low-dose tricyclic antidepressants such as amitriptyline (10-25mg at bedtime) or SSRIs like sertraline (50-100mg daily) may be beneficial.
- Muscle relaxants like cyclobenzaprine (5-10mg three times daily) can help with chest wall pain. These medications work by either reducing stomach acid production, decreasing inflammation, altering pain perception in the nervous system, or relaxing muscle tension.
Important Considerations
It's essential to identify the underlying cause of non-cardiac chest pain for appropriate treatment selection, and patients should always consult a healthcare provider before starting any medication regimen, as noted in the guidelines 1. Additionally, the use of NSAIDs, including selective COX-2 inhibitors, has been associated with increased cardiovascular risk, and their use should be carefully considered, especially in patients with established cardiovascular disease 1.
Recent Guidelines
Recent guidelines, such as the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain, recommend a stepped-care approach to pain management, starting with acetaminophen or aspirin, and progressing to NSAIDs or other medications as needed 1.
From the FDA Drug Label
Gastric Ulcer: In a multicenter, double-blind, controlled, US study of endoscopically diagnosed gastric ulcers, earlier healing was seen in the patients treated with ranitidine as shown in Table 6. Pathological Hypersecretory Conditions (such as Zollinger-Ellison syndrome): Ranitidine inhibits gastric acid secretion and reduces occurrence of diarrhea, anorexia, and pain in patients with pathological hypersecretion associated with Zollinger-Ellison syndrome, systemic mastocytosis, and other pathological hypersecretory conditions (e.g., postoperative, “short-gut" syndrome, idiopathic). Gastroesophageal Reflux Disease (GERD): In 2 multicenter, double-blind, placebo-controlled, 6-week trials performed in the United States and Europe, ranitidine 150 mg twice daily was more effective than placebo for the relief of heartburn and other symptoms associated with GERD.
Ranitidine can be given to help with non-cardiac chest pain, specifically for conditions such as Gastroesophageal Reflux Disease (GERD) and gastric ulcers. The medication has been shown to provide relief of heartburn pain and reduce the frequency of heartburn attacks 2.
From the Research
Medications for Non-Cardiac Chest Pain
The following medications can be used to help with non-cardiac chest pain:
- Proton pump inhibitors (PPI) twice daily for at least 8 weeks for patients with GERD-related NCCP 3
- Smooth muscle relaxants for temporary relief of NCCP with motility disorders 3
- Botulinum toxin injection of the distal oesophagus for treatment of NCCP and spastic oesophageal motility disorders 3
- Tricyclic antidepressants, trazodone, and selective serotonin reuptake inhibitors for oesophageal analgesic effect in NCCP patients 3
- Theophylline for non-GERD-related NCCP, but its usage should be weighed against its potential toxicity 3
- Pain modulators for primary treatment of non-GERD-related noncardiac chest pain, regardless of oesophageal dysmotility 3, 4
- Calcium channel blockers, nitrates, and anticholinergics for esophageal (hypercontractile or spastic) motility disorders 5
- Venlafaxine, sertraline, and imipramine for visceral hypersensitivity 5
Treatment Approaches
Treatment approaches for non-cardiac chest pain include:
- Double-dose PPI treatment for two months as a reasonable first choice approach in patients with NCCP 4
- Medical therapy for NCCP patients with hypercontractile oesophageal motility 4
- Cognitive behavioural therapy for patients with functional chest pain 3, 4
- Hypnotherapy, group therapy, or coping skills for NCCP patients 4
- Medical, endoscopic, and surgical therapeutic options for treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach 4, 6
- Neuromodulators for functional chest pain 6