Postgrad Med J: first published as 10.1136/pgmj.60.707.592 on 1 September 1984. Downloaded from Postgraduate Medical Journal (September 1984) 60, 592-596 Comparative study of four antacids M. R. JACYNA E. J. S. BOYD M.B., Ch.B. M.R.C.P. K. G. WORMSLEY M.D., F.R.C.P. Department of Therapeutics, University of Dundee, Dundee capacities. We also considered the cost of each Summary preparation. Four antacid preparations have been studied in a stratified, randomized, double-blind trial to evaluate Methods criteria which determine patients' acceptance of this type of therapy. There was a considerable range of Sixty consecutive patients (36 males and 24 fe- judgements about palatability, but preference was males; mean age 48 years (range 21-76 years)) were determined not only by factors such as the smell, recruited as volunteers from a gastroenterological taste, texture and after-taste of the preparation, but out-patient clinic. The patients suffered from peptic diseases, including duodenal or gastric ulcer and also by the order in which the antacids were tested by copyright. and by the age and sex of the patient. The prepara- oesophagitis. tions also differed considerably in acid-neutralizing capacity and ability to bind bile salts, as well as cost. TABLE 1. Antacids and ingredients We conclude that individuals requiring antacid ther- apy should be allowed to chose from among a range of Code Name Manufacturer Contents preparations, in order to maximize compliance. A Malinal A. H. Robins Almasilate (aluminium magnesium KEY WORDS: oesophagitis, duodenal ulcer, gastric ulcer. silicate) B Asilone Berk Dimethicone Introduction Aluminium hydroxide Magnesium oxide http://pmj.bmj.com/ With the advent and therapeutic efficacy of potent C Gaviscon Reckitt & Sodium bicarbonate inhibitors of gastric secretion, the role of antacids in Colman Sodium alginate the treatment of peptic ulcers has become less D Maalox Rorer Aluminium hydroxide important (Morris and Rhodes, 1979; Editorial, Magnesium hydroxide 1981). However, antacids remain very useful for treating oesophagitis and less well-defined causes of dyspepsia (De Carlo, 1978; Graham, Smith and The 4 antacids studied (Table 1) were placed in identical plain bottles and C Patterson, 1983). The choice of antacids is wide-the labelled A, B, and D. on September 26, 2021 by guest. Protected British National Formulary lists 33 different prepara- The identity of the preparations was not known by tions. The present study was undertaken in order to either investigator or patient. Ten millilitres of each define some criteria for the selection of antacids, by antacid were presented to each individual in a comparing 4 commonly used preparations which balanced, randomized order to ensure that each represent the range ofeffects considered desirable for antacid was evaluated first on 15 occasions. Subjects the treatment of oesophagitis. In a randomized, performed the assessment in a manner analogous to double-blind study, we tested aspects of the accepta- wine-tasting and were asked to 'sniff, sip and savour' bility of the antacids to the patients, and measured the preparation and subsequently to gargle, without the in vitro acid-neutralizing and bile salt-binding swallowing. Following expectoration of the antacid,' patients were asked to grade each of four Correspondence: Dr K. G. Wormsley, NinewelUs Hospital, Dun- criteria-aroma, flavour, texture and after-taste-as dee DD1 9SY, Scotland. 'pleasant', 'acceptable', or 'unpleasant' and then to Postgrad Med J: first published as 10.1136/pgmj.60.707.592 on 1 September 1984. Downloaded from Comparative study offour antacids 593 rank the preparations in order of preference for each these proportions were not significantly different criterion, with the most popular preparation being from the other antacids. given a value of 4 and the least popular a value of 1. When scores for all four criteria were pooled to After each preparation had been tested and assessed, produce an index ofoverall palatability, there was no the mouth was rinsed with warm water until there difference in results from antacids A, B and D. About was no residual taste and the procedure was repeated one-quarter of the patients considered each to be with each one of the other three preparations. 'unpleasant'. Nearly half the patients concluded that Sums of individual judgements for each criterion the overall palatability ofantacid C was 'unpleasant', were used to determine overall palatablity. To a proportion which was significantly higher than for determine overall order of preference, scores for each the other three antacids (P<0.01). criterion were summed. Statistical comparisons were made on absolute numbers using the x2 test. Rank Preference (Table 2) correlation was assessed using the Wilcoxon and Mann-Whitney 'U-tests. A P value of <0-05 was Antacid B was the preferred preparation for three taken as being statistically significant. criteria, including taste (P=n.s.), texture (P<0-02) To determine whether there were any specific age- and after-taste (P<0-02). Antacid C was the least or sex-related differences in patients' acceptance or popular for these criteria (P<0-01 for taste and preference for antacids, the patients were subdivided texture). for the purpose of analysis into four groups: males When preference scores for each ofthe four criteria older or younger than 50 years (n = 17 and 19, were pooled, antacid B was preferred to antacids A respectively) and females subdivided similarly (n = 12 and D (which were ranked equally). Antacid C was in each group). considered to be significantly less pleasant than the Acid-neutralizing capacity was measured by the other three antacids (P<0-01). method of Fordtran, Morawski and Richardson (1973). Bile salt-binding capacity was measured by TABLE 2. Order of preference of antacid prepara- adding 0 33 ml of antacid to 5 ml of a solution of tions by copyright. sodium taurocholate (10 mmol/litre). The pH was Aroma A D C B adjusted to 4 0 with 0-1 mol/litre hydrochloric acid. Taste B: D: A > C The suspension and control tubes (containing sodium Texture B > D: A >> C taurocholate without antacid) were incubated at 37°C Aftertaste B > A: D: C for 60 min and then centrifuged. The bile salt All-round concentration in the supernatant was determined palatability B > A: D >> C with 3-alpha-hydroxy-steroid dehydrogenase in kit :Difference not statistically significant. form (Sterognost-3alpha-Pho; Nyegaard and Co., > Difference significant P<O02. Oslo, Norway) and spectrophotometry. > Difference significant P<0-01. The cost of equivalent amounts of each prepara- http://pmj.bmj.com/ tion was derived from MIMS (Monthly Index of Order of sampling Medical Specialities, July 1983) or, when not avail- Comparison of the palatability scores when each able, from the manufacturer. antacid was tasted first or last showed that for all preparations, all criteria were considered more pleas- ant when the preparation was sampled first than Results when sampled last. The proportion of 'pleasant' judgements was about twice as great when antacids Palatability (Fig. 1) on September 26, 2021 by guest. Protected were tasted first than when tasted last (P<0-01). The There were no differences among the four antacids proportion of 'unpleasant' judgements on tasting last regarding aroma. Two-thirds of the patients consi- did not increase significantly for antacids A, B and D dered this to be 'pleasant' or 'acceptable' for each of but there was a marked increase in the conclusion of the four preparations. There was greater variation 'unpleasant' for antacid C (P<0-01). among the antacids from the point of view of taste, Order of sampling also affected the order of texture and after-taste. More than half the patients preference of each of the preparations. This effect considered that antacid C had an 'unpleasant' taste was so marked that antacids tasted first were invari- and texture, a proportion that was significantly ably ranked first in order of overall preference. higher than for preparations A, B and D (P<0.01). The majority of patients (82%) considered prepara- tion D to be 'pleasant' or 'acceptable' to taste, while Age- and sex-related differences in judgement antacid B was considered by almost all patients (9 1%) There was no significant difference between the to have a 'pleasant' or 'acceptable' after-taste, but different age and sex groups for order of preference Postgrad Med J: first published as 10.1136/pgmj.60.707.592 on 1 September 1984. Downloaded from 594 M. R. Jacyna, E. J. S. Boyd and K. G. Wormsley for the antacids. However, there were differences less than 50 years old. The latter, however, preferred between groups in their judgement of palatability. the smell, taste and after-taste of antacid C signifi- Males over the age of 50 were more likely to give cantly more than men older than 50 (P<0-02). antacid D a rating of 'pleasant' or 'acceptable' than other groups (P<001). Males (of all ages) gave Acid-neutralizing capacity antacid C more 'unpleasant' ratings than did females (P<0 05). The antacids showed a 4-fold range of buffering Among age-related differences, we noted that capacity, so that 10 ml of antacid buffered from 96 to patients under the age of 50 years (male and female) 350 ml gastic juice containing 100 mmol/litre of were more likely to regard antacid B as being hydrochloric acid (Table 3). pleasant than were patients older than 50 (P<0-02), while male patients older than 50 considered antacid Bile acid-binding capacity A to taste significantly better (P<0-02) than women The four preparations were all reasonably potent 100 100 100 100- 25~~~2 804 ......20'~~ ~2~~80842..... 2 60 43 50 26 38 60 ~~~~~~841 48 4 60 43A B 60 C D 61 A B 600C D A B C: D by copyright.