Over-the-counter drugs (OTCs) are ingrained in American culture.
If you walked up to random people on the street and asked, they could probably name at least five brands without a second thought. Moreover, people take a variety of OTC drugs based solely on their life experience, having never once read the label. They find themselves habitually taking ibuprofen for minor headaches or melatonin every night before sleep. Some even take Benadryl solely for its drowsiness side effect, despite it being an allergy medication. Of the many OTC drugs on the shelves at pharmacies and grocery stores, one of the most fundamental breeds is the antacid tablet. Just the word “antacid” conjures memories of Tums’ “Food Fight” commercials and binds the subsequent jingle – “Tum, ta-tum, tum, tums!” – to your mind. Through expert marketing alone, antacid tablets have become a big shot in the pharmaceutical industry. However, though these ads may paint antacids as harmless in the eyes (and hearts) of many, a recent case study suggests a link between overuse of antacid tablets to severe hypokalaemia, a condition involving low bodily levels of potassium. Doctors at the Royal United Hospitals Bath worked to publish this report outlining their diagnosis, treatment, and broader implications of the patient brought before them (Lattey et al. 2021). These findings challenge the safety many intrinsically believe is present in antacid tablets and OTC medication – just like any prescription drug, they can harm you if not used properly.
In January 2021, BMJ Case Reports published a report, titled “Over-the-counter antacids linked to severe hypokalaemia in the context of threatened preterm labour.” The study is authored by Dr. Katherine Lattey, Dr. Sarah Quinn, and Dr. Katherine O’Brien, three doctors working in the Department of Obstetrics and Gynaecology within the Royal United Hospitals Bath. They were sponsored by the National Health Service (NHS) Foundation Trust. As this is a case study, the study responded to the specific patient brought to doctors at the Bath, UK hospital in 2020 – the doctors did not initially intend to find the link, just to save a life. It began when the thirty-five-weeks-pregnant, twenty-nine-year-old patient was admitted to the hospital with abdominal pain and fear that her amniotic sac (fetus-protecting structure) would burst. The doctors checked her medical history: the patient had recovered from bulimia in her teenage years and was on anxiety/depression medication. She felt tightening in intervals of less than ten minutes, indicating pre-term labor. As this was her third admission to the labor ward during pregnancy, the doctors felt it necessary to perform routine blood tests; all results were normal except for a severe lack of potassium (2.4 mmol/L, with 3.6 mmol/L being a normal level) – they repeated the tests and confirmed this. Doctors took a drug history but found no explanation for the condition. Following further questioning, they learned she was ingesting roughly 72 antacid tablets daily to alleviate pregnancy-related reflux under the impression that the tablets were safe to take. They concluded that this was the only logical cause of hypokalaemia in the patient (Lattey et al. 2021).
This case study did not respond to any prior research and acknowledges that the link found in this case has not been widely documented. However, they note other cases which link overuse of OTC antacids to serious conditions. This cements misuse of antacids as a serious issue. Specifically, they reference a case report which found that antacid abuse caused bodily excess of calcium (hypercalcaemia). However, this study did not address the impact on potassium (Lattey et al. 2021). This link to hypercalcaemia has been documented a bit more than the link to hypokalaemia. A 2021 case study published by the European Journal of Case Reports in Internal Medicine found a fifty-three-year-old man suffering from abdominal pain, vomiting, and nausea due to calcium levels well above normal values (3.30 mmol/L, with 2.6 mmol/L being a normal level) due to ingestion of antacid tablets and sunflower seeds. While doctors treated this patient, hypercalcaemia can be life-threatening if not caught early. The patient initially denied using tablets when asked (Patoli et al. 2021), but later confided to the doctors, allowing them to properly treat him. In both instances, further questioning regarding antacid use led to the discovery of the link and the subsequent treatment that the patient received (Patoli et al. 2021; Lattey et al 2021); without this knowledge, both (treatable) cases could have become matters of life or death.
Additionally, the patient’s extreme overuse of antacids introduces the topic of medication literacy. A dosage of seventy-two tablets every day is not justified by any means; the patient would have known this had she read the label before ingesting. A 2017 observational study sought to find a relationship between lower medication literacy and inappropriate self-medication among adolescents. Through an online survey completed by 6226 students of primary through high school age, researchers found that approximately 10.1% of adolescents medicated without reading the drug label and 21.6% used excessive dosages (among all medications). Furthermore, they found that usage of antacids to self-medicate among participants was around 17.3% (Lee et al. 2017) – indicating antacids are a major source of misuse among adolescents. Both case studies make it clear that overusing OTC medication is an issue for people beyond adolescence, but this study adds depth to the narrative. It presents that society’s present treatment of OTC drugs does not adequately outline the risks associated with usage. Children follow adult behaviors toward OTC drugs. Based on the studies, this is an attitude that poses danger to their future.
The study linking the overuse of OTC antacids to the development of hypokalaemia follows a logical approach, one which supports their claim well. However, it does not elaborate on the process by which OTC antacids cause hypokalaemia – why their claim is rock solid, and how OTC antacids reduce bodily potassium. They admit this – that the reasoning behind why hypokalaemia occurred (in addition to alkalosis, a condition involving bodily fluids becoming too basic) is unknown – but still conclude that the tablets caused it. The authors admit that this is a subject that has little information on it, so the work they do for this patient could be a jumping-off point for retrospective studies. On a separate note, there are ethical concerns present in their methods. Routine blood tests are not recommended for preterm births, and the doctors sent for them. Because the patient was admitted two earlier times with similar pain, and preterm birth was ruled out as a possibility in both cases, they felt it necessary to understand what ailed the patient. Given the tests allowed the doctors to diagnose and treat the issue, however, it was justified (Lattey et al. 2021).
In brief, the case report linking OTC antacids to hypokalaemia is valuable, as it is the only known study to find this link. Given antacids are a fundamental medication in peoples’ lives, any severe consequences they might cause are crucial for the public to understand. The common misuse of antacids by adolescents (Lee et al. 2017) and the severe imbalances in potassium and calcium which OTC antacids can cause (Lattey et al. 2021; Patoli et al. 2021) prove that antacids can be dangerous if the public is not educated on them. This study also brings an issue affecting doctors: the exclusion of OTC antacids in drug and medical histories. The two 2021 case studies illustrate patients’ hesitancy to reveal OTC usage to doctors – or at least that they do not feel a need to tell doctors about such usage. The report thus asserts that there can be disastrous consequences when information regarding OTC drugs is omitted from medical histories. Though it adequately argues the necessity of this inclusion, more research must be done on the study’s specific topic of antacid overuse). Researchers should conduct experimental studies to see if daily usage – in smaller, ethical values to give to participants – leads to lower levels of potassium, higher levels of calcium, alkalosis, or any other effect they may find. The more the scientific community and society as a whole can learn about OTC antacid tablets, the safer they will become. At the very least, people will tend to take more precautions before ingesting them on impulse. For people who regularly take more than the recommended dosage of antacids or use them daily, this research serves as a reminder to look closer at what they put in their bodies, no matter how easy it is to acquire.
References
Lattey K, Quinn S, O’Brien K. 2021. Over-the-counter antacids linked to severe hypokalaemia in the context of threatened preterm labour. BMJ Case Reports. 14(1):1-4. https://www.proquest.com/docview/2476763707?pq-origsite=summon. doi:10.1136/bcr- 2020-236083.
Lee C, Fong-Ching C, Hsu S, Hsueh-Yun C, Li-Jung H, Ming-Kung Yeh. 2017. Inappropriate self-medication among adolescents and its association with lower medication literacy and substance use. PLoS One. 12(12):1-14. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189199. doi:10.1371/journal.pone.0189199.
Patoli I, Kazim M, Jamil S, Abbas S, 2021. Hypercalcaemia caused by sunflower seeds and calcium carbonate supplements. European Journal of Case Reports in Internal Medicine. 8(10):1-3. https://www.ejcrim.com/index.php/EJCRIM/article/view/2845. doi:10.128980/2021_002845
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