Megan Brooks
April 19, 2022
Sips of pickle juice may be all it takes to lessen the severity of muscle cramps in adults with cirrhosis, according to results of the PICCLES randomized controlled trial.
In the trial, patients with cirrhotic cramps who sipped pickle brine at the onset of a muscle cramp saw a significant decrease in cramp severity relative to peers who sipped tap water when the cramp hit.
Dr Elliot Tapper
“The acid (vinegar) in the brine triggers a nerve reflex to stop the cramp when it hits the throat. This is why only a sip is needed,” lead investigator Elliot Tapper, MD, division of gastroenterology and hepatology, University of Michigan, Ann Arbor, told Medscape Medical News.
The study was published online April 13 in American Journal of Gastroenterology.
Common and Bothersome
Cramps are common in adults with cirrhosis, irrespective of disease severity. They can sometimes last for hours, and treatment options are limited.
In a prior study, one tablespoon of pickle juice rapidly stopped experimentally induced cramps.
“This is something that athletes use, and kidney doctors often recommend to their patients, so it is nothing unique to cirrhosis,” Tapper said.
The PICCLES trial involved 74 adults (mean age, 56.6 years) with at least 4 muscle cramps in the prior month. In the cohort, 54% were men, and 41% had ascites.
The median cramp frequency was 11 to 12 per month, with an average cramp severity of > 4 out of 10 on the Visual Analog Scale (VAS) for cramps.
Some patients were receiving medications for their cramps at baseline, such as magnesium, potassium, baclofen, vitamin E, taurine, and gabapentin/pregabalin.
Thirty-eight patients were randomly allocated to sip pickle juice and 36 to sip tap water at the onset of a muscle cramp.
The proportion of cramps treated was similar in the pickle juice and tap water groups (77% and 72%). More patients in the pickle juice group said their cramps were aborted by the intervention (69% vs 40%).
The primary outcome was the change in cramp severity at 28-days VAS for cramps. Cramps were assessed 10 times over 28 days using interactive text messages.
Pickle juice was associated with a larger average reduction in cramp severity than tap water (–2.25 points vs –0.36 on the VAS-cramps), a difference that was statistically significant (P = .03).
There were no significant changes in the proportion of days with cramp severity of < 5 on the VAS, or on sleep quality or health-related quality of life.
Because pickle juice contains sodium, the researchers also assessed weight change as a safety outcome. They found no significant differences in weight change between the two groups overall or in the subset with ascites.
Pickle juice is a “safe option that can stop painful cramps,” Tapper told Medscape Medical News, but was “disheartened” that it did not improve quality of life.
Tapper encourages patients with cramps to ask their doctor about pickle juice and doctors to ask their patients about muscle cramps.
“Awareness of a patient’s cramps is often lacking. Asking about cramps is not routine but could be the most important advance relating to this study,” he told Medscape Medical News.
While sips of pickle juice are “unlikely to cause harm,” Tapper said, he is “a little nervous about advising patients to address their complex needs alone. [Doctors] are there to think through the root causes and help make adjustments that could prevent the cramps in the first place,” he said.
Outside Experts Weigh In
Medscape Medical News reached out to several outside experts for their perspective on the study.
Nancy Reau, MD, professor of internal medicine, associate director of solid organ transplantation, and section chief of hepatology. Rush University Medical Center, Chicago, Illinois, noted that interventions to manage and prevent muscle cramps are “important, as cramping is common in cirrhosis and strongly affects quality of life.”
Reau cautioned that while pickle juice “sounds benign, it does have a lot of salt. Despite the salt content, this study didn’t show any difference between patients with and without ascites.
“However, cramping is more common in our patients with sarcopenia and those on diuretics for fluid management and it would be easy to see how this might impact fluid management,” Reau noted.
“Given that it is the acid (not the salt) in the pickle juice, there might be low salt alternatives,” Reau said.
Echoing Reau, Ankur Shah, MD, Division of Kidney Disease and Hypertension, Warren Alpert Medical School of Brown University, Providence, Rhode Island, noted that “overuse of pickle juice could place patients at risk of developing high blood pressure and fluid overload, and pickle juice should be included in the sodium restriction guidance given to patients with high blood pressure and heart failure.”
In this study, however, the individual dose consumed was low, Shah noted.
He said the study “elegantly provides evidence to support the practice of sipping pickle juice for cramping.”
The authors should be “applauded for studying a simple solution with the most rigorous of methodologies, a randomized controlled trial,” Shah added.
“This simple treatment may be helpful to patients far beyond those with just cirrhosis, and expect future studies to explore this treatment in other populations,” Shah told Medscape Medical News.
Paul Martin, MD, chief of the division of digestive health and liver diseases and Mandel Chair in Gastroenterology, Miller School of Medicine at the University of Miami, Florida, noted that, while muscle cramps can have a major impact on quality of life, “in terms of some of the other complications of cirrhosis that healthcare providers are dealing with, they may seem relatively innocuous, but obviously patients have a slightly different interpretation because of the effect cramps can have on sleep and so on.
“There have been a variety of home remedies to treat muscle cramps, but this study is intriguing as it suggests that pickle juice, which is freely available, helps mitigate the severity of the cramps. However, it’s unclear whether it prevents cramps,” Martin told Medscape Medical News.
Given that the study is getting traction on Twitter, Martin encouraged healthcare providers to be aware of the study and prepared to answer questions from patients.
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