MBE: AINE IM vs VO

La pregunta

La via intramuscular és millor que la via oral a l'hora de tractar un dolor agut?

Com formular la pregunta

• P-> Problema: dolor agut
• I-> Intervenció: AINE VO
• C-> Control: AINE IM
• O-> Output (Resultat): millora del dolor subjectiva (EVA), concentracions en sang del fàrmac.

Cerca

Clinical Evidence

Clinical Evidence, només accés des de l'ICS.

Cerca: pain.

No hi ha res.

TripDatabase

TripDatabase en Español

dolor AINE intramuscular oral

Guía de Práctica Clínica sobre Lumbalgia. Guíasalud - 2007. link

 En cuanto a la vía de administración de los AINE, la revisión Cochrane [1] sugiere que
 no hay evidencia para recomendar otra vía que no sea la oral en la lumbalgia aguda.

The objective of this systematic review was to assess the effects of NSAIDs in the treatment of non-specific low back pain and to assess which type of NSAID is most effective [1].

TripDatabase

pain NSAID intramuscular oral

Acute pain management in older adults. National Guideline Clearinghouse (USA). 2006. link.

 Avoid intramuscular (IM) administration in older adults. 
 Because of muscle wasting and less fatty tissue in older as compared to younger adults, 
 intramuscular absorption of analgesics in older adults is slowed 
 and may result in delayed/prolonged effect of IM injections, 
 altered analgesic serum levels and possible toxicity with repeated injections [2, 3, 4, 5]. 
 Evidence Grade = B

• Variable pain control following intermittent intramuscular meperidine injections was shown to be due to inadequate, fluctuating and unpredictable blood concentrations [2].
• The purpose of this study was to identify patient patterns in intravenous patient-controlled analgesia (PCA) and intramuscular (IM) analgesia for patients after surgery [3].
• Patient-controlled analgesia (PCA) allows patients to self-administer small boluses of narcotic, allowing better dose titration, enhanced responsiveness to variability in narcotic requirements, and reduction in serum narcotic level fluctuation [4].
• [5]
  • OBJECTIVE: To examine and compare the pharmacokinetics and pharmacodynamics of meperidine when administered intramuscularly at gluteal and deltoid sites in elderly postoperative patients.
  • DESIGN: Prospective, randomized investigation.
  • SETTING: Tertiary care university teaching hospital.
  • PATIENTS: Fourteen patients 60 years of age or older who were undergoing general surgery.
  • INTERVENTION: A single dose of meperidine 0.75 mg/kg given intramuscularly at either a deltoid or gluteal site.
  • MAIN OUTCOME MEASURES: Pharmacokinetic (based on concentration-time curves) and pharmacodynamic (i.e., pain scales, need for additional pain medication) comparisons were made, based on site of meperidine injection.
  • RESULTS: No statistically significant differences were found in the maximum plasma concentration, volume of distribution, or clearance of meperidine by site of injection. Substantial interpatient variability in pharmacokinetic parameters was noted for both sites (range of maximum concentrations: 191-500 ng/mL gluteal, 166-374 ng/mL deltoid). Although pain scores were similar for the two groups, four of the patients in the group given gluteal injection required additional breakthrough pain management within 4 hours of meperidine injection compared with one patient in the group given deltoid injection.
  • CONCLUSIONS: There is no obvious relationship between meperidine pharmacokinetic and pharmacodynamic parameters, regardless of intramuscular injection site. Breakthrough pain is common when patients are given intramuscular injections postoperatively, particularly when the gluteal route is used. When meperidine is used for analgesia in elderly postoperative patients, consideration should be given to more rapid and predictable routes (e.g., intravenous injection) of meperidine administration.

Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review. DARE. 1998. link.

 In renal colic there was evidence that NSAIDs act quickest when given intravenously. 
 In all other pain conditions there was a lack of evidence 
 of any difference between administration routes. 
 In pain conditions other than renal colic, there is, therefore, 
 a strong argument to give oral NSAIDs when patients can swallow [6].

• AIM: To test the evidence for a difference in analgesic efficacy and adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) given by different routes.
• METHODS: Systematic review of published randomised controlled trials. Relevant trials were comparisons of the same drug given by different routes. Presence of internal sensitivity was sought as a validity criterion. Analgesic and adverse effect outcomes were summarised, and synthesised qualitatively.
• RESULTS: In 26 trials (2225 analysed patients), 8 different NSAIDs were tested in 58 comparisons. Fifteen trials (58%) compared the same drug by different routes. Drugs were given by intravenous, intramuscular, intrawound, rectal and oral routes in postoperative pain (14 trials), renal colic (4), acute musculoskeletal pain (1), dysmenorrhoea (1), and rheumatoid arthritis (6). Five of the 15 direct comparisons were invalid because they reported no difference between routes but without evidence of internal sensitivity. In all 3 direct comparisons in renal colic, intravenous NSAID had a faster onset of action than intramuscular or rectal. In 1 direct comparison in dysmenorrhoea, oral NSAID was better than rectal. In the 5 direct comparisons in postoperative pain, results were inconsistent. In 1 direct comparison in rheumatoid arthritis, intramuscular NSAID was better than oral. Injected and rectal administration had some specific adverse effects.
• CONCLUSION: In renal colic there is evidence that NSAIDs act quickest when given intravenously. This may be clinically relevant. In all other pain conditions there is a lack of evidence of any difference between routes. In pain conditions other than renal colic, there is, therefore, a strong argument to give oral NSAIDs when patients can swallow.

Cochrane

Cochrane, revisions sistemàtiques. Accessible des de casa.

• dolor and AINE and intramuscular and oral
• pain and NSAID and intramuscular and oral

 In renal colic there is evidence that NSAIDs actquickest when given intravenously. 
 This may be clinically relevant. 
 In all other pain conditions there is a lack of evidence of any difference between routes. 
 In pain conditions other than renal colic, there is, therefore, 
 a strong argument to give oral NSAIDs when patients can swallow [6]. 
 

La mateixa que en el TripDatabase.

PubMed

PubMed

Paraules MeSH utilitzades

 Pain
 Anti-Inflammatory Agents, Non-Steroidal
 Injections, Intramuscular
 Administration, Oral

1. Aquesta [7]:
   1. OBJECTIVE: There is a commonly held belief among health care providers that patients respond better to parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) than to oral forms by virtue of the patients' belief that getting an injection means they are receiving "stronger" medicine. To the authors' knowledge, this effect has never been adequately documented in the literature. The objective of this study was to compare the effects of a placebo analgesic injection vs placebo oral analgesia on patients with acute musculoskeletal pain.
   2. METHODS: A convenience sample of emergency department (ED) patients with acute musculoskeletal pain secondary to trauma were enrolled. Patients received 225 mL of orange-flavored drink containing 800 mg of ibuprofen. Patients then received either a physiologically inactive starch tablet resembling ibuprofen 800 mg in taste and appearance or a physiologically inactive saline intramuscular (IM) injection resembling ketorolac 60 mg. Both patients and research nurses were blinded to the addition of ibuprofen to the drink and the inactive nature of subsequent medication. Pain was evaluated at time 0 and at 30, 60, 90, and 120 minutes on a 10-mm visual analog scale (VAS).
   3. RESULTS: Sixty-four patients completed the study protocol. The VAS scores between groups did not differ significantly at baseline or at each subsequent interval (p = 0.86).
   4. CONCLUSIONS: These results contradict the belief that parenteral medications confer a selective placebo effect stemming from patients' beliefs regarding route of administration and efficacy. Therefore, the routine use of IM administration of NSAIDs for suspected enhanced analgesia appears unwarranted.
2. Tornem a trobar la referència [6].
3. I aquesta [8]:
   1. OBJECTIVE: To compare the clinical efficacy of single doses of intramuscular ketorolac and oral ibuprofen in the emergency department (ED) treatment of acute pain.
   2. DESIGN: A retrospective analysis of data collected during a prospective survey of pain management efficacy. The design was noninterventional, and therapy was selected by the treating physician independent of the trial.
   3. SETTING: Urban teaching hospital adult patient emergency department.
   4. PARTICIPANTS: A convenience sample of ED patients in acute pain.
   5. INTERVENTIONS: Patients received ibuprofen 800 mg po (n = 95), or ketorolac 60 mg im (n = 30) as a single dose. Therapy was selected by the treating physician and was not influenced by the study.
   6. RESULTS: Data collected were a 100-mm visual analog pain scale at patient arrival and discharge, verbal description of pain relief, patient demographics, pain management data, and discharge diagnosis. Baseline pain intensity was higher in patients receiving ketorolac (77 mm median) than in those receiving ibuprofen (65 mm, p = 0.02). Pain relief was similar (p = 0.29) with either treatment when assessed by visual analog scale or patient definition of pain relief.
   7. CONCLUSIONS: A single dose of either nonsteroidal antiinflammatory drug produced similar pain relief in the general ED population during clinical treatment of pain. Ketorolac should not necessarily be considered a more effective analgesic than ibuprofen in these commonly used doses.

Conclusions

• [1]: no és una revisió exactament sobre el què busquem.
• [2]: estudi descriptiu. Les injeccions intramusculars tenen una absorció erràtica mirant les concentracions del fàrmac en sang.
• [3]: no és el què busquem.
• [4]: no és el què busquem.
• [5]: estudi randomitzat. N=14. Les injeccions intramusculars tenen una absorció erràtica mirant les concentracions del fàrmac en sang.
• [6]: revisió sistemàtica d'assajos clínics. N=2225. Excepte en el còlic nefrític no hi ha evidència que cap de les rutes sigui millor que la oral.
• [7]: assaig clínic a doble cec. N=64. No hi havien diferències entre els 2 grups.
• [8]: anàlisi retrospactiu. N=?. El ketorolak IM no ha demostrat ser millor que l'ibuprofè VO.

Aplicació pràctica

 Davant d'un pacient amb dolor agut, millor intentar un tractament via oral, 
 a no ser que sigui un còlic nefrític o que el pacient no pugui deglutir. 
 L'absoció de la via intramuscular és erràtica.

Bibliografia

1. van Tulder MW, Scholten RJ, Koes BW, and Deyo RA. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2000(2):CD000396. DOI:10.1002/14651858.CD000396 |
2. Austin KL, Stapleton JV, and Mather LE. Multiple intramuscular injections: a major source of variability in analgesic response to meperidine. Pain. 1980 Feb;8(1):47-62. DOI:10.1016/0304-3959(80)90089-5 |
3. Conner M and Deane D. Patterns of patient-controlled analgesia and intramuscular analgesia. Appl Nurs Res. 1995 May;8(2):67-72. DOI:10.1016/s0897-1897(95)80502-8 |
4. Egbert AM, Parks LH, Short LM, and Burnett ML. Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men. Arch Intern Med. 1990 Sep;150(9):1897-903.
5. Erstad BL, Meeks ML, Chow HH, Rappaport WD, and Levinson ML. Site-specific pharmacokinetics and pharmacodynamics of intramuscular meperidine in elderly postoperative patients. Ann Pharmacother. 1997 Jan;31(1):23-8. DOI:10.1177/106002809703100102 |
6. Tramèr MR, Williams JE, Carroll D, Wiffen PJ, Moore RA, and McQuay HJ. Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review. Acta Anaesthesiol Scand. 1998 Jan;42(1):71-9. DOI:10.1111/j.1399-6576.1998.tb05083.x |
7. Schwartz NA, Turturro MA, Istvan DJ, and Larkin GL. Patients' perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia. Acad Emerg Med. 2000 Aug;7(8):857-61. DOI:10.1111/j.1553-2712.2000.tb02061.x |
8. Wright JM, Price SD, and Watson WA. NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother. 1994 Mar;28(3):309-12. DOI:10.1177/106002809402800301 |