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Sjoukes A, Venekamp RP, van de Pol AC, Hay AD, Little P, Schilder AGM, Damoiseaux RAMJ. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children. Cochrane Database Syst Rev 2016; 12:CD011534. [PMID: 27977844 PMCID: PMC6463789 DOI: 10.1002/14651858.cd011534.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Acute otitis media (AOM) is one of the most common childhood infectious diseases and a significant reason for antibiotic prescriptions in children worldwide. Pain from middle ear infection and pressure behind the eardrum is the key symptom of AOM. Ear pain is central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management in children. OBJECTIVES Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs compared with paracetamol in children with AOM. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 7, July 2016; MEDLINE (Ovid, from 1946 to August 2016), Embase (from 1947 to August 2016), CINAHL (from 1981 to August 2016), LILACS (from 1982 to August 2016) and Web of Science (from 1955 to August 2016) for published trials. We screened reference lists of included studies and relevant systematic reviews for additional trials. We searched WHO ICTRP, ClinicalTrials.gov, and the Netherlands Trial Registry (NTR) for completed and ongoing trials (search date 19 August 2016). SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in children with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections (URTIs) if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. DATA COLLECTION AND ANALYSIS Two review authors independently assessed methodological quality of the included trials and extracted data. We used the GRADE approach to rate the overall quality of evidence for each outcome of interest. MAIN RESULTS We included three RCTs (327 children) which were assessed at low to moderate risk of bias.One RCT included 219 children with AOM, and used a three-arm, parallel group, double-blind design to compare paracetamol versus ibuprofen versus placebo. All children also received antibiotics and those with fever > 39 °C could have received paracetamol (30 mg to 60 mg) additionally to the studied treatments.Another RCT involved 156 febrile children (26 of whom had AOM). The study design was a three-arm, parallel group, double-blind design and compared paracetamol versus ibuprofen versus ibuprofen plus paracetamol.The third RCT included 889 children with respiratory tract infections (82 of whom had AOM). This study applied a 3 x 2 x 2 factorial, open-label design and compared paracetamol versus ibuprofen versus ibuprofen plus paracetamol. Study participants were randomised to one of the three treatment groups as well as two dosing groups (regular versus as required) and two steam inhalation groups (steam versus no steam).Authors of two RCTs provided crude subgroup data on children with AOM. We used data from the remaining trial to inform comparison of paracetamol versus placebo (148 children) and ibuprofen versus placebo (146 children) assessments. Data from all included RCTs informed comparison of ibuprofen versus paracetamol (183 children); data from the two RCTs informed comparison of ibuprofen plus paracetamol versus paracetamol alone (71 children).We found evidence, albeit of low quality, that both paracetamol and ibuprofen as monotherapies were more effective than placebo in relieving pain at 48 hours (paracetamol versus placebo: proportion of children with pain 10% versus 25%, RR 0.38, 95% CI 0.17 to 0.85; number needed to treat to benefit (NNTB) 7; ibuprofen versus placebo: proportion of children with pain 7% versus 25%, RR 0.28, 95% CI 0.11 to 0.70; NNTB 6). Very low quality evidence suggested that adverse events did not significantly differ between children treated with either paracetamol, ibuprofen or placebo.We found insufficient evidence of a difference between ibuprofen and paracetamol in relieving ear pain at 24 hours (2 RCTs, 39 children; RR 0.83, 95% CI 0.59 to 1.18; very low quality evidence), 48 to 72 hours (3 RCTs, 183 children; RR 0.91, 95% CI 0.54 to 1.54; low quality evidence) and four to seven days (2 RCTs, 38 children; RR 0.74, 95% CI 0.17 to 3.23; very low quality evidence).Data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone came from two RCTs that provided crude subgroup data for 71 children with AOM. The small sample provided imprecise effect estimates and we were consequently unable to draw any firm conclusions (very low quality evidence). AUTHORS' CONCLUSIONS Despite explicit guideline recommendations on its use, current evidence on the effectiveness of paracetamol or NSAIDs, alone or combined, in relieving pain in children with AOM is limited. Low quality evidence indicates that both paracetamol and ibuprofen as monotherapies are more effective than placebo in relieving short-term ear pain in children with AOM. There is insufficient evidence of a difference between ibuprofen and paracetamol in relieving short-term ear pain in children with AOM, whereas data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone were insufficient to draw any firm conclusions. Further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol, and other analgesics such as anaesthetic eardrops, for children with AOM.
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Affiliation(s)
- Alies Sjoukes
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CareHeidelberglaan 100UtrechtUtrechtNetherlands3508 GA
| | - Roderick P Venekamp
- University Medical Center UtrechtJulius Center for Health Sciences and Primary Care & Department of OtorhinolaryngologyHeidelberglaan 100UtrechtNetherlands3508 GA
| | - Alma C van de Pol
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CareHeidelberglaan 100UtrechtUtrechtNetherlands3508 GA
| | - Alastair D Hay
- School of Social and Community Medicine, Unversity of BristolCentre for Academic Primary Care, NIHR School for Primary Care ResearchCanynge Hall, 39 Whatley RoadBristolUKBS8 2PS
| | - Paul Little
- Aldermoor Health Centre, University of SouthamptonPrimary Care and Population Sciences, Faculty of MedicineAldermoor CloseSouthamptonUKS016 5ST
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
| | - Roger AMJ Damoiseaux
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CareHeidelberglaan 100UtrechtUtrechtNetherlands3508 GA
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Little P, Stuart B, Mullee M, Thomas T, Johnson S, Leydon G, Rabago D, Richards-Hall S, Williamson I, Yao G, Raftery J, Zhu S, Moore M. Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial. CMAJ 2016; 188:940-949. [PMID: 27431306 DOI: 10.1503/cmaj.160362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Systematic reviews support nasal saline irrigation for chronic or recurrent sinus symptoms, but trials have been small and few in primary care settings. Steam inhalation has also been proposed, but supporting evidence is lacking. We investigated whether brief pragmatic interventions to encourage use of nasal irrigation or steam inhalation would be effective in relieving sinus symptoms. METHODS We conducted a pragmatic randomized controlled trial involving adults (age 18-65 yr) from 72 primary care practices in the United Kingdom who had a history of chronic or recurrent sinusitis and reported a "moderate to severe" impact of sinus symptoms on their quality of life. Participants were recruited between Feb. 11, 2009, and June 30, 2014, and randomly assigned to 1 of 4 advice strategies: usual care, daily nasal saline irrigation supported by a demonstration video, daily steam inhalation, or combined treatment with both interventions. The primary outcome measure was the Rhinosinusitis Disability Index (RSDI). Patients were followed up at 3 and 6 months. We imputed missing data using multiple imputation methods. RESULTS Of the 961 patients who consented, 871 returned baseline questionnaires (210 usual care, 219 nasal irrigation, 232 steam inhalation and 210 combined treatment). A total of 671 (77.0%) of the 871 participants reported RSDI scores at 3 months. Patients' RSDI scores improved more with nasal irrigation than without nasal irrigation by 3 months (crude change -7.42 v. -5.23; estimated adjusted mean difference between groups -2.51, 95% confidence interval -4.65 to -0.37). By 6 months, significantly more patients maintained a 10-point clinically important improvement in the RSDI score with nasal irrigation (44.1% v. 36.6%); fewer used over-the-counter medications (59.4% v. 68.0%) or intended to consult a doctor in future episodes. Steam inhalation reduced headache but had no significant effect on other outcomes. The proportion of participants who had adverse effects was the same in both intervention groups. INTERPRETATION Advice to use steam inhalation for chronic or recurrent sinus symptoms in primary care was not effective. A similar strategy to use nasal irrigation was less effective than prior evidence suggested, but it provided some symptomatic benefit. TRIAL REGISTRATION ISRCTN, no. 88204146.
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Affiliation(s)
- Paul Little
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Beth Stuart
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Mark Mullee
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Tammy Thomas
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Sophie Johnson
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Gerry Leydon
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - David Rabago
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Samantha Richards-Hall
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ian Williamson
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Guiqing Yao
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - James Raftery
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Shihua Zhu
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Michael Moore
- Primary Care Group (Little, Stuart, Moore, Thomas, Johnson, Williamson), Health Economic Analyses Team (Yao, Raftery, Zhu) and Research Design Service South Central (Mullee), Primary Care and Population Sciences Unit (Leydon), University of Southampton, Southampton, UK; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK; Department of Family Medicine and Community Health (Rabago), University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Little P, Stuart B, Andreou P, McDermott L, Joseph J, Mullee M, Moore M, Broomfield S, Thomas T, Yardley L. Primary care randomised controlled trial of a tailored interactive website for the self-management of respiratory infections (Internet Doctor). BMJ Open 2016; 6:e009769. [PMID: 27098821 PMCID: PMC4838709 DOI: 10.1136/bmjopen-2015-009769] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To assess an internet-delivered intervention providing advice to manage respiratory tract infections (RTIs). DESIGN Open pragmatic parallel group randomised controlled trial. SETTING Primary care in UK. PARTICIPANTS Adults (aged ≥18) registered with general practitioners, recruited by postal invitation. INTERVENTION Patients were randomised with computer-generated random numbers to access the intervention website (intervention) or not (control). The intervention tailored advice about the diagnosis, natural history, symptom management (particularly paracetamol/ibuprofen use) and when to seek further help. OUTCOMES Primary: National Health Service (NHS) contacts for those reporting RTIs from monthly online questionnaires for 20 weeks. Secondary: hospitalisations; symptom duration/severity. RESULTS Results 3044 participants were recruited. 852 in the intervention group and 920 in the control group reported one or more RTIs, among whom there a modest increase in NHS Direct contacts in the intervention group (intervention 44/1734 (2.5%) versus control 24/1842 (1.3%); multivariate Risk Ratio (RR) 2.53 (95% CI 1.10 to 5.82, p=0.029)). Conversely reduced contact with doctors occurred (283/1734 (16.3%) vs 368/1845 (20.0%); risk ratio 0.71, 0.53 to 0.95, p=0.019). Reduction in contacts occurred despite slightly longer illness duration (11.3 days versus 10.9 days respectively; multivariateestimate 0.48 days longer (-0.16 to 1.12, p=0.141) and more days of illness rated moderately bad or worse illness (0.53 days; 0.12 to 0.94, p=0.012). The estimate of slower symptom resolution in the intervention group was attenuated when controlling for whether individuals had used webpages which advocated ibuprofen use (length of illness 0.22 days, −0.51 to 0.95, p=0.551; moderately bad or worse symptoms 0.36 days, −0.08 to 0.80, p=0.105). There was no evidence of increased hospitalisations (risk ratio 0.13; 0.02 to 1.01; p=0.051). CONCLUSIONS An internet-delivered intervention for the self-management of RTIs modifies help-seeking behaviour, and does not result in more hospital admissions due to delayed help seeking. Advising the use of ibuprofen may not be helpful. TRIAL REGISTRATION NUMBER ISRCTN91518452.
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Affiliation(s)
- Paul Little
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Beth Stuart
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Panayiota Andreou
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Lisa McDermott
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Judith Joseph
- Centre for the Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Mark Mullee
- Research Design Service South Central, Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Mike Moore
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Sue Broomfield
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Tammy Thomas
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Lucy Yardley
- Centre for the Applications of Health Psychology, University of Southampton, Southampton, UK
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