Diclofenac is more effective for post-operative analgesia in patients undergoing lower abdominal gynecological surgeries: A comparative study

A randomized controlled trial of rectal versus intramuscular diclofenac for post-operative analgesia after open myomectomy

AIM

To determine the efficacy and safety of rectal versus intramuscularly administered Diclofenac in reducing post-operative pain in the first 24 h after open-myomectomy.

METHODS

A single blind, placebo controlled randomized trial consisting of 90 consenting women that had open-abdominal-myomectomy. They were randomized into two-groups (rectal-group and intramuscular-group) of 45 women (1:1 ratio). Rectal-group received 75 mg of Diclofenac suppository 12 hourly for 24 h and placebo (3 ml of intramuscular injection-water) 12hourly for 24 h while intramuscular-group received intramuscular Diclofenac 75 mg 12 hourly for 24 h and placebo (Anusol suppository) 12 hourly for 24 h. Both groups received intramuscular Pentazocine 30 mg 6 hourly for 24 h as primary analgesic after myomectomy. Pain was assessed using a Ten-Point Visual-Analogue-Scale. Participants' satisfaction of the mode of the pain relief was assessed using the Likert-scale after 24 h. The primary outcome was the pain score using the visual-analogue-scale. The secondary outcome-measures were participants' satisfaction after 24 h of administration of the drugs, the need and frequency of rescue-analgesia and maternal-side-effects.

RESULT

The baseline socio-demographic characteristics were similar in both groups. There was no statistically significant difference between both groups in pain assessment at 1 h post-myomectomy (p-value > 0.05). However, the pain assessments at 6, 12, 18 and 24 h post-myomectomy were statistically significant with more pain in intramuscular-group when compared to rectal-group. Majority of participants in rectal-group were both very satisfied (35.6 %) and satisfied (55.6 %) when compared to intramuscular-group (11.1 %) and (31,1%) respectively (p-value < 0.05). Also majority of the participants in intramuscular-group were dissatisfied (17.8 %) with none of the participant showing any form of dissatisfaction (p-value < 0.05). Majority of the participant in rectal-group had no drug side effects when compared with intramuscular-group. Epigastric discomfort was commoner in rectal-group while drowsiness was commoner in intramuscular-group.

CONCLUSION

Rectal Diclofenac with intramuscular Pentazocine is significantly associated with better effectiveness in pain reduction and maternal satisfaction when compared with intramuscular Diclofenac and intramuscular Pentazocine following open-myomectomy. While epigastric discomfort was the commonest side-effect in rectal-group, drowsiness was commoner in intramuscular-group.

TRIAL REGISTRATION

Pan-African-clinical-trial-registry (PACTR); PACTR202206556144219.

Kounis Syndrome Associated With the Use of Diclofenac

BACKGROUND

Diclofenac is a widely used analgesic, anti-inflammatory, antipyretic drug. In several case reports, its use was associated with the occurrence of Kounis syndrome. The aim of this review was to investigate and summarize published cases of Kounis syndrome suspected to be associated with the use of diclofenac.

METHODS

Electronic searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and the Serbian Citation Index.

RESULTS

Twenty publications describing the 20 patients who met inclusion criteria were included in the systematic review. Specified patient ages ranged from 34 to 81 years. Eighteen (90.0%) patients were male. Five patients (25.0%) reported a previous reaction to diclofenac. Reported time from the used dose of diclofenac to onset of the first reaction symptoms ranged from immediately to 5 hours. Diclofenac caused both type I and type II Kounis syndrome, with the presence of various cardiovascular, gastrointestinal, dermatologic, and respiratory signs and symptoms. Most patients experienced hypotension (n = 15 [75.0%]) and chest pain (n = 12 [60.0%]). The most frequently reported finding on electrocardiogram was ST-segment elevations (n = 17 [85.0%]). Coronary angiogram showed normal coronary vessels in 9 patients (45.0%), with some pathologic findings in 8 patients (40.0%).

CONCLUSION

Clinicians should be aware that Kounis syndrome may be an adverse effect of diclofenac. Prompt recognition and withdrawal of the drug, with treatment of both allergic and cardiac symptoms simultaneously, is important.

Oral Diclofenac Potassium Versus Intravenous Acetaminophen in Acute, Isolated, Closed-Limb Trauma

Pain control is an important concern in limb trauma. The most ideal agent for this purpose varies among different hospitals. The objective of this study was to compare the analgesic effect of oral diclofenac potassium versus intravenous acetaminophen in patients with limb trauma. This was a double-blind randomized clinical trial conducted on 60 adult patients. Oral diclofenac potassium (50 mg) was given in Group D, and intravenous acetaminophen (1 g in 500 ml normal saline over 20 min) was administered in Group A. Patients' pain scores (visual analogue scale) were recorded and compared at baseline, 5, 15, 30, 60 min, and 4 hr after drug administration. The mean age was 42.62 ± 15.42 and 38.04 ± 17.48 years in Group A and Group D, respectively. No significant change was observed between the 2 groups (p = 0.11). In this study, both drugs could decrease the pain score effectively and safely in isolated limb trauma.

The impact of intravenous acetaminophen on pain after abdominal surgery: a meta-analysis

BACKGROUND

Pain after surgery is commonly controlled with opioid pain medications. A multi-modal pain strategy that involves acetaminophen may help minimize the negative consequences of opioids, such as ileus, respiratory depression, and addictive potential. There are limited data on the effectiveness of intravenous (IV) acetaminophen in comparison with other nonopioid pain medications.

MATERIALS AND METHODS

Four databases were queried for the keywords "acetaminophen," "intravenous," and "postoperative". Prospective studies of adult patients receiving at least 24 h of IV acetaminophen after intraabdominal surgery were analyzed for 12- and 24-h pain scores and 24-h narcotic consumption. A random effects model was performed using mean differences and 95% confidence intervals to assess the effect of IV acetaminophen on outcomes. Heterogeneity was assessed using χ² and the I² statistics.

RESULTS

Seventeen articles were identified that complied with inclusion and exclusion criteria. There was no significant difference in 24-h pain scores between IV acetaminophen and any other comparator, or in secondary endpoints of 12-h pain scores and 24-h narcotic consumption. Subgroup analysis demonstrated significant benefit for IV acetaminophen in open surgeries for decreased 24-h narcotic consumption. When analyzing individual medications, non-steroidal anti-inflammatory drugs demonstrated the largest reduction in 24-h narcotic consumption. Data were of moderate quality and demonstrated significant heterogeneity between studies.

CONCLUSIONS

The lack of significant differences in primary endpoints may be explained by the heterogeneous, moderate-quality data. However, subgroup analyses suggested IV acetaminophen may be advantageous in open surgeries, and non-steroidal anti-inflammatory drugs may lower the 24-h narcotic requirement.