Diclofenac per-rectum or Diclofenac intramuscular in acute back pain
Date First Published:
June 21, 2009
Last Updated:
June 3, 2010
Report by:
Mr. Abdualla zentani, Staff Grade Emergency medicine (Fairfield General Hospital , Bury)
Search checked by:
Mr. Michael Saab , Fairfield General Hospital , Bury
Three-Part Question:
In[patients presenting to the emergency department with severe back pain requiring analgesia] is [ Diclofenac P/R superior to Diclofenac I.M ] in [ achiving quick pain relief]
Clinical Scenario:
56 years old man presented with history of sever back pain which is radiating to the left hip joint and associated with numbness over the left calf . you prescribed oral paracetamol which did not give any relife , so you prescribed diclofenac IM but one of your junior doctors told you that he read article recently in one of the medical journals about the efficacy of rectal diclofenac in the quick relife of the back pain .
Search Strategy:
Medline
(back AND pain OR backache OR mechnical AND back AND pain OR muscular AND back AND pain ).ti,ab AND (diclofenac OR voltarol ).ti,ab[limit to :Human and English language]
Embase
(back AND pain OR backache).ti,ab AND (diclofenac OR voltarol AND injection OR suppostries).ti,ab[ limit to:Human and English language]
(back AND pain OR backache OR mechnical AND back AND pain OR muscular AND back AND pain ).ti,ab AND (diclofenac OR voltarol ).ti,ab[limit to :Human and English language]
Embase
(back AND pain OR backache).ti,ab AND (diclofenac OR voltarol AND injection OR suppostries).ti,ab[ limit to:Human and English language]
Outcome:
40 papers found in medline, 10 papers found in Embase , only one was related to the main question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intramuscular versus rectal diclofenac associated with low dose spinal morphine for post-cesareean analgesia cardoso M.M.S.C; carvalho J.c.A; Tahamtani S.M.M. Nov-02 Portuguese | patients were randomly allocated into three groups, G50VR(n=62),50 mg rectally ; G50IM(n=62), 50 mg intramuscularly and G75IM(n=62), 75 mg intramuscularly | Random study | when associated with low dose of spinal morphine, intramuscular diclofenac offers better postoperative analgesia than the rectal route | mean pain scores in G50VR (0.9+/-1.4;1.4+/-1.4;1.3+/-1.5;1.3+/-1.2and 1.5+/-3.3cm)were higher as cmpared to to G50IM((0.4+/-0.8;0.5+/-0.8;0.7+/-1.0;0.7+/-1.1and0.7+/-1.1cm) and G75IM(0.4+/-0.8;0.7+/-1.3;0.7+/-1.1;0.8+/-1.2and0.7+/-1.0cm).the need for rescue meperidine (43.5%) and total meperidine consumption(21.3+/-28.9mg) were higher in G50VR as compared to G50IM ( 21% and 8.2+/-18.2mg ) and G75IM ( 19.4% and 6.8%+/- 16.7 mg ) respectivley | the study did not ask clear focused question. type of the study was not clearley mentioned . it was not cleared why two groups received diclofenac intramuscularley , 50mg , 75mg and only one group received diclofenac 50mg rectally |
Author Commentary:
From the papers found in both medline and Embase there is no strong evidence to support the advantage of using rectal diclofenac insted of intramuscular diclofenac for the acute back pain in the ED,however the only paper found related to the three part question showed that intramuscular diclofenac offers better postoperative analgesia than rectal route when associated with low dose of spinal morphine
Bottom Line:
Using of diclofenac for acute back pain is recomended , but the route of adminstration either rectally or intramuscularly should be according to the local policy of the individual ED
References:
- cardoso M.M.S.C; carvalho J.c.A; Tahamtani S.M.M.. Intramuscular versus rectal diclofenac associated with low dose spinal morphine for post-cesareean analgesia