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 Table of Contents  
EVIDENCE-BASED MEDICINE: SUMMARY OF STUDY
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 16-17

Intravenous or oral paracetamol: Which is better in the emergency department?


1 Lecturer, Department of Pharmacy Services, Christian Medical College, Vellore, India
2 Associate Professor, Department of Medicine, Christian Medical College, Vellore, India

Date of Web Publication27-Apr-2018

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_13_18

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How to cite this article:
Bright HR, Carey R. Intravenous or oral paracetamol: Which is better in the emergency department?. Curr Med Issues 2018;16:16-7

How to cite this URL:
Bright HR, Carey R. Intravenous or oral paracetamol: Which is better in the emergency department?. Curr Med Issues [serial online] 2018 [cited 2018 Aug 19];16:16-7. Available from: http://www.cmijournal.org/text.asp?2018/16/1/16/231366

Source: This is a summary of the study: Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018 Mar 1;35 (3):179.(1): Summary prepared by Mr. Heber Rew Bright, Lecturer, Department of Pharmacy Services, Christian Medical College, Vellore, India and Dr. Ronald Carey, Associate Professor, Department of Medicine, Christian Medical College, Vellore, India.

Clinical Question: Is injection paracetamol better than the oral preparation of the same drug in an emergency medicine setting?

Authors' conclusions: Intravenous paracetamol may not be superior to oral paracetamol when used as adjunct to opioid in emergency patients with moderate-to-severe pain. However, the researchers conclude by saying that there may be patients that fall outside the boundaries of this study whom may benefit.


  Why This Study? Top


There is often an assumption of superior efficacy of the intravenous (IV) preparation of paracetamol due to the pharmacokinetic advantages including higher bioavailability, faster target plasma concentrations, and avoidance of hepatic first-pass metabolism. However, comparisons with the oral form are limited.

Potential advantages of IV paracetamol over the oral in the emergency setting include faster onset of action, greater analgesic efficacy, and reduced opioid use.

However, is there evidence to justify the preferential use of IV paracetamol, when oral and rectal routes of administration are available, with the prospect of higher costs, time and inconvenience, and the possibility of complications with IV administration?



With this background in mind, a group of Australian researchers intended to compare the efficacy of IV paracetamol with oral paracetamol as an adjunct to IV opioids. They randomized 87 adult patients complaining of acute pain corresponding with visual analog scale (VAS) ≥40 mm at 5 min after receiving at least one dose of IV opioid to receive either 1 g paracetamol orally or intravenously. Due to difference in formulations, a double-blind, double-dummy technique was used so that all patients received both an oral and an IV preparation. Vital signs, adverse event data, and VAS scores (0 mm indicating no pain and 100 mm indicating severe pain) were collected immediately before the administration of paracetamol, then at every 15 min for the next 1 h and then every 30 min for the next 3 h until the patient was transferred to the ward or discharged.[1]


  Results Top


  • The researchers found no significant difference in pain reduction at any time points between the groups. At 30 min, a difference in VAS score of only − 2.6 mm was observed. The maximum difference (−13.4 mm) observed was at 240 min which was not found to be statistically significant
  • There was no difference in rescue opioids as well. A total of 86.2% patients in IV paracetamol group and 84.1% of the oral group (P = 0.69) were administered with rescue opioids. However, patients receiving IV paracetamol were more satisfied (100%) than those who received paracetamol orally (90%), but the difference did not reach statistical significance. The side-effect profile was similar in both the groups
  • In addition, 25.5% in the IV group and 20% in the oral group achieved clinically significant pain reduction (50% reduction from baseline) at 30 min (P = 0.54).



  Conclusions Top


This small, single-center study conducted in the Emergency Department setting at Townsville hospital was published in the Emergency Medicine Journal.[1]

The study results reveal that IV paracetamol may not be superior to oral paracetamol when used as adjunct to opioid in emergency patients with moderate-to-severe pain. However, the researchers conclude by saying that there may be patients that fall outside the boundaries of this study whom may benefit.

This is the first study comparing IV paracetamol and oral paracetamol for the reduction of pain among emergency patients. Although the IV preparation is often anecdotally regarded as superior, the results demonstrating no difference are congruent with a recent systematic reviews comparing oral and IV paracetamol in a variety of settings.[2],[3],[4] IV paracetamol has also compared favorably with IV morphine in randomized controlled trials and found not superior.

The researchers also discussed possible reasons for the IV paracetamol not demonstrating a superior effect over its oral comparator. The first is that there may exist a true difference but not clinically meaningful difference or be the result of a type II error. Alternatively, heterogeneity in the patient population or prior administration of opioid analgesic may have obscured any real treatment effect.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, et al. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: A prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J 2018;35:179-84.  Back to cited text no. 1
    
2.
McNicol ED, Ferguson MC, Haroutounian S, Carr DB, Schumann R. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane Database Syst Rev 2016;23(5): CD007126.  Back to cited text no. 2
    
3.
Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus oral acetaminophen for pain: Systematic review of current evidence to support clinical decision-making. Can J Hosp Pharm 2015;68:238-47.  Back to cited text no. 3
    
4.
Sun L, Zhu X, Zou J, Li Y, Han W. Comparison of intravenous and oral acetaminophen for pain control after total knee and hip arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2018;97:e9751.  Back to cited text no. 4
    




 

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