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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]

Search Outcome

40 papers found in medline, 10 papers found in Embase , only one was related to the main question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cardoso M.M.S.C; Carvalho J.C.A; Tahamtani S.M.M November 2002 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

Comment(s)

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

Clinical 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

1. 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 Revista Brasileira de Anestesiologia November 2002, Vol/is. 52/6(666-672),0034-7094