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Three Part Question

In [adult patients presenting to the emergency department with acute pain], are [intramuscular non-steroidal anti-inflammatory drugs] compared to [oral NSAIDs] more efficacious at [reducing musculoskeletal pain]?

Clinical Scenario

A 40-year-old male presents to the emergency department with low back pain after lifting and moving a heavy piece of furniture. After your history and physical exam, you conclude that the patient’s pain is musculoskeletal in nature secondary to using poor form while performing heavy lifting. You contemplate whether an oral or intramuscular NSAID would provide more effective pain relief.

Search Strategy

Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
[("oral"[All Fields] AND "intramuscular"[All Fields]) AND (Anti-Inflammatory Agents, Non-Steroidal / administration & dosage OR Anti-Inflammatory Agents, Non-Steroidal / therapeutic use)]. Limit to English language and randomized controlled trial

Search Outcome

99 studies were identified; three clinical trials were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Qureshi I, et al July 2019 Quatar	300 adults presenting to the ED within 24 hours of an acute MSI, who had a triage pain score measured using numerical rating scale of at least five or above.	RCT	Proportion of IM versus PO participants attaining a 50% reduction in pain score at 30min	99.3% in the IM group and 86.7% in PO group	Patient demographics consisted mostly of younger males and may limit comparison to population of different patient demographics; restriction of endpoint assessment to 30 min limits complete picture of pain reduction
			Number needed to treat receiving IM rather than the PO diclofenac in order to achieve one additional case of 50% pain reduction	8 cases (95%CI 6 to 14)
			Adverse effects	None
Turturro MA, et al August 1995 USA	82 adult patients with acute musculoskeletal pain due to trauma	RCT	Pain evaluated with 100-mm visual analog scale at 0, 15, 30, 45, 60, 75, 90, and 120 minutes after dosing	Mean pain scores improved in each group but no difference in analgesic effect.	A placebo group was not included; potential selection bias as patients with extreme pain were not included; small sample size
			Side-effects	No significant differences
Neighbor ML et al August 1995 USA	119 adult patients who presented to ED with moderate to severe pain from a variety of etiologies.	RCT	Pain scores measured at 0, 15, 30, 45, 60, 90, and 120 minutes after dosing	No difference in analgesic effect, IM versus PO	Convenience sample of patients; patients with extreme pain were not included; patients were a heterogeneous group with different etiologies for their pain which may not have been responsive to NSAIDs

Comment(s)

Pain alleviation is a frequent clinical priority in the emergency department. Recent years have seen ED practice shift towards increased use of non-opioid pharmacotherapy, including non-steroidal anti-inflammatory drugs (NSAIDs), in an effort to avoid the dependency-related risk factors associated with opioids. NSAIDs are available in multiple forms (oral and enteral) which adds to their utility in pain regimens in different patient scenarios. Patients can also obtain certain NSAIDs over-the-counter, allowing them to continue therapy at home without needing a prescription.

Clinical Bottom Line

Intramuscular NSAIDs may provide slightly more rapid time to analgesia, but there is no significant difference in analgesic efficacy between oral and intramuscular NSAIDs.

References

1. Qureshi I, Pathan SA, Qureshi RS, Thomas SH. Intramuscular versus oral diclofenac for acute pain in adults with acute musculoskeletal injuries presenting to the ED setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J 2019 Jul;36(7):401-406.
2. Turturro MA, Paris PM, Seaberg DC. Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain. Ann Emerg Med 1995 Aug;26(2):117-20.
3. Neighbor ML, Puntillo KA Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Acad Emerg Med 1998 Feb;5(2):118-22