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Three Part Question

In [adults with biliary colic and no evidence of infection] is [buscopan(hyoscine bromide) better than/equal to analgesics] in [controlling pain]

Clinical Scenario

A 42 year old female patient presents with moderate to severe right upper quadrant colicky pain radiating to the back with one episode of vomiting. She is apyrexial and examination reveals mild right subcostal tenderness with no guarding. You diagnose biliary colic and wonder is buscopan is effective in relieving pain.

Search Strategy

Medline 1966-05/05 using the OVID interface.
Two searches: [Biliary colic/ or analgesia for biliary colic mp.] and [buscopan or butylscopolammonium bromide] undertaken. Both combined and limited to human and English.

Search Outcome

22 papers found of which three were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kumar et al 2004 new Zealand	72 patients with biliary colic treated with IM 75 mg diclofenac (n=36) or buscopan 25 mg IM (n=36)	Prospective double blind study.	Complete pain relief at 4h	Diclofenac 91.7% vs. buscopan 69.4%. p=0.037	Small number of patients involved
			Progression to cholecystitis in 72h	Diclofenac 16.66% vs. buscopan 52.77%. p=0.003
G. Schmieder, G. Stankov, G. Zerle, S. Schnitzel and K. Brune 1993 Germany	74 patients with biliary colic treated with metimazole 2.5mg IV (n=25), tramadol 100mg IV (n=25) or buscopan 20 mg IV (n=24.)	Multicentre, observer blind, parallel group study.	Onset of pain relief	Metimazole 10.9 (+/- 5.8 minutes); tramadol: 15.8 (+/-11.7 minutes); buscopan: 25.6 (+/- 24.3 minutes.) Metimazole vs. tramadol: p-value insigificant. Metimazole vs. buscopan: p-value<0.037.	Small number patients involved. Overall assessment of pain relief during the whole period of observation was not adequately quantified or assessed.
			Overall assessment of treatement efficacy	Metimazole was the most effective drug (p=0.004)
N. Al-Awaili and K.Y. Saloom 1998 U.A.E.	32 patients with biliary colic treated with tenoxicam 20mg IV (n=16) or buscopan 20mg IV (n=16).	Prospective double blind study	Pain relief at 30 minutes using a five point score	Tenoxicam: 10 out of 16 patients had significant pain relief (P<0.005). Buscopan: 7 out of 16 paitents had significant pain relief (p<0.05). Difference between both drugs: insignificant.	Small number of patients involved. Tenoxicam is not a widely used analgesic. Although stating that tenoxicam is significantly more effective than buscopan in preventing relapse of pain and progression to chlecystitis no p-value was given.
			Pain relief at 60 minutes using a five point score	Tenoxicam 14 out of 16 patients had significant pain relief (p<0.005). Buscopan: 10 out of 16 patients had significant pain relief (p<0.005). Difference between both drugs: insignificant.
			relapse of pain and development of acute cholecystitis within 24h	Tenoxicam: none. Hyoscine: 4 patients had pain relapse, 2 had cholecystitis. Significant difference between both drugs in both parameters. No p-vlue given for either.

Comment(s)

The three available papers involved a small number of patinets each. Two papers reported a significant difference in pain relief of non-infective biliary colic between analgesics and buscopan. One paper reported the difference in pain relief being insignificance.

Clinical Bottom Line

Buscopan is less effective than analgesics in non-infective biliary colic.

References

1. Anup Kumar, Jagpreed S. Deed, Bharat Bhasin, Ashok Kumar and Shaji Thomas. Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic ANZ Journal of Surgery. 2004; 74:573-576
2. G. Schmieder, G. Stankov, G. Zerle, S. Schnitzel and K. Brune Observer-blind study with Metimazole versus Tramadol and Butylscopolamine in Acute Biliary Colic Pain. Arzneimittel Forschung 1993; 43(11):1216-1221
3. N. Al-Waili, K.Y. Saloom The analgesic effect of intravenous tenoxicam in symptomatic treatment of biliary colic: A comparison with hyoscine N-butylbromide. Eur J. Med. Res. 1998; 3: 475-479