Page 28 Acute Pain Management

Anti‐inflammatory drugs

Corticosteroids
1. Subacromial injections of corticosteroids are superior to oral NSAIDs in treating rotator
cuff tendonitis (N) (Level I).
2. Lumbar epidural steroid administration is effective for short ‐term relief of acute
radicular pain (N) (Level I).
3. Following knee joint arthroscopy, intra‐articular steroids in combination with either local
anaesthetic or opioids reduce pain, analgesic consumption and duration of
SUMMARY 4. Intravenous regional anaesthesia combining dexamethasone with lignocaine improves
immobilisation (N) (Level II).

analgesia for up to 24 hours (N) (Level II).
5.
There is a risk of septic arthritis with intra‐articular steroids (N) (Level IV).
Non‐steroidal anti‐inflammatory drugs
1. Topical NSAIDs are of limited efficacy in lateral elbow pain and provide short‐term
functional improvement; they result in fewer gastrointestinal side effects compared with
oral NSAIDs (N) (Level I [Cochrane Review]).
2. Non‐selective NSAIDs added to local anaesthetic solutions for IVRA improve
postoperative analgesia (N) (Level I).
3. Topical NSAIDs are effective in treating acute strains, sprains or sports injuries for up to
1 week with ketoprofen being significantly better than all other topical NSAIDs, and
indomethacin similar to placebo (N) (Level I).
4. Topical diclofenac significantly reduces pain and inflammation in a range of sports,
traumatic and inflammatory conditions and in acute musculoskeletal injuries is at least
comparable to oral naproxen (N) (Level I).
5. Topical NSAIDs are effective analgesics for traumatic corneal abrasions (N) (Level I).

6. ADMINISTRATION OF SYSTEMIC ANALGESIC DRUGS
1. Paracetamol combined with codeine is more effective than either drug alone and shows
a dose‐response effect (N) (Level I [Cochrane Review]).
2. NSAIDs (both nsNSAIDs and coxibs) given parenterally or rectally are not more effective
and do not result in fewer side effects than the same drug given orally (U) (Level I
[Cochrane Review]).
3. Paracetamol combined with tramadol is more effective than either drug alone and shows
a dose‐response effect (N) (Level I).

4. Early postoperative oral administration of paracetamol results in highly variable plasma
concentrations that may remain subtherapeutic in some patients (N) (Level II).
5. Rectal administration of single doses of paracetamol results in highly variable plasma
concentrations that often remain subtherapeutic (N) (Level II).
6. Intermittent subcutaneous morphine injections are as effective as intramuscular
injections and have better patient acceptance (U) (Level II).
7. Intranasal opioids, in particular the more lipid‐soluble drugs such as fentanyl, are
effective for the management of acute pain (N) (Level II).

xxviii Acute Pain Management: Scientific Evidence