In this episode, I’ll discuss an article comparing IV acetaminophen with IV hydromorphone for acute pain in elderly ED patients.
IV acetaminophen has been a tremendous disappointment when compared to opioids in terms of both efficacy and reducing opioid-related side effects. I have not yet seen a study demonstrating a clinically meaningful improvement of IV acetaminophen over an IV opioid for acute pain. However, there continues to be a desire to find a niche for IV acetaminophen, especially in patient populations at risk for opioid related side effects such as the elderly. To this end a Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain was recently published in Annals of Emergency Medicine.
The authors sought to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids.
The primary outcome being investigated was an improvement in a 0 to 10 pain score from baseline compared to 60 minutes after study medication was administered. The secondary outcomes included the need for additional analgesic medication and any adverse events that could be related to the study medication. The authors pre-specified a minimum clinically important difference of an improvement of 1.3 or more on the 0 to 10 pain scale.
The patients enrolled definitely represented a cohort with severe acute pain as the median baseline pain score was 10/10.
After 60 minutes, the patients who received 1000 mg IV acetaminophen improved by 3.6 and the patients who received 0.5 mg IV hydromorphone improved by 4.6 out of 10.
Overall pain relief after 1 dose however was not very good for either group. Almost half of the IV acetaminophen patients required additional doses of an analgesic, as did just over one-third of the patients who received IV hydromorphone.
Adverse events were similar between groups and minimal consisting of dizziness, drowsiness, headache, and nausea.
Unfortunately, it seems that efforts to provide analgesia with lower doses of opioids like 0.5 mg IV hydromorphone or alternatives to opioids like IV acetaminophen cannot reliably provide adequate pain relief in a cohort of elderly ED patients with severe acute pain.
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