Monday, March 5, 2007

Ibuprofen best for treating kids' pain

The first head-to-head study of three common painkillers found that ibuprofen works best, at least for kids with broken bones, bruises and sprains.

Available generically and under the brand names Advil and Motrin, ibuprofen beat generic acetaminophen and codeine in an emergency room study of 300 children treated at a Canadian hospital.
Not that I don't have enough soapboxes, but one of them is certainly the incredible underuse of ibuprofen and other NSAIDS for acute pain. Granted, I haven't read the real paper, and there's certainly a chance that narcotics may have been underdosed (which resembles real world situations--docs aren't nearly as afraid to prescribe higher doses of NSAIDs compared to narcotics). But I think we at least see further evidence that, barring any reasonable contraindication, there's little reason not to include ibuprofen as either a primary or adjunct pain reliever in the setting of acute pain.


nicole said...

one quickie comment - the reason people don't use the ibuprofen as much in fractures/broken bones is that it's been shown to delay the earliest stages of bone healing (which is, at it's most simple, an inflammatory process to begin with)

Garrett said...

Well there ya go. Is that a class effect for NSAIDs?

Matz said...

I've heard the same thing, but I have to say, so what? I always hear orthopods telling their patients and consults to stay way from Ibuprofen, but when the alternatives are pain or narcotics it seems a small price to pay. This is the same argument I've heard for not giving nicotine replacement to people who are quitting smoking.

Garrett said...

I would like to see a review of a bit of the evidence on ibuprofen and healing, because it sounds like something that could either be A) what somebody has just been saying for years, and how everybody practices, or B) something that has excellent evidence for it that super justifies avoidance of ibuprofen or other NSAIDs.

If I was un-lazy enough to go to the real article, maybe that would help. And Adobe 8 is all messed up on my computer, and pdfs are all looking wacky.

nicole said...

it's actually thought to be a pretty significant delay in bone healing. and, actually especially in kids, tylenol (and similars) seem to do just fine in controlling the (not enough to require narcotics) pain. in vitro studies have shown NSAIDS (ibu, indomethacin, etc) to have an inhibitory role on osteoblast recruitment and proliferation. NSAIDS are actually frequently used to prevent post-traumatic heterotopic ossification in patients prone to it specifically for the reason that it inhibits bony callus formation. moreover, NSAIDS (ibuprofen, especially) have also been shown to slow general wound healing by inhibiting angiogenesis and fibroblast recruitment/organization.

just a couple of results from a brief pubmed search:
J Orthop Trauma. 1995;9(5):392-400.

Arch Orthop Trauma Surg. 2007 Jan 24; [Epub ahead of print]

J Wound Care. 2007 Feb;16(2):76-8

Oper Orthop Traumatol. 2005 Dec;17(6):569-7

J Am Acad Orthop Surg. 2004 May-Jun;12(3):139-43

Arch Orthop Trauma Surg. 2003 Sep;123(7):327-3

when it comes to soft-tissue healing, NSAIDS are typically preferred for analgesia. and there is a good point that maybe there isn't enough *clinical* evidence (Emerg Med J. 2005 Sep;22(9):652-3) but more theoretical and lab/in vitro/animal model evidence against using NSAIDS in these peds fracture situations .... but if another analgesic agent (i.e. tylenol in kids, or even weak opiates, etc) works to relieve the pain, why not start with that?

if there is a delay in healing - that could actually lead to more pain/trauma down the line, as non-unions are the result of delayed fracture healing and those hurt like a bitchin.

sorry - i'll get off my soapbox now. sorry to get up there in the first place, garrett. :) i guess my point is that the world won't end if you do use NSAIDS, but it's definitely something to think about, especially if the fracture is in a site where non-union is high risk or there could be avascular necrosis as a result of non-union. etc.

Garrett said...

Touche'! I'll leave this one in the ER doc's court. Again, I'm too lazy to look up the article the news report references, but I'd like to know if they even addressed this issue.

Of course, there might have been a completely separate discussion for fractures, as opposed to the other conditions mentioned.

I don't have to disclose my Motrin stock, right?