Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta‐Analysis of Randomised Controlled Trials

Abstract

Background The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. Objective The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP. Methods A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Results Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting. Conclusions There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.

Acute Pancreatitis: Diagnosis and Treatment

“…Abdominal pain can be profound in acute pancreatitis, and for most patients, strong opioid analgesia is appropriate, reducing the need for supplementary analgesia over other regimens; analgesia ladders can be used for those with less severe pain, mindful that early and effective relief is a priority [174]. NSAIDs are an opiate-sparing alternative for uncomplicated disease [175], but run the risk of renal injury in more severe disease. Experimental evidence indicates opiates increase sphincter of Oddi phasic contractions that may increase pressure within the bile duct [176], but randomised trials have demonstrated that opiates are as, if not more, effective than alternatives, and as safe in acute pancreatitis [177].…”

Prediction of infected pancreatic necrosis in acute necrotizing pancreatitis by the modified pancreatitis activity scoring system

“…In the early phase of AP, pain is ubiquitous, caused by the release of inflammatory mediators, arachidonic acid metabolites, bradykinins, and proteases, all of which may stimulate primary afferent sensory neurons. 27 Adequate analgesia is essential to AP patient management 28 and may reduce systemic inflammation. The MED score of the original PASS did not define a maximal upper limit, while the other four components have defined ranges, which may skew the composite PASS.…”

Update on the management of acute pancreatitis

“…Traditionally, pain management is cornered on the use of opiates although nowadays a multimodal approach paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), metamizole, opiates, ketamine and epidural analgesia is commonly used. Two recent meta-analyses have appeared, identifying 6 and 12 RCTs, respectively [16,17]. Both meta-analyses indicate that NSAIDs and opiates are equally effective, but a substantial paucity of data exists.…”