Intravenous single-dose tramadol versus meperidine for pain relief in renal colic

A Pilot Study on the use of Tramadol Hydrochloride for Pain Control in an Emergency Department

Introduction

Tramadol hydrochloride is a synthetic μ,-opioid agonist. It has been used in the control of moderate to severe pain. Most of the studies on tramadol were related to post-operative pain control. Data on acute pain control in the emergency setting were limited. This study reported on the initial evaluation of tramadol for pain control in an emergency department.

Materials and methods

It was a prospective observational study. Patients aged 16 years or above attending our emergency department with moderate to severe pain were recruited. Patients with known allergy, current psychiatric medication, intake of alcohol, major systemic illness and opioid dependence were excluded. All patients received 100 mg intramuscular tramadol injection. A 10 cm Visual Analogue Scale (VAS) was used to assess the pain severity before injection, 30 minutes and 60 minutes after injection. Vital signs and side effects were also recorded.

Results

Forty patients (M: 24, F: 16) were recruited from October to December 2002. Their mean age was 53.5 years. The majority of them suffered from acute musculoskeletal pain or arthritis. Tramadol was shown to be effective in pain control. The VAS decreased by 1.90 (p<0.001) and 3.38 (p<0.001) at 30 minutes and 60 minutes respectively. Four patients reported nausea and three patients vomited.

Conclusion

Tramadol appeared to be a safe drug to be used in the emergency setting. Only a few insignificant side effects were reported. The comparison of efficacy with other analgesics requires further studies.

Tramadol can selectively manage moderate pain in children following European advice limiting codeine use

The European Medicine Agency recommendations limiting codeine use in children have created a void in managing moderate pain. We review the evidence on the pharmacokinetic, pharmacodynamic and safety profile of tramadol, a possible substitute for codeine.

CONCLUSION

Tramadol appears to be safe in both paediatric inpatients and outpatients. It may be appropriate to limit the current use of tramadol to monitored settings in children with risk factors for respiratory depression, subject to further safety evidence.

Management of Pain in the Emergency Department

Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.

Emergency management of ureteral stones: Recent advances

Most ureteral stones can be observed with reasonable expectation of uneventful stone passage. When an active ureteral stone treatment is warranted, the best procedure to choose is dependent on several factors, besides stone size and location, including operators’ experience, patients’ preference, available equipment and related costs. Placement of double-J stent or nephrostomy tube represents the classical procedures performed in a renal colic due to acute ureteral obstruction when the conservative drug therapy does not resolve the symptoms. These maneuvers are usually followed by ureteroscopy or extracorporeal shockwave lithotripsy, which currently represent the mainstay of treatment for ureteral stones. In this review paper a literature search was performed to identify reports dealing with emergency management of renal colic due to ureteral stones. The main aspects related to this debated issue are analyzed and the advantages and disadvantages of each treatment option are carefully discussed.

Advances in perioperative pain management: use of medications with dual analgesic mechanisms, tramadol & tapentadol

Recovery from ambulatory surgical procedures can be limited by postoperative pain. Inadequate analgesia may delay or prevent patient discharge and can result in readmission. More frequently, postoperative pain produces discomfort and interrupts sleep, contributing to postoperative fatigue. The development of effective analgesic regimens for the management of postoperative pain is a priority especially in patients with impaired cardiorespiratory, hepatic, or renal function. Tramadol and tapentadol hydrochloride are novel in that their analgesic actions occur at multiple sites. Both agents are reported to be mu-opioid receptor agonists and monoamine-reuptake inhibitors. In contrast to pure opioid agonists, both drugs are believed to have lower risks of respiratory depression, tolerance, and dependence. The Food and Drug Administration has approved both drugs for the treatment of moderate-to-severe acute pain in adults. This article provides an evidence-based account of the role of tramadol and tapentadol in modern clinical practice.

Incontinence after radical prostatectomy: surgical treatment options

PURPOSE OF REVIEW

Stress urinary incontinence is an uncommon finding in healthy men. Following radical prostatectomy, however, stress urinary incontinence is the most important complication influencing patient morbidity following surgery and influencing satisfaction, regardless of the surgical technique applied. Conservative treatment options centre at early restoration of bladder and pelvic floor function. When significant and bothersome stress urinary incontinence persists, even after six to 12 months active treatment follow-up, surgical restoration of continence seems advisable.

RECENT FINDINGS

Two themes emerge in reviewing the recent publications in this field. Implantation of the hydraulic artificial urinary sphincter is still the gold standard, particularly in severe cases. Alternatively, new techniques and other artificial materials are gaining favour, aiming at a large cohort of patients with less severe incontinence, which have been not treated or overtreated so far. Advances in both areas are covered within this review article in detail.

SUMMARY

For treatment of incontinence following prostatectomy, a large variety of surgical techniques are readily available and have proven to be helpful tools in making patients' uncomfortable lives much easier. In addition, the wide armamentarium of artificial materials and techniques may help to choose the proper surgical technique for every patients' needs.

Tramadol: does it have a role in emergency medicine?

Tramadol is a synthetic analgesic new to the Australasian market where its use is rapidly increasing. It is used extensively overseas, particularly in Europe where it has been popular since its introduction in Germany in the late 1970s. Tramadol has a dual mechanism of action: weak mu opioid receptor agonist and a reuptake inhibitor of serotonin and noradrenaline. Thus, it has distinct advantages and disadvantages compared to other available analgesics. Its use is advocated in a variety of acute and chronic pain states as well as some non-analgesic applications. The use of tramadol in an emergency setting is not well studied, with most published trials assessing its efficacy and tolerability in postoperative or dental models. This literature review concludes that tramadol does not offer any particular benefits over existing analgesics for the majority of emergency pain relief situations.

Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic

BACKGROUND

Renal colic is a common cause of acute severe pain. Both opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for treatment, but the relative efficacy of these drugs is uncertain.

OBJECTIVES

To examine the benefits and disadvantages of NSAIDs and opioids for the management of pain in acute renal colic.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register (May 2003), the Cochrane Central Register of Randomised Controlled Trials (CENTRAL - The Cochrane Library issue 2, 2003), MEDLINE (1966 - 31 January 2003), EMBASE (1980 - 31 January 2003) and handsearched reference lists of retrieved articles. Most recent search date: January 2005

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any opioid with any NSAID, regardless of dose or route of administration were included.

DATA COLLECTION AND ANALYSIS

Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Subgroup analysis by study quality, drug type and drug route have been performed where possible to explore reasons for heterogeneity.

MAIN RESULTS

Twenty trials from nine countries with a total of 1613 participants were identified. Both NSAIDs and opioids lead to clinically significant falls in patient-reported pain scores. Due to unexplained heterogeneity these results could not be pooled although 10/13 studies reported lower pain scores in patients receiving NSAIDs. Patients treated with NSAIDs were significantly less likely to require rescue medication (RR 0.75, 95% CI 0.61 to 0.93, P = 0.007), though most of these trials used pethidine. The majority of trials showed a higher incidence of adverse events in patients treated with opioids, but there was significant heterogeneity between studies so the results could not be pooled. There was significantly less vomiting in patients treated with NSAIDs (RR 0.35, 95% CI 0.23 to 0.53, P < 0.00001). In particular, patients receiving pethidine had a much higher rate of vomiting compared with patients receiving NSAIDs. Gastrointestinal bleeding and renal impairment were not reported.

AUTHORS' CONCLUSIONS

Both NSAIDs and opioids can provide effective analgesia in acute renal colic. Opioids are associated with a higher incidence of adverse events, particularly vomiting. Given the high rate of vomiting associated with the use of opioids, particularly pethidine, and the greater likelihood of requiring further analgesia, we recommend that if an opioid is to be used it should not be pethidine.

Clinical pharmacology of tramadol

Tramadol, a centrally acting analgesic structurally related to codeine and morphine, consists of two enantiomers, both of which contribute to analgesic activity via different mechanisms. (+)-Tramadol and the metabolite (+)-O-desmethyl-tramadol (M1) are agonists of the mu opioid receptor. (+)-Tramadol inhibits serotonin reuptake and (-)-tramadol inhibits norepinephrine reuptake, enhancing inhibitory effects on pain transmission in the spinal cord. The complementary and synergistic actions of the two enantiomers improve the analgesic efficacy and tolerability profile of the racemate. Tramadol is available as drops, capsules and sustained-release formulations for oral use, suppositories for rectal use and solution for intramuscular, intravenous and subcutaneous injection. After oral administration, tramadol is rapidly and almost completely absorbed. Sustained-release tablets release the active ingredient over a period of 12 hours, reach peak concentrations after 4.9 hours and have a bioavailability of 87-95% compared with capsules. Tramadol is rapidly distributed in the body; plasma protein binding is about 20%. Tramadol is mainly metabolised by O- and N-demethylation and by conjugation reactions forming glucuronides and sulfates. Tramadol and its metabolites are mainly excreted via the kidneys. The mean elimination half-life is about 6 hours. The O-demethylation of tramadol to M1, the main analgesic effective metabolite, is catalysed by cytochrome P450 (CYP) 2D6, whereas N-demethylation to M2 is catalysed by CYP2B6 and CYP3A4. The wide variability in the pharmacokinetic properties of tramadol can partly be ascribed to CYP polymorphism. O- and N-demethylation of tramadol as well as renal elimination are stereoselective. Pharmacokinetic-pharmacodynamic characterisation of tramadol is difficult because of differences between tramadol concentrations in plasma and at the site of action, and because of pharmacodynamic interactions between the two enantiomers of tramadol and its active metabolites. The analgesic potency of tramadol is about 10% of that of morphine following parenteral administration. Tramadol provides postoperative pain relief comparable with that of pethidine, and the analgesic efficacy of tramadol can further be improved by combination with a non-opioid analgesic. Tramadol may prove particularly useful in patients with a risk of poor cardiopulmonary function, after surgery of the thorax or upper abdomen and when non-opioid analgesics are contraindicated. Tramadol is an effective and well tolerated agent to reduce pain resulting from trauma, renal or biliary colic and labour, and also for the management of chronic pain of malignant or nonmalignant origin, particularly neuropathic pain. Tramadol appears to produce less constipation and dependence than equianalgesic doses of strong opioids.