THE EFFECTIVENESS, HEALTH CARE RESOURCE UTILIZATION AND COST-EFFECTIVENESS OF INTRAVENOUS PARACETAMOL VERSUS ALTERNATIVE ANALGESICS USED AMONG PATIENTS WITH ACUTE PAIN IN EMERGENCY DEPARTMENTS: SYSTEMATIC REVIEWS AND A META-ANALYSIS
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Background: Intravenous paracetamol (IVP), non-steroidal anti-inflammatory drugs (NSAIDs), and opioids are widely used to provide analgesia in the emergency department (ED). This study evaluates the level of analgesia provided by IVP alone as compared to NSAIDs, opioids alone, or in combination in adults attending the ED with acute pain. Additionally, the study assesses systematic economic evaluation evidence to determine health care resource utilization and costs associated with drug administration for the management of acute pain. Methods: To study the effectiveness of IVP, PubMed (MEDLINE), Web of Science, EMBASE OVID, Cochrane Library, SCOPUS, and Google Scholar were searched for randomized trials conducted on adult patients presenting to EDs with acute pain. The risk of bias (ROB 2) tool was used to evaluate the quality of identified trials. Meta-analysis was conducted to synthesize evidence on the clinical effectiveness of IVP versus NSAIDs or opioids or a combination for managing ED acute pain from these trials. A systematic review of economic evaluation studies was further conducted to assess health care resource utilization and costs of drugs used in patients with acute pain. Electronic searches were conducted in EMBASE, PubMed, and the Health Technology Assessment Database (HTA). Drummond et al. and Phillips checklists were used to evaluate the quality of identified studies. No meta-analysis was done for synthesizing economic evaluation evidence. Results: To study the effectiveness of IVP, twenty-seven trials (including 5426 patients) were included in the systematic review and twenty-five trials (5002 patients) in the meta-analysis. At 30 minutes IVP provided equivalent levels of analgesia compared to opioids, NSAIDs alone or in combination; pooled mean difference=0.09 [95%CI: -0.85, 1.05]. Patients treated with IVP, and opioids required similar quantities of rescue analgesia, but this was lower in those who received NSAIDs. Adverse events were 50% lower in patients receiving IVP (RR: 0.50; 95%CI: 0.40, 0.62) as compared to opioids and 30% higher in IVP than NSAIDs (RR: 1.30; 95%CI: 0.78, 2.17). Seven studies were included in the systematic review on economic evaluation with varied pain etiologies, suggesting that ED acute pain management treatments vary across healthcare systems which lead to differential costs and healthcare resource use. The IV administration of opioids was associated with significant costs and most of the cost of IV opioid administration occurs in the initial IV-line setting. Conclusion: Based on the available evidence, IVP is an equally effective analgesic as opioids or NSAIDs or combined at initial 30 minutes in patients with acute pain. However, the use of IV opioids inflicts an economic burden on the healthcare system. A considerable heterogeneity was estimated in the meta-analysis results, and we were unable to assess the cost-effectiveness of IVP due to a lack of published studies.
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