Findings support NSAIDs as first-line therapy for reducing nonsurgical pain in children

Key takeaways:

• NSAIDs should be the top choice for treating nonsurgical pain in children.
• Combinations like acetaminophen and ibuprofen did not perform as well as anticipated, the researchers noted.

NSAIDs “provide the greatest benefit and least harm” for treating acute pain in children compared with ketamine and opioids, according to findings from a systematic review and meta-analysis published in JAMA Pediatrics.

The findings support the use of NSAIDs as first-line therapy for children with acute pain, researchers said.

“In pediatric practice, it is common to use the WHO pain relief ladder as a guide for managing pain,” Laura Olejnik, MD, from the department of emergency medicine at London Health Sciences Centre in London, Ontario, Canada, told Healio. “This framework helps clinicians determine appropriate treatment based on the severity of pain, progressing from nonopioid medications to stronger opioids as needed.”

Last fall, the AAP published its first clinical guidance for prescribing opioids to children, which affirmed that pediatricians can and should prescribe opioids when appropriate but not as monotherapy. Instead, they should also prescribe other nonopioid medications like acetaminophen or ibuprofen, before or at the same time, the AAP said. The guidelines also recommend prescribing naloxone to all patients who receive opioids and teaching their families how to use it.

Olejnik and colleagues performed a systematic review of 41 randomized controlled trials of 4,935 children (median age, 9.7 years; interquartile range, 7.98-11.68 years) with acute pain that compared the performance of different pain medications. The researchers scored patients’ pain severity with a 10-point scale and calculated the weighted mean difference (WMD) in pain scores with each drug vs. placebo.

At baseline, patients reported an average pain severity of 6.9 out of 10 (standard deviation, 1.3) in 40 studies.

According to the authors, the only drugs that reduced pain vs. placebo with moderate or high certainty evidence were NSAIDs (WMD = –1.29; 95% CI, –1.89 to –0.7), ketamine (WMD = –1.12; 95% CI, –2.09 to –0.14) and mid- to high-potency opioids (WMD = –1.19; 95% CI, –1.83 to –0.55). NSAIDs were the only drug type to perform significantly better than codeine to reduce pain (WMD = –1.05; 95% CI, –2.08 to –0.03). Additionally, the results of one study suggested that topical NSAIDs may be more effective than other routes.

NSAIDs were also the only drug type that significantly reduced patients’ need for rescue medication compared with placebo (RR = 0.31; 95% CI, 0.14-0.68), which Olejnik and colleagues determined from high certainty evidence.

The researchers noted that NSAIDs and acetaminophen did not increase patients’ risk for short-term gastrointestinal events vs. placebo. No serious or life-threatening adverse drug events were reported in any of the studies.

Other drugs and drug combinations did not significantly reduce pain vs. placebo, or their efficacy was supported by low certainty evidence, according to Olejnik and colleagues.

“Adjuvant multimodal pharmacologic therapy is frequently employed to enhance pain relief,” Olejnik said, “A common example is combining medications like acetaminophen with ibuprofen, as they work through different mechanisms to reduce pain and inflammation. The evidence currently available suggests that these combinations are less effective at reducing pain than anticipated.”

Based on the findings of this study, Olejnik said NSAIDs should be the top choice for managing nonsurgical pain, followed by ketamine or mid- to high-potency opioids. She said more research is needed to evaluate efficacy of different drug combinations.