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Additive or synergistic analgesic effect of metamizole on standard pain treatment at home after arthroscopic shoulder surgery

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AUTHORS: Stessel, Björn et al 

European Journal of Anaesthesiology 40(3):p 171-178, March 2023.

BACKGROUND

There is growing evidence that the analgesic effect of metamizole is mediated at least partly by central mechanisms, including the endocannabinoid/endovanilloid system. Consequently, metamizole may have additive or even synergistic analgesic effects with paracetamol and nonsteroidal anti-inflammatory drugs (NSAID).

OBJECTIVE

This study aimed to assess if triple therapy with metamizole, ibuprofen and paracetamol (MIP) is superior to double therapy with ibuprofen and paracetamol (i.p.) in treating pain at home after ambulatory arthroscopic shoulder surgery.

DESIGN/SETTING/PATIENTS/INTERVENTION

In this double-blind, controlled, high-volume single centre, superiority trial, 110 patients undergoing elective ambulatory arthroscopic shoulder surgery were randomised to receive either MIP (n = 55) or i.p. (n = 55) orally for 4 days between December 2019 and November 2021. Pain intensity at movement and rest, using a numeric rating scale (NRS), perceived pain relief, use of rescue medication and adverse effects of study medication were recorded at the post-anaesthesia care unit (PACU) and on postoperative day (POD) 1 to 4 and 7. Quality of Recovery (QoR) and satisfaction with study medication were measured at POD 7 with telephone follow-up.

RESULTS

For the primary outcome, superiority of MIP in reducing postoperative pain at movement on POD 1 was not confirmed: mean difference NRS [95% confidence interval (CI), −0.08 (−1.00 to 0.84)]. For pain on movement and at rest, no significant differences were found between groups in the PACU nor on POD 1 to 4 or day 7. Nausea was reported significantly more frequently in the metamizole group (22.6 vs. 58.5; P < 0.001). Other adverse effects of study medication, rescue opioid consumption, perceived pain relief, QoR at POD 7, and overall patient satisfaction were similar in both groups.

CONCLUSION

Clinically, triple oral treatment with metamizole, paracetamol and ibuprofen is not superior to oral paracetamol and ibuprofen in multimodal pain treatment at home after ambulatory arthroscopic shoulder surgery.

KEY POINTS

  • Triple oral treatment with metamizole, paracetamol and ibuprofen is not superior to oral paracetamol and ibuprofen in reducing postoperative pain at home after ambulatory surgery.
  • Metamizole has no additive or synergistic analgesic effects in combination with paracetamol and NSAID.
  • Nausea was reported more frequently in the metamizole group.
  • Patients undergoing ambulant arthroscopic shoulder surgery still suffer from moderate-to-severe pain at movement during the first postoperative week despite multimodal analgesic treatment.
  • Pain at rest is well treated with a combination of paracetamol, NSAID and rescue tramadol in patients undergoing ambulant arthroscopic shoulder surgery.

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