From the Guidelines
For gallstone pain, acetaminophen (1000mg every 6 hours) is recommended as a first-line treatment, and if the pain is severe, opioid medications like oxycodone (0.7 mg/kg—background continuous infusion of 1 to 2 mL/h 1 mL bolus with a 15-min lockout) or fentanyl (fentanyl 12 mg/kg,—background continuous infusion of 1 to 2 mL/h 1 mL bolus with a 15-min lockout) may be necessary for short-term use, as they have been shown to be effective in managing moderate-to-severe postoperative pain 1.
Considerations for Analgesic Selection
When selecting an analgesic for gallstone pain, it's essential to consider the severity of the pain and the patient's medical history.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) can be used for mild to moderate pain, but their effectiveness in severe pain is limited 1.
- Acetaminophen is a valid and effective option for managing postoperative pain, and its use in a multimodal therapy regimen has been shown to provide a cost-effective strategy to improve outcomes and patient satisfaction with a side-effect profile that is superior to opioids alone in moderate–severe acute pain 1.
- Opioid medications like oxycodone or fentanyl are effective in managing severe pain, but their use should be limited to the shortest duration possible due to the risk of dependency and side effects 1.
Multimodal Analgesia Approach
A multimodal approach to analgesia, which combines different classes of medications, such as acetaminophen, NSAIDs, and opioids, can provide more effective pain relief and reduce the risk of side effects.
- The use of gabapentinoids, such as gabapentin and pregabalin, can be considered as a component in multimodal analgesia, as they have been shown to decrease the release of neurotransmitters in the synapse, thus providing a nociceptive blocking activity 1.
- Alpha-2-agonists, such as dexmedetomidine, can also be used in combination with fentanyl-based intravenous PCA to provide antalgic effects without hemodynamic instability 1.
Important Considerations
It's essential to note that these medications only provide symptomatic relief and don't treat the underlying gallstones. Patients should seek medical attention if pain is severe or persistent, as definitive treatment often requires surgical removal of the gallbladder (cholecystectomy). Those with known gallstones should also avoid fatty meals which can trigger painful episodes by causing gallbladder contractions.
From the Research
Appropriate Analgesics for Cholelithiasis
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for analgesia in patients with cholelithiasis, as they avoid the central side effects of opiate drugs 2.
- Diclofenac sodium is a suitable option for postoperative analgesia after laparoscopic cholecystectomy, significantly reducing early postoperative pain 2.
- Paracetamol can also be used as an opioid adjuvant for postoperative pain therapy, although further comparative studies with higher doses of paracetamol are needed to assess its use as a unique drug 3.
- For biliary colic, NSAIDs have been widely used to relieve pain and may decrease the frequency of short-term complications, but their role needs further elucidation due to potential adverse events 4.
Comparison of Analgesics
- NSAIDs have been shown to obtain a significantly lower proportion of participants without complete pain relief when compared with placebo 4.
- NSAIDs have also been found to have more pain control than spasmolytic drugs, although this was not confirmed by Trial Sequential Analysis 4.
- There was no difference in the proportions of participants without complete pain relief when comparing NSAIDs versus opioids, suggesting moderate heterogeneity among trials 4.
Treatment of Cholelithiasis
- Laparoscopic cholecystectomy is indicated for symptomatic gallstones, as the risk of recurrence or complications increases over the course of the disease 5.
- Biliary colic is treated with nonsteroidal anti-inflammatory drugs and spasmolytics, while opioids can also be used in cases of severe acute pain 5.
- Dietary factors, such as polyunsaturated fat, monounsaturated fat, fiber, and caffeine, may help prevent the development of gallstones, while nutritional supplements like vitamin C, soy lecithin, and iron may also be beneficial 6.