Pain Medication for Acute Appendicitis
Opioids, NSAIDs, and acetaminophen should all be used as first-line pain control in adults with acute appendicitis, as adequate analgesia does not delay diagnosis or lead to unnecessary intervention. 1
Pain Management Approach
Pain control should be a priority in all patients with suspected or confirmed acute appendicitis. The evidence clearly demonstrates that providing adequate analgesia does not result in delayed diagnosis, missed diagnoses, or unnecessary surgical intervention. 1
Recommended Analgesic Options
You can use any combination of the following agents based on pain severity and patient factors:
- Opioids (morphine, hydromorphone, fentanyl) for moderate to severe pain 1
- NSAIDs (ketorolac, ibuprofen) for mild to moderate pain 1
- Acetaminophen for mild pain or as adjunctive therapy 1
Clinical Implementation
The key principle is that pain medication should not be withheld while awaiting diagnosis or surgical consultation. 1 This represents a significant shift from older practice patterns where clinicians feared that analgesia would mask peritoneal signs or alter the physical examination.
Start with multimodal analgesia using a combination of the above agents to optimize pain control while minimizing opioid requirements. 1 For example, combining acetaminophen with an NSAID provides additive analgesia and may reduce the total opioid dose needed.
Common Pitfalls to Avoid
Do not delay pain medication while waiting for imaging studies or surgical evaluation. 1 The outdated concern that analgesia will obscure the diagnosis has been definitively disproven in the literature.
Do not confuse pain management with antibiotic therapy. While antibiotics must be administered to all patients diagnosed with appendicitis 2, pain control is a separate and equally important priority that should begin immediately upon presentation. 1
Integration with Antibiotic Therapy
Once appendicitis is diagnosed, antimicrobial therapy should be initiated along with appropriate pain medication and antipyretics if indicated. 2 The antibiotic regimen should include coverage for facultative gram-negative organisms and anaerobes, such as ceftriaxone 2g daily plus metronidazole 500mg every 6 hours. 3, 4
For patients with equivocal imaging and high clinical suspicion, both antibiotics and pain medication should be provided together for a minimum of 3 days until symptoms resolve or a definitive diagnosis is made. 2, 3