Intravenous (IV) administration of hydromorphone may be more effective than IV lidocaine in alleviating abdominal pain in the emergency department (ED), according to a study published in the Annals of Emergency Medicine.

Adults weighing between 60 and 120 kg who presented to one of 2 EDs in the Bronx, New York, for acute abdominal pain, were randomly assigned to receive 120 mg IV lidocaine (n=77) or 1 mg IV hydromorphone (n=77). Patients were stratified based on clinical suspicion of nephrolithiasis and were asked whether they required a second dose of medication approximately 30 minutes after the initial dose. Improvement from baseline in pain intensity — evaluated using a 0 to 10 scale — at 90 minutes was the study’s primary outcome. The need for “off-protocol” parenteral analgesics (eg, opioids and nonsteroidal anti-inflammatory drugs) was the secondary outcome.

Patients who received hydromorphone vs lidocaine reported greater improvements in pain intensity at 90 minutes (5.0 points vs 3.8 points, respectively; mean difference, 1.2; 95% CI, 0.3-2.2). A greater percentage of patients who received lidocaine vs hydromorphone required off-protocol rescue medications (51% vs 26%, respectively; difference, 25%; 95% CI, 10%-40%). Patients with nephrolithiasis who received hydromorphone vs lidocaine also indicated greater improvements in pain levels (6.4 points vs 3.4 points, respectively; mean difference, 3.0; 95% CI, 0.5-5.5). No differences were observed between the 2 groups in terms of adverse events.

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Study limitations of the study include a possible underdosing of the initial lidocaine bolus.

“Our data do not provide any compelling reasons to choose [IV] lidocaine as a first-line analgesic over hydromorphone for abdominal pain,” the researchers concluded. “Placebo-controlled studies are needed to determine whether [IV] lidocaine should play any role in the management of ED patients with pain.”

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Chinn E, Friedman BW, Naeem F, et al. Randomized trial of intravenous lidocaine versus hydromorphone for acute abdominal pain in the emergency department [published online February 25, 2019]. Ann Emerg Med. doi:10.1016/j.annemergmed.2019.01.021