Acupuncture for ARC 2021

Inspired by Zhang et al 2021.[1]

Photo by Anton Nikolov on Unsplash.

ARC – acute renal colic
IF – impact factor
MA – manual acupuncture
IM – intramuscular (injection – a route for administering drugs)
IV – intravenous (ditto)
NSAID – non-steroidal anti-inflammatory drug
COX – cyclooxygenase
SEs – side effects
VAS – visual analogue scale (score)

key to acronyms

This is a small prospective 2-arm double dummy trial from Lanzhou. It is published in the open access Journal of Pain Research (IF 3.133), which has been around since 2008. It is one of 89 open access journals published by Dove Medical Press, which is part of the Taylor Francis Group, and came into existence in 2003.

SP6 and SP9 bilaterally vs IM lornoxicam

In this trial (n=84) MA at SP6 and SP9 bilaterally was compared with IM lornoxicam 8mg in terms of acute pain relief – VAS was measured at baseline, 5, 10, 15, 20 and 40 minutes following the interventions.

A double dummy method was used so that every patient had an IM injection in the buttock of either lornoxicam or normal saline, and they also had either sham or real acupuncture. The sham was a non-penetrating technique involving a Streitberger-like fixing using modified self-adhesive skin electrodes.[2]

It looks as though they used very fine long needles in both real and sham groups and just left the tips touching the skin in the sham group. The needles were 0.16mm in diameter and 100mm long. How they managed to insert those fine needles through the self-adhesive dressings I don’t know! But anyway, since the depth of insertion in the real acupuncture group was about 1cun (~20mm), using such long needles would have meant that there was little difference in the appearance between the real and sham groups.

There was no test for blinding but we are told that the acupuncturist (the only member of personnel who was not blind to allocation) was not allowed to participate in the follow-up or statistical analysis.

Lornoxicam was new to me, although I was familiar with some of the oxicam cousins. They are, of course, a class of NSAID, and most are non-selective inhibitors of COX enzymes. I was surprised to find that it had been approved for medical use in 1997, and first received a patent in 1977.

I thought I better see how well it stacked up against alternative conventional medications in ARC and found that it holds up well against other NSAIDs and may even work faster.[3] There does not appear to be any clinically significant difference between IM and IV administration,[4] and when combined with a small dose of ketamine, it performs better than pethidine with fewer SEs.[5] So, 8mg of IM lornoxicam seems like a very reasonable conventional comparator for MA in ARC.

MA reduced VAS to <4/10 in 5 minutes

Lornoxicam took 40 minutes to do the same

The baseline VAS (pain) was between 8 and 9 out of 10 as you might expect with ARC, but within 5 minutes the real MA group (plus saline injection) had dropped to an average of under 4, which is considered an acceptable level in post-op pain. By contrast the lornoxicam (plus sham MA) group took 40 minutes to achieve a VAS level below 4.

I wish I had the opportunity to go back to acute medicine and try this out! I have it on good authority that it works in practice, and someone who has done this many times may appear on the webinar on Wednesday to tell you about their experiences.

References

1          Zhang X, Liu X, Ye Q, et al. Acupuncture versus Lornoxicam in the Treatment of Acute Renal Colic: A Randomized Controlled Trial. J Pain Res 2021;Volume 14:3637–48. doi:10.2147/JPR.S339006

2          Streitberger K, Kleinhenz J. Introducing a placebo needle into acupuncture research. The Lancet 1998;352:364–5. doi:10.1016/S0140-6736(97)10471-8

3          Cevik E, Cinar O, Salman N, et al. Comparing the efficacy of intravenous tenoxicam, lornoxicam, and dexketoprofen trometamol for the treatment of renal colic. Am J Emerg Med 2012;30:1486–90. doi:10.1016/j.ajem.2011.12.010

4          Soylu A, Sarier M, Altunoluk B, et al. Comparison of the Efficacy of Intravenous and Intramuscular Lornoxicam for the Initial Treatment of Acute Renal Colic: A Randomized Clinical Trial. Urol J 2019;16:16–20. doi:10.22037/uj.v0i0.4496

5          Metry AA, Fahmy NG, Nakhla GM, et al. Lornoxicam with Low-Dose Ketamine versus Pethidine to Control Pain of Acute Renal Colic. Pain Res Treat 2019;2019:3976027. doi:10.1155/2019/3976027


Declaration of interests MC