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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　January 20, 2010 — 根據發表在一月號考科藍系統性綜論資料庫的一篇系統性綜論結果，非類固醇抗發炎藥物（NSAIDs）在治療經痛上比Paracetamol好
　　
　　紐西蘭奧克蘭考科藍經期異常與輔助生育小組的Jane Marjoribanks博士與其同事們寫到，痛經是一個常見的婦產科問題，包括伴隨著月經而來的腹部絞痛，沒有任何潛在異常的稱為原發性痛經。研究已經證實有痛經的女性，其前列腺素濃度比較高，這是個已知會造成腹部絞痛的荷爾蒙，NSAIDs類藥物可以阻斷前列腺素生成。
　　
　　這項系統性綜論的目標在於比較NSAIDs類藥物用於治療原發性痛經相較於安慰劑、paracetamol或這兩個藥物的效果。評論者們搜尋考科藍經期異常與輔助生育小組試驗註冊資料庫、考科藍控制研究中心註冊資料庫、MEDLINE、EMBASE以及科學網路截至2009年5月的資料。他們也搜尋國家研究註冊資料庫、臨床試驗註冊資料庫、重要科學會議發表的摘要以及找出的文獻書目。
　　
　　收納標準包括所有比較NSAIDs類藥物相較於安慰劑、其他NSAIDs類藥物或是paracetamol用於治療原發性痛經。兩位評論者獨立地評估研究方法品質、提取數據、以及計算二變項勝算比（ORs）以及連續變項的平均差異值。評論者們接著以反向變異數方法合併數據。
　　
　　根據73項合乎收納標準的隨機分派臨床研究，罹患原發性痛經女性，使用NSAIDs類藥物在疼痛緩解上，顯著地比安慰劑有效（OR為4.50；95%信賴區間[CI]為3.85-5.27），但是這項發現有非常大的異質性（I2統計分數為53%）。排除兩項沒有或可忽略安慰劑效應的邊緣研究降低了異源性（OR為4.14；95% CI為3.52-4.86；I2=40%）。相較於paracetamol，NSAIDs類藥物在疼痛緩解上顯著更有效（OR為1.90；95% CI為1.05-3.44），但是相較於安慰劑，NSAIDs類藥物發生不良反應風險更高（OR為1.37；95% CI為1.12-1.66）。
　　
　　Marjoribanks博士在一項新聞稿中表示，使用這些藥物的女性需要注意副作用。透過降低劑量合併其他藥物，例如paracetamol，或是其他治療，例如經皮電神經刺激，是否可以降低這些副作用，且不會失去效果。
　　
　　比較不同NSAIDs類藥物與其他NSAIDs，並沒有太多證據可以證實任何NSAIDs在疼痛緩解或安全性上比較好。
　　
　　這項系統性綜論的限制包括偵測NSAIDs類藥物之間差異的統計力量有限，因為大部分個體比較是根據樣本數目非常小且數量有限的研究。
　　
　　這項綜論作者們的結論是，雖然使用NSAIDs類藥物的女性應該注意不良反應顯著的風險，但這些藥物在痛經治療上是有效的。不過，沒有足夠證據可以確定哪個NSAID類藥物在治療痛經上是最安全的且最有效的。
　　
　　奧克蘭大學醫學院以及紐西蘭Mercia Barnes基金會管理的威爾斯王子紀念信託基金贊助這項研究。研究作者們表示已無相關資金上的往來。


NSAIDs May Be More Effective Than Paracetamol for Menstrual Pain

By Laurie Barclay, MD
Medscape Medical News

January 20, 2010 — Nonsteroidal anti-inflammatory drugs (NSAIDs) may be more effective than paracetamol for menstrual pain, according to the results of a systematic review reported online January 20 in the Cochrane Database of Systematic Reviews.

"Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea," write Dr. Jane Marjoribanks, Cochrane Menstrual Disorders and Subfertility Group in Auckland, New Zealand, and colleagues. "Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. ...NSAIDs are drugs which act by blocking prostaglandin production."

The goal of this review was to compare the effectiveness and safety of NSAIDs used in the treatment of primary dysmenorrhea vs placebo, paracetamol, and each other. The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science to May 2009. They also searched the National Research Register, the Clinical Trials Register, abstracts of major scientific meetings, and bibliographies of identified articles.

Inclusion criteria were all randomized controlled comparisons of NSAIDs vs placebo, other NSAIDs, or paracetamol for treatment of primary dysmenorrhea. Two reviewers independently evaluated trials for methodologic quality, extracted data, and calculated odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes. The reviewers then combined the data using inverse variance methods.

Based on 73 randomized controlled trials meeting selection criteria, NSAIDs were significantly more effective for pain relief than placebo among women with primary dysmenorrhea (OR, 4.50; 95% confidence interval [CI], 3.85 - 5.27), but there was marked heterogeneity for this finding (I2 statistic = 53%). Excluding 2 outlying studies with no or negligible placebo effect decreased heterogeneity (OR, 4.14; 95% CI, 3.52 - 4.86; I2 = 40%). Compared with paracetamol, NSAIDs were also significantly more effective for pain relief (OR, 1.90; 95% CI, 1.05 - 3.44), but NSAIDs were associated with significantly more overall adverse effects than placebo (OR, 1.37; 95% CI, 1.12 - 1.66).

"Women using these drugs need to be aware of the side effects," Dr.?Marjoribanks said in a news release. "It would be interesting to see whether these could be reduced, without loss of effectiveness, by combining lower doses with other drugs such as paracetamol, or with other therapies such as transcutaneous electrical nerve stimulation."

Comparison of various NSAIDs vs other NSAIDs showed limited evidence that any individual NSAID was superior for either pain relief or safety.

Limitations of this review include limited power to detect differences among NSAIDs because most individual comparisons were based on very few trials with small sample size.

"NSAIDs are an effective treatment for dysmenorrhoea, though women using them need to be aware of the significant risk of adverse effects," the review authors conclude. "There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea."

The University of Auckland School of Medicine and Princess of Wales Memorial Trust Fund administered by the Mercia Barnes Fund, New Zealand, supported this study. The study authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online January 20, 2010.