A patient who suffers from severe dysmenorrhea has relief from rectal Voltaren (diclofenac) but get

Fråga: A patient who suffers from severe dysmenorrhea has relief from rectal Voltaren (diclofenac) but gets no help from NSAIDs taken orally. Suppositories cannot be used presently because she has developed proctitis. Is there any support for the view that NSAIDs given as suppositores could be more efficient than given as tablets?

Sammanfattning: The question has been raised whether NSAIDs given as suppositories could be more efficient than oral administration of these compounds but this hypothesis could not be confirmed in a controlled study on naproxen. Oral preparations of NSAIDs registered for the use in dysmenorrhea remains the first choice.

Svar: In a letter to the editor of the Lancet, Fox reported in 1953 that phenylbutazone seemed to decrease menstrual pain in rheumatic patients (1). The therapeutic effect of indomethacin and newer NSAIDs on dysmenorrhea was evaluated during the 70s (2). This effect of the NSAIDs was then intelligible in the light of their prostaglandin inhibitory effect and today some of these drugs are in frequent use on this indication.

A Finnish group (3) reported excellent relief of dysmenorrhea in women who took naproxen suppositories in a small placebo controlled double blind study. These authors suggested that prostaglandin inhibitors given as suppositories could be more efficient than tablets because presumable higher and more efficient drug concentrations were expected locally in the pelvic organs. The same investigators then made a controlled cross-over study comparing the effect of 500 mg of naproxen in tablets and suppositories (4). The study comprised 32 women with severe dysmenorrhea. Interestingly there was a significantly (p<0.05) better effect on spasmodic pain with the tablets compared to suppositories. Considerable relief compared to the situation assessed before the study was obtained with both formulations. There were no significant differences between the formulations in the 11 other indexed symptoms related to dysmenorrhea. Four women complained of rectal irritation after using naproxen suppositories.

During the literature search we have found two studies on bioavailability of NSAIDs. The bioavailability after rectal administration was considered to be equivalent to the oral route for piroxicam (5) and isoxicam (6). 1 Fox WW: Butazolidine. Lancet 1953; I: 195 (Letter) 2 Lundström V: Treatment of primary dysmenorrhea with prostaglandin synthetase inhibitors - a promising therapeutic alternative. Acta Obstet Gynecol Scand 1978; 57: 421-428 3 Ylikorkala O, Kauppila A, Puolakka J: Naproxen suppositories in primary dysmenorrhoea. Lancet 1979; I: 278-279 4 Ylikorkala O, Puolakka J, Kauppila A: Comparison between naproxen tablets and suppositores in primary dysmenorrhea. Prostaglandins 1980; 20: 463-468 5 Kozjek F, Mrhar A, Kmetec V, Primozic S, Karba R, Janezic A, Jerman P: Bioavailability of piroxicam: oral and rectal multiple application in humans. Int J Clin Pharmacol Ther Toxicol 1987; 25: 313-316 6 Kölle EU, Vollmer KO: Pharmacokinetics of isoxicam following intravenous, intramuscular, oral and rectal administration in healthy volunteers. Br J Clin Pharmacol 1986; 22: 135S-141S