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Pommier W, Minoc EM, Morice PM, Lescure P, Guillaume C, Lafont C, Fischer MO, Boddaert J, Thietart S, Lelong-Boulouard V, Beauplet B, Villain C. NSAIDs for Pain Control During the Peri-Operative Period of Hip Fracture Surgery: A Systematic Review. Drugs Aging 2024; 41:125-139. [PMID: 37880500 DOI: 10.1007/s40266-023-01074-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Hip fracture (HF) mostly affects older adults and is responsible for increased morbidity and mortality. Non-steroidal anti-inflammatory drugs (NSAIDs) are part of the peri-operative multimodal analgesic management, but their use could be associated with adverse events in older adults. This systematic review aimed to assess outcomes associated with NSAIDs use in the peri-operative period of HF surgery. METHODS This systematic review was conducted according to the PRISMA guidelines. Three databases (PubMed/EMBASE/Cochrane Central) were used to search for clinical trials and observational studies assessing efficacy, safety and impact of NSAIDs use on non-specific post-operative outcomes, such as functional status and post-operative complications. RESULTS Among the 1320 references initially identified, four provided data on efficacy, four on safety and six on non-specific post-operative outcomes (three randomized controlled clinical trials, three observational studies). Mean study population ages ranged from 68 to 87 years. Two studies found that NSAIDs were effective on pain control, but two studies found conflicting results on opioid sparing. No increased risk of acute kidney injury was observed, while results concerning bleeding risk and delirium were conflicting. No study has found any effect of NSAIDs use on walk recovery. Quality of evidence was high for pain control, but low to very low for all the other studied outcomes. CONCLUSIONS The use of NSAIDs may be effective for pain control in the peri-operative period of HF surgery. However, safety data were conflicting with low levels of certainty. Further studies are needed to assess their benefit-risk balance in this context. The research protocol was previously registered on PROSPERO (registration number: CRD42021237649).
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Affiliation(s)
- Wilhelm Pommier
- Department of Geriatric Medicine, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Elise-Marie Minoc
- Normandie Univ, UNICAEN, INSERM U1075, COMETE, Department of Geriatric Medicine, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Pierre-Marie Morice
- Normandie Univ, UNICAEN, INSERM U1086, ANTICIPE, Department of Pharmacology, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Pascale Lescure
- Normandie Univ, UNICAEN, INSERM U1075, COMETE, Department of Geriatric Medicine, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Cyril Guillaume
- Normandie Univ, UNICAEN, INSERM U1075, COMETE, Department of Palliative Care, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Claire Lafont
- Department of Geriatric Medicine, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | | | - Jacques Boddaert
- Département de Gériatrie, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Sara Thietart
- Département de Gériatrie, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Véronique Lelong-Boulouard
- Normandie Univ, UNICAEN, INSERM U1075, COMETE, Department of Pharmacology, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Bérengère Beauplet
- Normandie Univ, UNICAEN, INSERM ANTICIPE, U1086, Department of Geriatric Medicine, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
- Normandy Interregional Oncogeriatric Coordination Unit, 28 Rue Bailey, 14000, Caen, France
| | - Cédric Villain
- Normandie Univ, UNICAEN, INSERM U1075, COMETE, Department of Geriatric Medicine, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France.
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Bell S, Rennie T, Marwick CA, Davey P. Effects of peri-operative nonsteroidal anti-inflammatory drugs on post-operative kidney function for adults with normal kidney function. Cochrane Database Syst Rev 2018; 11:CD011274. [PMID: 30488949 PMCID: PMC6517026 DOI: 10.1002/14651858.cd011274.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) provide effective analgesia during the post-operative period but can cause acute kidney injury (AKI) when used peri-operatively (at or around the time of surgery). This is an update of a Cochrane review published in 2007. OBJECTIVES This review looked at the effect of NSAIDs used in the peri-operative period on post-operative kidney function in patients with normal kidney function. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 4 January 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at the use of NSAIDs versus placebo for the treatment of post-operative pain in patients with normal kidney function were included. DATA COLLECTION AND ANALYSIS Data extraction was carried out independently by two authors as was assessment of risk of bias. Disagreements were resolved by a third author. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) together with their 95% confidence intervals (CI). Meta-analyses were used to assess the outcomes of AKI, change in serum creatinine (SCr), urine output, renal replacement therapy (RRT), death (all causes) and length of hospital stay. MAIN RESULTS We identified 26 studies (8835 participants). Risk of bias was high in 17, unclear in 6and low in three studies. There was high risk of attrition bias in six studies.Only two studies measured AKI. The use of NSAIDs had uncertain effects on the incidence of AKI compared to placebo (7066 participants: RR 1.79, 95% CI 0.40 to 7.96; I2 = 59%; very low certainty evidence). One study was stopped early by the data monitoring committee due to increased rates of AKI in the NSAID group. Moreover, both of these studies were examining NSAIDs for indications other than analgesia and therefore utilised relatively low doses.Compared to placebo, NSAIDs may slightly increase serum SCr (15 studies, 794 participants: MD 3.23 μmol/L, 95% CI -0.80 to 7.26; I2 = 63%; low certainty evidence). Studies displayed moderate to high heterogeneity and had multiple exclusion criteria including age and so were not representative of patients undergoing surgery. Three of these studies excluded patients if their creatinine rose post-operatively.NSAIDs may make little or no difference to post-operative urine output compared to placebo (6 studies, 149 participants: SMD -0.02, 95% CI -0.31 to 0.27). No reliable conclusions could be drawn from these studies due to the differing units of measurements and measurement time points.It is uncertain whether NSAIDs leads to the need for RRT because the certainty of this evidence is very low (2 studies, 7056 participants: RR 1.57, 95% CI 0.49 to 5.07; I2 = 26%); there were few events and the results were inconsistent.It is uncertain whether NSAIDs lead to more deaths (2 studies, 312 participants: RR 1.44, 95% CI 0.19 to 11.12; I2 = 38%) or increased the length of hospital stay (3 studies, 410 participants: MD 0.12 days, 95% CI -0.48 to 0.72; I2 = 24%). AUTHORS' CONCLUSIONS Overall NSAIDs had uncertain effects on the risk of post-operative AKI, may slightly increase post-operative SCr, and it is uncertain whether NSAIDs lead to the need for RRT, death or increases the length of hospital stay. The available data therefore does not confirm the safety of NSAIDs in patients undergoing surgery. Further larger studies using the Kidney Disease Improving Global Outcomes definition for AKI including patients with co-morbidities are required to confirm these findings. .
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Affiliation(s)
- Samira Bell
- NHS Tayside, Ninewells HospitalRenal UnitDundeeUKDD1 9SY
- University of DundeeDivision of Population Health and GenomicsDundeeUK
| | | | - Charis A Marwick
- University of DundeeDivision of Population Health and GenomicsDundeeUK
| | - Peter Davey
- University of DundeeDivision of Population Health and GenomicsDundeeUK
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