Intravenous lornoxicam is more effective than paracetamol as a supplemental analgesic after lower abdominal surgery: a randomized controlled trial

Value of indomethacin suppository for preoperative analgesia and anti-inflammation in laparoscopic appendectomy: a protocol of prospective, double-blinded, single-centre, randomised controlled trial in China

INTRODUCTION

Postoperative pain has always been a problem for patients and surgeons. Local inflammation, surgical trauma and pain in the body can cause a systemic stress response and immune imbalance, which can affect the patient's rapid recovery. Currently, most of the perioperative pain management is focused on the postoperative phase. The non-steroidal anti-inflammatory drug indomethacin suppository has antipyretic and analgesic effects. This study will evaluate the value of indomethacin suppository for analgesia and anti-inflammation before laparoscopic appendectomy (LA).

METHODS AND ANALYSIS

A single-centre, double-blinded (clinician, assessor, data entry), randomised controlled trial will be conducted in 128 adult patients undergoing LA under emergency general anaesthesia with a Visual Analogue Scale (VAS) >2. The trial was divided into two groups (n=64) using a randomised number table: group A will be given 100 mg of indomethacin suppository rectally and group B will be given 8 mg of intravenous lornoxicam. The postoperative analgesic effect, inflammatory response and incidence of postoperative adverse effects will be compared.

ETHICS AND DISSEMINATION

The study is in accordance with the Declaration of Helsinki and will be conducted in accordance with the principles of Good Clinical Practice. This trial was approved by the Ethics Committee of Beijing Luhe Hospital, Capital Medical University (2021-LHKY-123-02). We will disseminate our study findings at national and international paediatric research conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200062004).

Evidence for the Efficacy of an Opioid-Sparing Effect of Intravenous Acetaminophen in the Surgery Patient: A Systematic Review

BACKGROUND

Intravenous (IV) acetaminophen is used in multimodal analgesia to reduce the amount and duration of opioid use in the postoperative setting.

METHODS

A systematic review of published randomized controlled trials was conducted to define the opioid-sparing effect of IV acetaminophen in different types of surgeries. Eligible studies included prospective, randomized, double-blind trials of IV acetaminophen compared with either a placebo- or active-treatment group in adult (age ≥18 years) patients undergoing surgery. Trials had to be published in English in a peer-reviewed journal.

RESULTS

A total of 44 treatment cohorts included in 37 studies were included in the systematic analysis. Compared with active- or placebo-control treatments, IV acetaminophen produced a statistically significant opioid-sparing effect in 14 of 44 cohorts (32%). An opioid-sparing effect was more common in placebo-controlled comparisons. Of the 28 placebo treatment comparisons, IV acetaminophen produced an opioid-sparing effect in 13 (46%). IV acetaminophen produced an opioid-sparing effect in only 6% (one out of 16) of the active-control groups. Among the 16 active-control groups, opioid consumption was significantly greater with IV acetaminophen than the active comparator in seven cohorts and not significantly different than the active comparator in eight cohorts.

CONCLUSIONS

The results of this systematic analysis demonstrate that IV acetaminophen is not effective in reducing opioid consumption compared with other adjuvant analgesic agents in the postoperative patient. In patients where other adjuvant analgesic agents are contraindicated, IV acetaminophen may be an option.

The impact of intravenous acetaminophen on pain after abdominal surgery: a meta-analysis

BACKGROUND

Pain after surgery is commonly controlled with opioid pain medications. A multi-modal pain strategy that involves acetaminophen may help minimize the negative consequences of opioids, such as ileus, respiratory depression, and addictive potential. There are limited data on the effectiveness of intravenous (IV) acetaminophen in comparison with other nonopioid pain medications.

MATERIALS AND METHODS

Four databases were queried for the keywords "acetaminophen," "intravenous," and "postoperative". Prospective studies of adult patients receiving at least 24 h of IV acetaminophen after intraabdominal surgery were analyzed for 12- and 24-h pain scores and 24-h narcotic consumption. A random effects model was performed using mean differences and 95% confidence intervals to assess the effect of IV acetaminophen on outcomes. Heterogeneity was assessed using χ² and the I² statistics.

RESULTS

Seventeen articles were identified that complied with inclusion and exclusion criteria. There was no significant difference in 24-h pain scores between IV acetaminophen and any other comparator, or in secondary endpoints of 12-h pain scores and 24-h narcotic consumption. Subgroup analysis demonstrated significant benefit for IV acetaminophen in open surgeries for decreased 24-h narcotic consumption. When analyzing individual medications, non-steroidal anti-inflammatory drugs demonstrated the largest reduction in 24-h narcotic consumption. Data were of moderate quality and demonstrated significant heterogeneity between studies.

CONCLUSIONS

The lack of significant differences in primary endpoints may be explained by the heterogeneous, moderate-quality data. However, subgroup analyses suggested IV acetaminophen may be advantageous in open surgeries, and non-steroidal anti-inflammatory drugs may lower the 24-h narcotic requirement.

Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 10, 2011. Paracetamol (acetaminophen) is the most commonly prescribed analgesic for the treatment of acute pain. It may be administered orally, rectally, or intravenously. The efficacy and safety of intravenous (IV) formulations of paracetamol, IV paracetamol, and IV propacetamol (a prodrug that is metabolized to paracetamol), compared with placebo and other analgesics, is unclear.

OBJECTIVES

To assess the efficacy and safety of IV formulations of paracetamol for the treatment of postoperative pain in both adults and children.

SEARCH METHODS

We ran the search for the previous review in May 2010. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE (May 2010 to 16 February 2016), EMBASE (May 2010 to 16 February 2016), LILACS (2010 to 2016), a clinical trials registry, and reference lists of reviews for randomized controlled trials (RCTs) in any language and we retrieved articles.

SELECTION CRITERIA

Randomized, double-blind, placebo- or active-controlled single dose clinical trials of IV paracetamol or IV propacetamol for acute postoperative pain in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We contacted study authors for additional information. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence.

MAIN RESULTS

We included 75 studies (36 from the original review and 39 from our updated review) enrolling a total of 7200 participants.Among primary outcomes, 36% of participants receiving IV paracetamol/propacetamol experienced at least 50% pain relief over four hours compared with 16% of those receiving placebo (number needed to treat to benefit (NNT) = 5; 95% confidence interval (CI) 3.7 to 5.6, high quality evidence). The proportion of participants in IV paracetamol/propacetamol groups experiencing at least 50% pain relief diminished over six hours, as reflected in a higher NNT of 6 (4.6 to 7.1, moderate quality evidence). Mean pain intensity at four hours was similar when comparing IV paracetamol and placebo, but was seven points lower on a 0 to 100 visual analog scale (0 = no pain, 100 = worst pain imaginable, 95% CI -9 to -6, low quality evidence) in those receiving paracetamol at six hours.For secondary outcomes, participants receiving IV paracetamol/propacetamol required 26% less opioid over four hours and 16% less over six hours (moderate quality evidence) than those receiving placebo. However, this did not translate to a clinically meaningful reduction in opioid-induced adverse events.Meta-analysis of efficacy comparisons between IV paracetamol/propacetamol and active comparators (e.g., opioids or nonsteroidal anti-inflammatory drugs) were either not statistically significant, not clinically significant, or both.Adverse events occurred at similar rates with IV paracetamol or IV propacetamol and placebo. However, pain on infusion occurred more frequently in those receiving IV propacetamol versus placebo (23% versus 1%). Meta-analysis did not demonstrate clinically meaningful differences between IV paracetamol/propacetamol and active comparators for any adverse event.

AUTHORS' CONCLUSIONS

Since the last version of this review, we have found 39 new studies providing additional information. Most included studies evaluated adults only. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides high quality evidence that a single dose of either IV paracetamol or IV propacetamol provides around four hours of effective analgesia for about 36% of patients with acute postoperative pain. Low to very low quality evidence demonstrates that both formulations are associated with few adverse events, although patients receiving IV propacetamol have a higher incidence of pain on infusion than both placebo and IV paracetamol.

Efficacy of preemptive lornoxicam on postoperative analgesia after surgical removal of mandibular third molars

OBJECTIVE

Pain is the most encountered complication following third molar surgery. Although nonsteroidal anti-inflammatory drugs are often used for pain control, the effect of preemptive lornoxicam has not been detailed. We compare the analgesic efficacy of preemptive lornoxicam versus postoperative lornoxicam.

STUDY DESIGN

Forty-three participants aged 18 to 33 years who had bilateral, symmetrical third molars were included in this double-blind, randomized, placebo-controlled study. All participants took part in each of the 2 groups for a 1-month interval (crossover design). Group Pre received lornoxicam 8 mg intravenously 25 minutes before surgery and 2 mL serum saline postoperatively. Group Post was given the opposite protocol. Pain was evaluated by visual analog scale in the first 12 hours.

RESULTS

We observed statistically significant differences in the reduction of the pain level in group Pre (P < .05). These participants felt less pain in the first 5 postoperative hours and needed fewer analgesics in the first 12 postoperative hours.

CONCLUSIONS

Preemptive lornoxicam is effective for postoperative pain control.

Lornoxicam : pharmacology and usefulness to treat acute postoperative and musculoskeletal pain a narrative review

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDS) are commonly used for acute pain management. Lornoxicam is a nonselective NSAID for oral and intravenous administration. It has been available for human use since two decades and there is a growing body of evidence supporting its efficacy and tolerability for management of acute pain.

AREAS COVERED

Public domain literature around the clinical use of lornoxicam for acute pain management has been reviewed.

EXPERT OPINION

There are a growing number of clinical studies documenting lornoxicam effects for short-term treatment of acute postoperative pain following various surgical procedures. It has in the majority of comparative studies been shown superior as compared to paracetamol, non-inferior compared to other NSAIDs, and commonly similarly effective as standard clinical doses of opioids, but associated with better tolerability. Its effect on other acute pain, for example, headache, back pain, or sports injury is not well studied. Lornoxicam 8 mg twice daily is a seemingly effective and tolerable alternative NSAID for use as sole agent or as part of multimodal analgesia in adults. Available data does however not show any outstanding benefits or special risk. The general precautions with regard to the use of NSAIDs, the potential risks, for example, gastrointestinal bleeding and or cardiovascular side effects must be acknowledged.