Efficacy of ibuprofen versus lornoxicam after third molar surgery: a randomized, double-blind, crossover pilot study

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

Effect of preemptive photobiomodulation associated with nimesulide on the postsurgical outcomes, oxidative stress, and quality of life after third molar surgery: a randomized, split-mouth, controlled clinical trial

OBJECTIVE

The aim of this study is to compare the effect of photobiomodulation with low-level laser therapy (LLLT) and nimesulide on inflammatory parameters, biomarkers of oxidative stress and inflammation, and quality of life after lower third molar (L3M) surgery.

MATERIAL AND METHODS

A randomized, two-factor, triple-blind, controlled, split-mouth clinical trial was performed with 40 volunteers who required bilateral L3M removal. Patients were allocated depending on the use or not of 100 mg nimesulide 1 hbefore surgery, as well as the use or not of LLLT in the preoperative period.

RESULTS

Pain peaks occurred after 6 h (nimesulide-placebo [N-P] group) and 8 h (nimesulide group). In the N-P group, LLLT resulted in significantly lower mean pain scores than the subgroup without LLLT after 4 h (p = 0.009) and 6 h (p = 0.048). As for edema, a shorter distance between the mandibular angle and the outer canthus of the eyes after 7 days (p = 0.037) and a smaller cumulative effect (p = 0.036) were observed in the N-P group associated with LLLT. A direct effect between LLLT (p = 0.047) and a reduction in the mean scores of overall dissatisfaction with quality of life was detected.

CONCLUSIONS

Preemptive use of nimesulide only delayed peak pain. LLLT reduced edema, trismus, and contributed to a better perception of quality of life. Nimesulide inhibits peroxidation by increasing GSH and stopping neutrophil migration. The benefit of the association of both strategies was not superior to the use of LLLT alone.

CLINICAL RELEVANCE

Translational study with impact on clinical-surgical protocols involving L3M surgery related to pharmacological and non-pharmacological methods.

CYP450 polymorphisms and clinical pharmacogenetics of ibuprofen after lower third molar extraction

PURPOSE

This study hypothesized that drugs accumulate in the bloodstream of poor-metabolizing patients and may have more adverse effects and different pain perceptions and aimed to investigate the influence of CYP450 polymorphisms on acute postoperative pain, swelling, and trismus controlled by ibuprofen (600 mg) in 200 volunteers after dental extraction. In addition, surgical outcomes can determine pain, edema, and trismus and indicate inflammatory reactions after oral surgeries.

METHODS

Genetic sequencing was performed to identify CYP450 polymorphisms and the surgical parameters evaluated: pre and postoperative swelling, trismus, and temperature; self-reported postoperative pain with visual analog scale (VAS); rescue medication consumed; and severity of adverse reactions.

RESULTS

A multiple linear regression model with independent variables [single nucleotide polymorphisms (SNPs), BMI (body mass index), duration, and difficulty of surgery] and dependent variables [postoperative pain by sum of pain intensity difference (SPID), trismus, and swelling] was used for analysis. The duration of surgery was a predictor for pain at 8 h and 96 h after surgery, and BMI was a predictor for both swelling and trismus on the 2nd postoperative day. When evaluating CYP2C8 and C9 genotyped SNPs, it was observed that normal metabolizers showed higher pain levels than the intermediate/poor metabolizers on the postoperative periods as compared with time 0 h. In another analysis, the poor metabolizers for CYP2C8 and C9 presented lower levels of postoperative pain after 8 h and used rescue medication earlier than normal metabolizers.

CONCLUSION

Ibuprofen 600 mg was very effective in controlling inflammatory pain after lower third molar surgeries, without relevant adverse reactions; although in a very subtle way, patients with poor metabolism had higher levels of pain in the first hours, and no longer after 8 h, and used pain relief medication earlier.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov ID (NCT03169127), on March 16th, 2017.

Comparison of safety and analgesic efficacy of diclofenac sodium with etodolac after surgical extraction of third molars: a randomized, double-blind, double-dummy, parallel-group study

Background

Surgical extraction of third molars is associated with postoperative pain and swelling at the extraction site. Pain is commonly managed using non-steroidal anti-inflammatory drugs (NSAIDs). Postoperative pain is usually moderate to severe in the first 12 h postoperatively and lasts for 3–5 days. However, with NSAIDs, these symptoms usually subside within 24 h. Diclofenac sodium and etodolac are NSAIDs, more selectively cyclooxygenase-2 inhibitors, with good analgesic efficacies.

Methods

We compared the safety and analgesic efficacy of diclofenac sodium with etodolac peroral after surgical extraction of third molars in a double-blind, double-dummy, parallel-group study. The subjective pain improvement and pain relief after 2, 6, 24, 48, and 72 h using the visual analogue scale were measured as the study outcome.

Results

Etodolac was equivalent to diclofenac sodium in pain alleviation at all postoperative time periods. No significant differences were found between diclofenac sodium and etodolac groups (P > 0.05). Both study medications were well tolerated and safe with mild adverse effects in only a few participants.

Conclusion

Diclofenac sodium and etodolac are comparable in terms of analgesic efficacy and safety after surgical removal of third molars.

Impact of Pre-Emptive Intravenous Ibuprofen on Perioperative Analgesia in Patients Undergoing Third Molar Extraction: A Randomised Controlled Study

Objective

The aim of the present study was to evaluate the analgesic efficacy of pre-emptive intravenous (iv) ibuprofen on pain during and after the mandibular third molar surgery.

Methods

A total of 60 patients were included in the study. They were allocated as ibuprofen 800 mg iv+dexketoprofen 50 mg (group 1), ibuprofen 800 mg iv alone (group 2) or placebo (group 3). A local anaesthetic infiltration was administered to all patients. In all patients, haemodynamic values (mean arterial pressure (MAP) and heart rate (HR)) were recorded preoperatively, and infusions were started. State-Trait Anxiety Inventory (STAI) scale was used to assess anxiety states. Surgery started 15 min after the infusion. Haemodynamic values and pain scores with visual analogue scale (VAS) were recorded. Pain scores were recorded postoperatively at rest (VASR) and swallowing (VASS).

Results

There was no significant difference in the preoperative STAI values between the groups (p>0.05). HR, MAP and VAS pain scores were significantly higher in group 3 than in groups 1 and 2 (p<0.05). VASR and VASS scores were significantly higher in group 3 than in group 1 in the first 4 h postoperatively (p<0.05). VASS scores were significantly higher in group 3 than in group 2 at 1-4 h postoperatively (p<0.05), but there was no difference in VASR and VASS scores at 48 h after surgery.

Conclusion

Ibuprofen alone or in combination with dexketoprofen provided similar analgesia in the perioperative period when administered pre-emptively.

Analysis of the Effectiveness of Lornoxicam and Flurbiprofen on Management of Pain and Sequelae Following Third Molar Surgery: A Randomized, Controlled, Clinical Trial

The aim of this study was to analyze the effectiveness of Lornoxicam and Flurbiprofen in reducing perioperative sequelae after impacted mandibular third molar surgery. Ninety-one patients who needed surgical extraction of an impacted mandibular third molar were selected for the study. All subjects were randomly allocated to receive one of the following treatments twice a day for 5 days after surgery: placebo (n = 29), Flurbiprofen (n = 31), or Lornoxicam (n = 31). The primary outcome was postoperative pain, evaluated using the visual analogue scale (VAS) score at 30 min, 2, 6, 12, 24, 48 h, 7 and 10 days following surgery. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with Flurbiprofen and Lornoxicam was characterised by an improvement in the primary outcome. Moreover, the treatment with Lornoxicam presented significantly lower median pain scores at 2 h (p < 0.001) and at 6 h (p = 0.016) compared to Flurbiprofen and at 2 h (p < 0.001), 6 h (p = 0.01), and at 24 h (p = 0.018) after surgery compared with placebo. Swelling and maximum mouth opening values were not significantly different between the groups at each follow-up session. This trial demonstrated that treatment with Lornoxicam showed a decrease in the incidence and severity of pain in the first postoperative phase following third molar surgery compared to Flurbiprofen and placebo.

Randomized Controlled Trial Comparing the Effects of 2 Analgesic Drug Protocols in Patients who Received 5 Dental Implants

PURPOSE

This randomized controlled trial compares postoperative pain and swelling after placing dental implants in patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs) versus NSAIDs and corticosteroids.

MATERIALS AND METHODS

Thirty patients received 5 dental implants each in the interforaminal region of the mandible. All patients were treated with ketorolac tromethamine 10 mg, 2 tablets daily for 2 days and amoxicillin 500 mg, 3 tablets daily for 7 days starting 24 hours before surgery. Experimental patients received an im injection of betamethasone 2 mL within 10 hours after surgery. Pain perception, intraoral inflammation (InIn), and extraoral inflammation (ExIn) data were collected 3, 7, and 14 days after surgery. Patients filled out a pain visual analog scale. InIn and ExIn were recorded by observing the existence of 7 signs.

RESULTS

One patient was excluded from control group. Pain perception, InIn, and ExIn were not different between groups at each time point. However, these variables were different from the previous time point within each group.

CONCLUSION

This study suggests that there is no difference in managing postoperative pain and swelling with betamethasone versus betamethasone and ketorolac.

Decreased post-operative pain using a sublingual injection of dexamethasone (8 mg) in lower third molar surgery

Background

Every patient who undergoes mandibular third molar surgery is concerned about post-operative pain. Indeed, previous researchers have used various methods to treat such pain. This study aimed to assess the effectiveness of sublingual injection of dexamethasone (8 mg) to treat post-operative pain after mandibular third molar surgery.

Method

This was a randomized, double-blind, split-mouth, clinical trial, involving 48 healthy patients who required surgical removal of two mandibular third molars with similar bilateral positions. All operations were performed by the same experienced surgeon. The patients were randomized into a study group (8 mg dexamethasone injection) and a placebo group (normal saline injection). Both interventions were injected into the sublingual space immediately after local anesthesia, 30 min before the first incision. The study group received an 8 mg dexamethasone injection, while the placebo group received a normal saline injection. The wash period between the patients' two operations was 3 to 4 weeks. Pain was assessed by recording the number of analgesic tablets (rescue drug) consumed, as well as by noting the patients' responses to the visual analog scale (VAS) on the first, second, and third days after surgery.

Results

The study group differed significantly from the placebo group in terms of VAS score and analgesic consumption.

Conclusion

Dexamethasone (8 mg), injected sublingually, significantly eased post-operative pain after surgical removal of the mandibular third molar.

Pre-emptive analgesic effect of lornoxicam in mandibular third molar surgery: a prospective, randomized, double-blind clinical trial

The aim of this study was to establish whether the pre-emptive use of lornoxicam (16mg) in third molar surgery ensures successful postoperative analgesia and reduces rescue analgesic intake when compared to postoperative application, and in comparison with placebo. Ninety patients were split randomly into three groups: group A received lornoxicam 60min before surgery and placebo 60min after surgery; group B received placebo 60min before surgery and lornoxicam 60min after surgery; group C received placebo 60min before surgery and placebo 60min after surgery. Postoperative pain was recorded on a visual analogue scale and on a numerical rating scale at 1, 2, 4, 6, 8, 12, and 24h after surgery. The patients recorded total dose of paracetamol intake during the 24h after the procedure. The efficacy of postoperative analgesia was greater in lornoxicam groups when compared to the placebo group; there was no difference between the two lornoxicam groups (A and B). Patients in group C took their first rescue analgesic dose earlier after surgery than patients in the two lornoxicam groups. The average dose of paracetamol taken in group C was 1000mg, while it was500 mg in the lornoxicam groups.

Tolerability of the COX-1/COX-2 inhibitor lornoxicam in the treatment of acute and rheumatic pain

Aim: To assess the safety of lornoxicam with particular focus on gastrointestinal (GI) events. Methods: Data on adverse drug reactions (ADRs) were pooled from 60 comparative studies of lornoxicam. Results: A total of 6420 patients received lornoxicam, 1192 received placebo and 3770 received a comparator analgesic. ADRs were reported by 21% of lornoxicam-treated patients, with GI events the most frequent (14 vs 8% with placebo). Across 15 studies that compared lornoxicam (n = 1287) with another NSAID (n = 1010), there was a reduced risk of a GI ADR with lornoxicam (0.78 [95% CI: 0.64–0.96]; p = 0.017). Conclusion: Lornoxicam was well tolerated with the type of GI events observed consistent with the known safety profile of NSAIDs.

A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars

Pain after third molar extraction has been considered the most suitable pharmaceutical model to evaluate acute pain. This study aimed to evaluate the pre-emptive analgesic/anti-inflammatory efficacy of etoricoxib 120 mg following mandibular third molar surgery. A split-mouth, randomized, triple-blind, placebo-controlled study was conducted with patients undergoing the surgical removal of mandibular third molars. All volunteers were allocated randomly to receive either etoricoxib 120 mg or placebo 1h preoperatively, and inflammatory events were evaluated. An estimated sample of 18 surgical units per group was required based on a pilot study (95% confidence level and 80% statistical power). Rescue medication was analyzed by Kaplan-Meier method through log-rank Mantel-Cox test and Pearson linear correlation (P<0.05). Pre-emptive etoricoxib reduced postoperative pain scores significantly in comparison to placebo (P<0.001), with a pain score peak at 6h after surgery (P<0.001). The mean rescue medication consumption was lower in the etoricoxib group compared to the placebo group over the study period (P<0.05). There was no statistically significant difference between groups related to swelling and trismus. The pre-emptive administration of etoricoxib 120 mg significantly reduced the postoperative pain intensity and the need for rescue medication, but did not reduce swelling or trismus.

Comparison between lornoxicam quick-release and parecoxib for post-operative analgesia after laparoscopic cholecystectomy: A prospective randomized, placebo-controlled trial

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are valuable for post-operative pain as they reduce the use of opioids. Cyclooxygenase-2 inhibitors and traditional NSAIDs can be used. This is a prospective, randomized, placebo-controlled trial to study the efficacy and the safety of the oral administration of lornoxicam quick release tablets versus intravenously administered parecoxib for the management of pain after laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

One hundred and eight patients, American Society of Anesthesiologists I-II, were randomized to either group A (n = 36): Lornoxicam quick-release 8 mg PO, group B (n = 36): Parecoxib 40 mg intravenous (IV) or group C (n = 36) placebo, for post-operative analgesia, 30 min before the operation and 12 and 24 h post-operatively. All patients received a standard dose of meperidine 1 mg/kg intramuscularly before the incision and post-operatively as rescue analgesia, when visual analog scale (VAS) pain score was <4. Pain at rest and on movement was assessed at 20 min, 3, 6, 12, 18 and 24 h post-operatively. Total meperidine administration and adverse events were also recorded.

RESULTS

There were significantly lower VAS pain scores at 20 min, 3, 6, 12 and 18 h at rest or with movement in the lornoxicam quick release and parecoxib groups compared with the placebo group. The number of patients requiring rescue analgesia (meperidine) was significantly higher in the placebo group (P = 0.001). The average dose of meperidine administered was significantly higher in the placebo group, both at 20 min (P = 0.013/0.007) and 24 h (P = 0.037/0.023) post-operatively. VAS scores and meperidine requirements were similar in patients who received lornoxicam or parecoxib.

CONCLUSIONS

Parecoxib 40 mg IV and lornoxicam quick-release 8 mg PO every 12 h are equivalent adjuvant analgesics with a greater efficacy than placebo for post-operative analgesia in patients undergoing LC.

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.

Postoperative analgesia in impacted third molar surgery: the role of preoperative diclofenac sodium, paracetamol and lornoxicam

OBJECTIVE

The aim of this study was to compare the postoperative analgesic effects of preoperative intravenous (i.v.) paracetamol, diclofenac sodium and lornoxicam (nonsteroidal anti-inflammatory drugs).

SUBJECTS AND METHODS

Sixty patients with impacted third molar who underwent surgical removal were randomly allocated into three groups: group P (n = 20), group D (n = 20) and group L (n = 20). Group P received preoperatively 1 g paracetamol i.v., group D 75 mg diclofenac sodium i.m. and group L 8 mg lornoxicam i.v. Postoperative pain intensity, additional consumption of analgesics postoperatively and postoperative complications were compared among groups.

RESULTS

The groups were comparable for pain scores (p > 0.05). Maximum pain scores were recorded in postoperative 4th h in all groups (group L 22, 14-44 mm; group P 24, 13-43 mm; group D 14, 10-24 mm, p = 0.117). Patients experienced high satisfaction scores which were comparable among groups (group L 85, 75-100 mm; group P 87, 70-95 mm; group D 84, 77-98 mm, p = 0.457).

CONCLUSION

Preoperative intramuscular diclofenac, intravenous paracetamol and lornoxicam effectively decreased the pain scores. The patients were satisfied with the three postoperative pain management regimens.