Preemptive meloxicam achieves a better effect on postoperative pain control and similar tolerance compared with postoperative meloxicam in patients receiving arthroscopic knee surgery

Functional infrared thermography imaging can be used to assess the effectiveness of Maxicam Gel® in pre-emptively treating transient synovitis and lameness in horses

Introduction

Diagnosing and treating lameness in horses is essential to improving their welfare. In equine orthopedic practice, infrared thermography (IRT) can indirectly detect soreness. Non-steroidal anti-inflammatory drugs can treat painful and inflammatory processes in horses. Using IRT, the efficacy of meloxicam (Maxicam Gel®) was evaluated in pre-treating transient synovitis in horses induced by a middle carpal joint injection of lipopolysaccharides (LPS) from E. coli 055:B5 at a dose of 10 endotoxin units.

Methods

In a cross-over design, six healthy horses were randomly assigned to receive either 0.6 mg/kg of oral Maxicam Gel® (MAXVO) or a mock administration (control group, C) following a two-week washout period. IRT of the middle carpal joint, visual lameness assessment and joint circumference were recorded over time. Clinical and hematological evaluations were performed. Synovial fluid aspirates were analyzed for total nucleated cell count, total protein, and prostaglandin E2. A mixed effects analysis of variance was performed for repeated measures over time, followed by Tukey's test. A multinomial logistic regression was conducted to determine whether there is a relationship between a thermography temperature change and the lameness score.

Results

There were no changes in joint circumference. The MAXVO group showed a lower rectal temperature 4 h after synovitis induction. The C group presented an increase in neutrophils and a decrease in total hemoglobin and hematocrit 8 h after induction. No changes were observed in the synovial fluid between groups. The horses that received meloxicam did not show clinically significant lameness at any time, while the C group showed an increase in lameness 2, 4, and 8 h after synovitis induction.

Discussion

IRT indicated that the skin surface temperature of the middle carpal joint was lower in horses who received meloxicam, suggesting a reduction in the inflammatory process induced by LPS. It was observed that the maximum temperature peaks in the dorsopalmar and lateropalmar positions can be utilized to predict the severity of lameness, particularly when the temperature rises above 34°C. Horses pre-treated with meloxicam showed either reduced or no indication of mild to moderate pain and presented a lowehr thermographic temperature, which indicates the effectiveness of Maxicam Gel® as an anti-inflammatory.

Early perioperative versus postoperative meloxicam for pain control in patients undergoing orthopedic surgery: a systematic review and Meta-analysis of randomized controlled trials

OBJECTIVE

Post-orthopaedic operative pain is a serious concern that often requires the administration of analgesics; however, the optimal time of analgesic administration is still inconclusive. Perioperative analgesia is administrating pre-emptive analgesia before and during the surgery followed by postoperative analgesia to decrease the procedure associated nociceptive response. We aim to assess perioperative meloxicam versus postoperative meloxicam for pain control after orthopaedic operations.

METHODS

A systematic review and meta-analysis involving randomized controlled trials from PubMed, Embase, Scopus, WOS, and Cochrane until 28th May 2022. We pooled dichotomous outcomes using risk ratio (RR) presented with a 95% confidence interval (CI) and continuous outcomes using mean difference (MD) with 95% CI. We registered our protocol in PROSPERO with ID: CRD42022336046.

RESULTS

We included five RCTs with 964 patients. All the included trials showed high risk of performance and detection biases because of lack of blinding. Pooled analysis favored perioperative meloxicam in reducing pain score after six hours (MD: -0.42 with 95% CI [-0.63, -0.21], p = .0001), 12 h (MD: -0.54 with 95% CI [-0.69, -0.39], p = .00001), and 24 h (MD: -0.23 with 95% CI [-0.36, -0.10]. Pooled analysis favored perioperative meloxicam in improving patient global assessment scale after 12 h (MD: -0.66 with 95% CI [-0.86, -0.46], p = .00001), 24 h (MD: -0.30 with 95% CI [-0.49, -0.11, p = .002), and 48 h (MD: -0.17 with 95% CI [-0.33, -0.01], p = .04). Pooled analysis favored perioperative meloxicam in reducing patient-controlled analgesia (MD: -4.25 with 95% CI [-5.96, -2.54], p = .00001).

CONCLUSION

Short-term pain management after orthopaedic procedures is better accomplished with perioperative meloxicam than postoperative meloxicam. Before recommending perioperative meloxicam for pain control following orthopaedic surgeries, further multicentre trials are still warranted to examine the impact of perioperative meloxicam in different orthopaedic procedures.

Efficacy and safety of preoperative versus postoperative NSAIDs on pain relief in patients undergoing hip arthroscopy surgery: A multicentre, randomized, controlled trial

WHAT IS KNOWN AND OBJECTIVE

Postoperative pain relief is a critical issue for hip arthroscopy surgery (HAS). This study aimed to investigate the effect of preemptive non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative analgesia in femoroacetabular impingement (FAI) patients receiving HAS.

METHODS

This multicenter, randomized, controlled study enrolled 204 FAI patients receiving HAS, then assigned them to preoperative (PRE, N = 103) or postoperative (POS, N = 101) group as a 1:1 ratio; the PRE group administrated NSAIDs from 24 h pre-surgery to day 7 (D7) post-surgery, while the POS group administrated NSAIDs from 12 h post-surgery to D7 post-surgery.

RESULTS AND DISCUSSION

Pain at rest was reduced at D1 (p = 0.016) and D2 (p = 0.023); pain at movement was decreased at D1 (p = 0.002), D2 (p = 0.020), and D3 (p = 0.030) in the PRE group compared with POS group, but not at other time points (all p > 0.05). Patient's satisfaction was increased at D1 (p = 0.013) and D3 (p = 0.029) in the PRE group compared to the POS group, but not at D7 (p = 0.145). Pethidine was less consumed at D3 (p = 0.038) and D7 (p = 0.017) in the PRE group in contrast with the POS group. Harris hip scores were similar at D7 (p = 0.124), month 1 (M1) (p = 0.273), and M3 (p = 0.360) between groups. Adverse events incidence was similar between groups (all p > 0.05). Besides, subgroup analysis discovered that pain was not influenced by the types of NSAID in both groups (all p > 0.05).

WHAT IS NEW AND CONCLUSION

Starting NSAIDs before HAS provides better short-term pain relief and improves patient's satisfaction compared with its postoperative utilization, while does not induce additional adverse events in FAI patients.

Pre-emptive and preventive NSAIDs for postoperative pain in adults undergoing all types of surgery

BACKGROUND

Postoperative pain is a common consequence of surgery and can have many negative perioperative effects. It has been suggested that the administration of analgesia before a painful stimulus may improve pain control. We defined pre-emptive nonsteroidal anti-inflammatories (NSAIDs) as those given before surgery but not continued afterwards and preventive NSAIDs as those given before surgery and continued afterwards. These were compared to a control group given the NSAIDs after surgery instead of before surgery.

OBJECTIVES

To assess the efficacy of preventive and pre-emptive NSAIDs for reducing postoperative pain in adults undergoing all types of surgery.

SEARCH METHODS

We searched the following electronic databases: CENTRAL, MEDLINE, Embase, AMED and CINAHL (up to June 2020). In addition, we searched for unpublished studies in three clinical trial databases, conference proceedings, grey literature databases, and reference lists of retrieved articles. We did not apply any restrictions on language or date of publication.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs) only. We included adult participants undergoing any type of surgery. We defined pre-emptive NSAIDs as those given before surgery but not continued afterwards and preventive NSAIDs as those given before surgery and continued afterwards. These were compared to a control group given the NSAIDs after surgery instead of before surgery. We included studies that gave the medication by any route but not given on the skin.

DATA COLLECTION AND ANALYSIS

We used the standard methods expected by Cochrane, as well as a novel publication bias test developed by our research group. We used GRADE to assess the certainty of the evidence for each outcome. Outcomes included acute postoperative pain (minimal clinically important difference (MCID): 1.5 on a 0-10 scale), adverse events of NSAIDs, nausea and vomiting, 24-hour morphine consumption (MCID: 10 mg reduction), time to analgesic request (MCID: one hour), pruritus, sedation, patient satisfaction, chronic pain and time to first bowel movement (MCID: 12 hours).

MAIN RESULTS

We included 71 RCTs. Seven studies are awaiting classification. We included 45 studies that evaluated pre-emptive NSAIDs and 26 studies that evaluated preventive NSAIDs. We considered only four studies to be at low risk of bias for most domains. The operations and NSAIDs used varied, although most studies were conducted in abdominal, orthopaedic and dental surgery. Most studies were conducted in secondary care and in low-risk participants. Common exclusions were participants on analgesic medications prior to surgery and those with chronic pain. Pre-emptive NSAIDs compared to post-incision NSAIDs For pre-emptive NSAIDs, there is probably a decrease in early acute postoperative pain (MD -0.69, 95% CI -0.97 to -0.41; studies = 36; participants = 2032; I² = 96%; moderate-certainty evidence). None of the included studies that reported on acute postoperative pain reported adverse events as an outcome. There may be little or no difference between the groups in short-term (RR 1.00, 95% CI 0.34 to 2.94; studies = 2; participants = 100; I² = 0%; low-certainty evidence) or long-term nausea and vomiting (RR 0.85, 95% CI 0.52 to 1.38; studies = 5; participants = 228; I² = 29%; low-certainty evidence). There may be a reduction in late acute postoperative pain (MD -0.22, 95% CI -0.44 to 0.00; studies = 28; participants = 1645; I² = 97%; low-certainty evidence). There may be a reduction in 24-hour morphine consumption with pre-emptive NSAIDs (MD -5.62 mg, 95% CI -9.00 mg to -2.24 mg; studies = 16; participants = 854; I² = 99%; low-certainty evidence) and an increase in the time to analgesic request (MD 17.04 minutes, 95% CI 3.77 minutes to 30.31 minutes; studies = 18; participants = 975; I² = 95%; low-certainty evidence). There may be little or no difference in opioid adverse events such as pruritus (RR 0.40, 95% CI 0.09 to 1.76; studies = 4; participants = 254; I² = 0%; low-certainty evidence) or sedation (RR 0.51, 95% CI 0.16 to 1.68; studies = 4; participants = 281; I² = 0%; low-certainty evidence), although the number of included studies for these outcomes was small. No study reported patient satisfaction, chronic pain or time to first bowel movement for pre-emptive NSAIDs. Preventive NSAIDs compared to post-incision NSAIDs For preventive NSAIDs, there may be little or no difference in early acute postoperative pain (MD -0.14, 95% CI -0.39 to 0.12; studies = 18; participants = 1140; I² = 75%; low-certainty evidence). One study reported adverse events from NSAIDs (reoperation for bleeding) although the events were low which did not allow any meaningful conclusions to be drawn (RR 1.95; 95% CI 0.18 to 20.68). There may be little or no difference in rates of short-term (RR 1.26, 95% CI 0.49 to 3.30; studies = 1; participants = 76; low-certainty evidence) or long-term (RR 0.85, 95% CI 0.52 to 1.38; studies = 5; participants = 456; I² = 29%; low-certainty evidence) nausea and vomiting. There may be a reduction in late acute postoperative pain (MD -0.33, 95% CI -0.59 to -0.07; studies = 21; participants = 1441; I² = 81%; low-certainty evidence). There is probably a reduction in 24-hour morphine consumption (MD -1.93 mg, 95% CI -3.55 mg to -0.32 mg; studies = 16; participants = 1323; I² = 49%; moderate-certainty evidence). It is uncertain if there is any difference in time to analgesic request (MD 8.51 minutes, 95% CI -31.24 minutes to 48.27 minutes; studies = 8; participants = 410; I² = 98%; very low-certainty evidence). As with pre-emptive NSAIDs, there may be little or no difference in other opioid adverse events such as pruritus (RR 0.56, 95% CI 0.09 to 3.35; studies = 3; participants = 211; I² = 0%; low-certainty evidence) and sedation (RR 0.84, 95% CI 0.44 to 1.63; studies = 5; participants = 497; I² = 0%; low-certainty evidence). There is probably little or no difference in patient satisfaction (MD -0.42; 95% CI -1.09 to 0.25; studies = 1; participants = 72; moderate-certainty evidence). No study reported on chronic pain. There is probably little or no difference in time to first bowel movement (MD 0.00; 95% CI -15.99 to 15.99; studies = 1; participants = 76; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There was some evidence that pre-emptive and preventive NSAIDs reduce both pain and morphine consumption, although this was not universal for all pain and morphine consumption outcomes. Any differences found were not clinically significant, although we cannot exclude this in more painful operations. Moreover, without any evidence of reductions in opioid adverse effects, the clinical significance of these results is questionable although few studies reported these outcomes. Only one study reported clinically significant adverse events from NSAIDs administered before surgery and, therefore, we have very few data to assess the safety of either pre-emptive or preventive NSAIDs. Therefore, future research should aim to adhere to the highest methodology and be adequately powered to assess serious adverse events of NSAIDs and reductions in opioid adverse events.

Efficiency and safety: comparison between preoperative analgesia and postoperative analgesia using non-steroidal anti-inflammatory drugs in patients receiving arthroscopic knee surgery in a multicenter, randomized, controlled study

BACKGROUND

This study aimed to compare the efficiency regarding postoperative pain control, consumption of rescue drug, patients' satisfaction and the safety of preoperative analgesia versus postoperative analgesia using non-steroidal anti-inflammatory drugs (NSAIDs) in patients who received arthroscopic knee surgery (AKS).

METHODS

Four hundred and sixty-four patients who received AKS were recruited in this multicenter, randomized, controlled study. Subsequently, they were randomized into PRE group (N = 232) and POST group (N = 232). In PRE group, patients received celecoxib, meloxicam or rofecoxib from 2 h pre-operation (Pre (- 2 h)) to 48 h post-operation for analgesia. In POST group, patients received celecoxib, meloxicam or rofecoxib from 4 to 48 h post-operation for analgesia.

RESULTS

h and 12 h; pain VAS at passive movement was reduced in PRE group than POST group at 6 h, 12 h and 24 h. Additionally, consumption of rescue drug (pethidine) was decreased, while overall satisfaction was increased in PRE group compared to POST group. As for adverse events, the incidences of nausea, vomiting, constipation, drowsiness and dizziness were similar between PRE group and POST group. In subgroup analysis, the pain VAS score at passive movement at 6 h and nausea and constipation incidences were distinctive among subgroups categorized by meloxicam, celecoxib and rofecoxib administration. However, no difference of other assessments was found among subgroups categorized by meloxicam, celecoxib and rofecoxib administration.

CONCLUSION

Preoperative analgesia using NSAIDs is more efficient and equivalently tolerable compared to postoperative analgesia using NSAIDs in patients who receive AKS.

Preoperative meloxicam versus postoperative meloxicam for pain control, patients' satisfaction and function recovery in hip osteoarthritis patients who receive total hip arthroplasty: a randomized, controlled study

This study aimed to compare the analgesic effect, patients’ satisfaction, tolerance and hip-joint function recovery by preoperative meloxicam versus postoperative meloxicam in treating hip osteoarthritis (OA) patients receiving total hip arthroplasty (THA). 132 hip OA patients who underwent THA surgery were allocated into postoperative analgesia (POST) and preoperative analgesia (PRE) groups at a 1:1 ratio. In the PRE group, patients took meloxicam 15 mg at 24 h pre-operation, 7.5 mg at 4 h, 24 h, 48 h and 72 h post-operation; in the POST group, patients received meloxicam 15 mg at 4 h post-operation, then 7.5 mg at 24 h, 48 h and 72 h post-operation. Furthermore, postoperative pain, consumption of patient-controlled analgesia (PCA), overall satisfaction and adverse events were evaluated within 96 h post-operation; meanwhile, Harris hip score was assessed within 6 months post-operation. Pain VAS at rest at 6 h, 12 h, 24 h, and pain VAS at passive movement at 6 h, 12 h were decreased in PRE group compared to POST group. In addition, additional consumption of PCA and the total consumption of PCA were both reduced in PRE group compared to POST group. Additionally, overall satisfaction in PRE group was higher at 24 h, 48 h and 72 h compared to POST group. While Harris hip score was of no difference between POST group and PRE group at M3 or M6. Besides, no difference in adverse events incidence was found between the two groups. In conclusion, preoperative meloxicam achieves better efficacy and similar tolerance compared to postoperative meloxicam in hip OA patients post THA.