Comparison of the postoperative analgesic effects of naproxen sodium and naproxen sodium-codeine phosphate for arthroscopic meniscus surgery

Multimodal Pain Management After Outpatient Orthopedic Hand Surgery: A Prospective Randomized Trial

Purpose

Opioid stewardship ensures effective pain management while avoiding overprescribing of opioids after surgery. This prospective randomized study investigates the efficacy of a multimodal postoperative pain regimen compared to a traditional opioid-only pain regimen following elective outpatient orthopedic hand surgery. We hypothesized that patients receiving multimodal pain management would consume fewer opioids and report greater satisfaction than patients receiving only opioids.

Methods

Consecutive patients undergoing outpatient hand and upper extremity surgery performed by two board-certified fellowship-trained orthopedic hand surgeons at one institution were recruited and randomized into either a study or control group. The study group received a standing multimodal postoperative regimen consisting of scheduled oral acetaminophen and naproxen as well as oxycodone to be taken as needed. The control group received only oxycodone to be taken as needed. Postoperatively, daily pain levels, medication usage, refills, satisfaction, and adverse events were recorded. Descriptive statistics were performed.

Results

Of the 112 patients enrolled, 54 were randomized to the control group, and 58 were randomized to the study group. Study and control group patients did not differ significantly based on daily average pain scores or daily worst pain scores. However, study group patients reported fewer average daily oxycodone intake and total oxycodone pill count (7.0 vs 2.4 total pills, P <.005). In addition, the study group patients were more likely to report satisfaction with their postoperative pain control than control regimen patient's and were more likely to use the same pain regimen again if required.

Conclusion

A multimodal postoperative pain regimen reduces opioid usage and has higher patient satisfaction rates in comparison to traditional opioid-only regimens. Use of multimodal pain regimens that use nonopioids, such as acetaminophen and naproxen, over an opioid should be considered for postoperative pain after orthopedic hand surgery.

Level of Evidence

Therapeutic II.

A Validated Method for Separation and Determination of Codeine Phosphate Hemihydrate Impurities in Bilayer Tablet Dosage Form of Naproxen Sodium and Codeine Phosphate by Using UHPLC

Background:

Apranax Plus® is a new bilayer tablet dosage form, which combines two active pharmaceutical ingredients: naproxen sodium and codeine phosphate.

Objective:

The purpose of this work was to develop an ultra-high-performance liquid chromatography (UHPLC) method for the separation and determination of codeine phosphate hemihydrate impurities in a bilayer tablet dosage form.

Methods:

The separation and determination of codeine phosphate hemihydrate and its impurities, methylcodeine, morphine, codeine dimer, 10-hydroxycodeine, 14-hydroxycodeine, thebaine and codeinone were achieved by using reversed-phase liquid chromatography with TUV (Tunable UV Detector) and PDA (Photodiode Array Detector) detection by UHPLC. The new proposed method utilized by the Waters Acquity UHPLC® TUV and PDA systems using a UHPLC column Waters Acquity, BEH, C18, 2.1x100 mm, 1.7 μm particle size with a mixture of component A and acetonitrile in a gradient mode at a flow rate of 0.3mL/min, at 25°C with a load of 5μL. The detection for all eluted compounds was carried out at 245nm.

Results:

The codeine phosphate hemihydrate and peaks of its impurities were adequately obtained, thus proving the stability-indicating power of the method. The developed method was validated as per the ICH guidelines with respect to parameters such as precision, accuracy, linearity, limit of detection (LOD), limit of quantification (LOQ) and robustness.

Conclusion:

It was verified as being adequate for all the mentioned impurities of codeine phosphate hemihydrate. The described method was found to be useful for routine purity testing and was also found suitable for the analysis of the stability samples of the drug product.

Opioid Use Is Reduced in Patients Treated with NSAIDs After Arthroscopic Bankart Repair: A Randomized Controlled Study

Purpose

To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability.

Methods

This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction.

Results

Between December 2017 and May 2019, 80 patients (mean age 31.3 ± 10.4 years) were enrolled. Overall there were no significant differences in VAS pain score or patient satisfaction between the 2 groups. Patients in the opioid-only group had a significantly higher mean opioid consumption on postoperative days (PODs) 2 to 4 (5.5 versus 2.9, P = .05) and after 1 week (11.7 versus 7.9 tablets, P = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group.

Conclusions

Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups.

Level of Evidence

II, nonblinded randomized control trial.

Analgesic efficacy of naproxen-codeine, naproxen+dexamethasone, and naproxen on myofascial pain: A randomized double-blind controlled trial

OBJECTIVE

To assess the effects of naproxen sodium-codeine phosphate, naproxen sodium-dexamethasone, and naproxen sodium on myofascial pain.

METHODS

This randomized, double-blind prospective clinical study was conducted with patients who applied with the complaint of pain in the temporomandibular region. A total of 169 patients were randomly divided into four groups and received the following treatments: Group A: naproxen sodium 550 mg; Group B: naproxen sodium 550 mg + codeine phosphate 30 mg; Group C: naproxen sodium 550 mg + single-dose dexamethasone 8 mg, and Group D: paracetamol 500 mg.

RESULTS

Of the patients, 132 were female, and 37 were male, with a mean age of 27.04 ± 10.56 (18-69 years). Analgesic efficiency of the naproxen sodium-codeine phosphate group was the most effective at the 2nd week and 4th week (p < 0.05).

CONCLUSION

Naproxen sodium-codeine phosphate might be preferred as an analgesic in similar cases with severe myofascial pain.