Over-the-counter oral analgesia for postcesarean pain

The effect of a scheduled regimen of acetaminophen and ibuprofen on opioid use following cesarean delivery

Objective The primary objective was to evaluate if the administration of ibuprofen and acetaminophen at regularly scheduled intervals impacts pain scores and total opioid consumption, when compared to administration based on patient demand. Methods A retrospective chart review was performed comparing scheduled vs. as-needed acetaminophen and ibuprofen regimens, with 100 women included in each arm. Demographics and delivery characteristics were collected in addition to pain scores and total ibuprofen, acetaminophen and oxycodone use at 24, 48 and 72 h postoperatively. Results The scheduled dosing group was found to have a statistically significant decrease in pain scores at all time intervals. Acetaminophen and ibuprofen usage were also noted to be higher in this group while narcotic use was reduced by 64%. Conclusion Scheduled dosing of non-narcotic pain medications can substantially decrease opioid usage after cesarean delivery and improve post-operative pain.

Systemic adjunct analgesics for cesarean delivery: a narrative review

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.

Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial

OBJECTIVES

To compare the efficacy, safety and satisfaction from two modes of oral analgesia administration for the treatment of post-caesarean pain in the first 48 h following surgery: on-demand versus fixed time interval administration.

DESIGN

Open label parallel-group, randomised-controlled trial from February to December 2013.

SETTING

University-affiliated hospital in Israel.

POPULATION

Two-hundred women who underwent caesarean delivery with regional anaesthesia.

METHODS

Patients were randomly assigned to receive predetermined combinations of tramadol, paracetamol and diclofenac either following patient demand or at predetermined 6-h intervals for the first 48 h. If the patient requested additional analgesia, Percocet (oxycodone and paracetamol) was given as a rescue treatment.

MAIN OUTCOME MEASURES

Pain intensity and satisfaction were self-evaluated with visual analogue scale of 0 (no pain/least satisfaction) to 10 (worst pain/highest satisfaction). Breastfeeding, need for supplemental formula, and maternal and neonatal adverse effects were also evaluated.

RESULTS

The 'fixed time interval' group, compared with the 'on-demand' group, had lower mean pain score (2.8 ± 0.84 versus 4.1 ± 0.48, respectively; P < 0.0001), higher satisfaction rate (9.1 ± 1.2 versus 8.3 ± 1.5, respectively; P < 0.0001), more breastfeeds (23.7 ± 6.5 versus 19.2 ± 6.2, respectively; P < 0.0001) and less use of supplemental formulas (8.2 ± 5.2 versus 11.9 ± 6.5, respectively; P < 0.0001). The number of times that drugs were given was slightly higher in the 'fixed time interval' group without an increase in maternal adverse effects, which were mild. No adverse effects were reported for the neonates.

CONCLUSION

Administration of oral analgesia in fixed time intervals is superior to drug administration following patient demand without increasing maternal or neonatal adverse outcomes.

TWEETABLE ABSTRACT

Oral analgesia in fixed time intervals is superior to analgesia following demand.

Pain management after cesarean: a randomized controlled trial of oxycodone versus intravenous piritramide

PURPOSE

Primary objective was to assess whether oral analgesia with oxycodone offers superior pain relief after cesareans than patient controlled analgesia (PCA). Secondary outcomes were additional pain medication, time to first mobilization, therapeutic side effects, postoperative restrictions, overall satisfaction and costs.

MATERIALS AND METHODS

Randomized controlled trial at a University Hospital conduct between July 2009 and November 2009. Of the 1,112 patients, 257 met the inclusion criteria and 239 agreed to participate. Patients were randomly assigned to either receive intravenous piritramide PCA (2 mg piritramide/ml 0.9 % saline) or oral oxycodone (20 mg). Pain was assessed on a visual analog pain scale (VAS) at 2, 12, 24, 32, 40, 48 and 72 h after cesarean.

RESULTS

No differences in VAS scores were observed within the general study population. Pain scores of oxycodone versus PCA were comparable at 24 h. Patients randomized to PCA demonstrated increased demand for rescue medication 48 h after cesarean (p = 0.057). In the PCA group, patients with previous cesarean had increased operative times, a trend towards increased VAS scores after 48 h (p = 0.081) and increased VAS scores in comparison to patients who did not have cesarean before (p = 0.044). For this subgroup, no difference was seen in the oxycodone patients (p = 0.883).

CONCLUSION

General satisfaction with both treatment regimes was high. The results support the potential use of oral pain regimes and emphasis the importance of a multimodal approach to treat post-cesarean pain. Oral oxycodone is a not expensive, convenient and comparable analgesic to PCA devices with opioids after cesarean. Trial registration at clinicaltrials.gov identifier: NCT 01115101.

Over-the-counter ibuprofen and risk of gastrointestinal bleeding complications: a systematic literature review

BACKGROUND

Exposure to over-the-counter (OTC) ibuprofen and other OTC non-steroidal anti-inflammatory drugs (NSAIDs) is substantial. Although the literature on gastrointestinal (GI) safety of NSAID therapy is extensive, the risk profiles of OTC and prescription dosing are seldom separated, and few studies provide risks specific to OTC ibuprofen.

OBJECTIVE

To conduct a literature review to evaluate the risk of GI bleeding events related to OTC ibuprofen use.

METHODS

Published clinical trials, observational studies, and meta-analyses of OTC ibuprofen use, defined as up to 1200 mg/day or stated as 'over the counter,' reporting endpoints of incidence rates and proportions of GI bleeding events (e.g., GI bleeding-related hospitalizations and deaths) were identified via MEDLINE through 2010. Data from these studies were summarized.

RESULTS

Twenty studies (nine observational, ten clinical trials, one meta-analysis) reporting incidence rates and proportions of a GI bleeding-related event associated with OTC or OTC-specific doses of ibuprofen were included. The frequency of a GI-related hospitalization was <0.2% for patients on OTC-comparable doses. Incidence rates among those using OTC-comparable doses ranged from 0 to 3.19 per 1000 patient-years. The incidence of a GI bleeding-related event increased with age and the use of concomitant medications, and there was a general, though not always statistically significant, ibuprofen dose-response relationship. The relative risk of any GI bleeding-related event ranged from 1.1 to 2.4 for users of OTC-specific doses of ibuprofen compared to non-users.

CONCLUSIONS

Studies reported low incidence of GI bleeding events with use of OTC ibuprofen. Few published studies that specifically investigated OTC ibuprofen use were identified. Varying methodologies and definitions of exposure and outcomes prevented direct comparison of many results. Only studies that used the methods herein described were identified. Further research evaluating the risk of GI bleeding events in patients taking OTC-specific ibuprofen use may be useful.

Analgesia after caesarean delivery

As the number of women giving birth by caesarean increases throughout most of the developed world, so too is research into postoperative pain relief for these women. Like most other post-surgical populations, the new mother needs effective pain relief so that she can mobilise early but she also has the added responsibility of needing to care for her newborn baby. There is no 'gold standard' for post-caesarean pain management; the number of options is large and the choice of method is at least partly determined by drug availability, regional and individual preferences, resource limitations and financial considerations. Most methods rely on opioids, supplemented with anti-inflammatory analgesics, nerve blocks or other adjunctive techniques. The aim of this review is to detail commonly used opioid-based methods and to review the evidence supporting non-opioid methods, when incorporated into a multimodal approach to post-caesarean pain management. Areas of promising research are also discussed.

Pain Catastrophizing, Response to Experimental Heat Stimuli, and Post–Cesarean Section Pain

This prospective study assessed the relation between pain catastrophizing, response to experimental pain stimuli, and pain perceived by women after elective cesarean sections. Forty-seven women who were scheduled for elective cesarean section were enrolled in the study. Magnitude estimation to suprathreshold phasic and tonic heat pain stimuli was assessed 1 or 2 days before surgery. Women completed the Pain Catastrophizing Scale after the heat stimuli and again on the first postoperative day. During the first and second postoperative days, perception of pain intensity was assessed by visual analog scale at each analgesia request. A multiple regression analysis revealed that pain on the first postoperative day was predicted by patient response to preoperative tonic heat stimuli (r(2) = .167, P = .008). Pain on the second postoperative day was predicted by preoperative pain catastrophizing (r(2) = .139, P = .021). No significant association was observed between preoperative response to heat stimuli or pain catastrophizing and the patient's analgesic consumption in the obstetrical ward. It is concluded that pain catastrophizing and response to experimental tonic heat pain correlate with post-cesarean section pain.

PERSPECTIVE

This article presents psychological and psychophysical measures that may be of help in the prediction of post-cesarean section pain. It may therefore contribute to the treatment of the sequelae of the most common major surgical procedure performed in women in their reproductive years.

Preoperative analgesia with local lidocaine infiltration for abdominal hysterectomy pain management

OBJECTIVE

To evaluate the impact of preemptive local analgesia at the incision site in reducing pain in women undergoing abdominal hysterectomy for a benign myomatous uterus.

STUDY DESIGN

In this prospective, randomized, double-blinded, placebo-controlled study, 20 mL of 1% lidocaine or 0.9% saline was injected at the abdominal incision site prior to the performance of the hysterectomy. Thirty-two women were enrolled in the study, 16 received preemptive analgesia while 14 were treated by placebo; 2 were excluded. All operations were performed under general anesthesia. The standard postoperative pain treatment consisted of oral analgesia with ibuprofen (400 mg) in liquid-filled capsules. Morphine (10 mg) was used for rescue analgesia. Pain intensity was self-evaluated with the use of a 100 mm visual analog scale.

RESULTS

Compared to the placebo group, women who received preemptive analgesia with lidocaine 1% perceived a significant reduction in postoperative pain in the first hours after surgery (2 h: 50.1+/-27.9 versus 70.6+/-22.6, p=0.043; 5 h: 42.5+/-25.2 versus 64.6+/-28.3, p=0.043; 8 h: 31.2+/-22.4 versus 53.3+/-30.3, p=0.031).

CONCLUSION

Preemptive analgesia with lidocaine 1% is a simple, cheap and efficient mode to reduce pain in the first hours after hysterectomy.

Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial

OBJECTIVE

The purpose of this study was to determine whether oral analgesia with oxycodone-acetaminophen or a patient-controlled analgesia device with morphine provides superior analgesia after cesarean delivery.

STUDY DESIGN

Ninety-three patients with scheduled cesarean delivery were assigned randomly to receive either oral analgesia with oxycodone-acetaminophen or a morphine patient-controlled analgesia device. At 6 and 24 hours after the procedure, pain was assessed on a visual analog pain scale of 0 to 10. Nausea, sedation, pruritus, ambulation, emesis, and oral fluid intake were also assessed.

RESULTS

Patients who used oral analgesia without a patient-controlled analgesia device experienced less pain at 6 and 24 hours after cesarean delivery. They also had less nausea and drowsiness at 6 hours but slightly more nausea at 24 hours.

CONCLUSION

Oral analgesia with oxycodone-acetaminophen may offer superior pain control after cesarean delivery with fewer side-effects as compared with morphine patient-controlled analgesia. Consideration should be given to expanding the use of oral analgesia in patients immediately after cesarean delivery.