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Biase TMMA, Rocha JGM, Silva MT, Ribeiro-Vaz I, Galvão TF. Renal effects of selective cyclooxygenase-2 inhibitor anti-inflammatory drugs: A systematic review and meta-analysis. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 15:100475. [PMID: 39114538 PMCID: PMC11304066 DOI: 10.1016/j.rcsop.2024.100475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 08/10/2024] Open
Abstract
Background Selective cyclooxygenase-2 inhibitor anti-inflammatory drugs (coxibs) are associated with the development of adverse events, mainly gastrointestinal and cardiovascular, but renal effects are less known. Objective To assess the renal risks of coxibs compared to placebo by means of a systematic review and meta-analysis. Methods Randomized controlled trials that assessed renal effects of coxibs (celecoxib, etoricoxib, lumiracoxib, parecoxib, and valdecoxib) were searched in PubMed, Embase, Scopus and other sources up to March 2024. Two independent reviewers performed study screening, data extraction, and risk of bias assessment. Random effect meta-analysis was employed to calculate the relative risks (RR) and 95% confidence intervals (CI) of renal effects of coxibs compared to placebo and inconsistency among studies (I 2 ). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Results Out of 5284 retrieved records, 49 studies (comprising 46 reports) were included. Coxibs increased the risk of edema (RR 1.46; 95% CI 1.15, 1.86; I 2 = 0%; 34 studies, 19,754 participants; moderate-certainty evidence), and celecoxib increased hypertensive or renal events (RR 1.24; 95% CI 1.08, 1.43; I 2 = 0%; 2 studies, 3589 participants; moderate-certainty evidence). Etoricoxib increased the risk of hypertension (RR 1.98; 95% CI 1.14, 3.46; I 2 = 34%; 13 studies, 6560 participants; moderate-certainty evidence); no difference was observed when pooling all coxibs (RR 1.26; 95% CI 0.91, 1.76; I 2 = 26%; 30 studies, 16,173 participants; moderate-certainty evidence). Conclusions Coxibs likely increase the renal adverse effects, including hypertension and edema. Awareness about the renal risks of coxibs should be increased, mainly in high-risk patient.
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Affiliation(s)
| | | | - Marcus Tolentino Silva
- Department of Public Health, School of Health Sciences, University of Brasília, Brasília, Brazil
| | - Inês Ribeiro-Vaz
- Department of Community Medicine, Health Information and Decision, School of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, School of Medicine, University of Porto, Porto, Portugal
| | - Taís Freire Galvão
- School of Pharmaceutical Sciences, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
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Muacevic A, Adler JR, Kandru M, Dendukuri NK, Gandla G, Vemuri SSS, Peri H, Linga S. Effect of Parecoxib on Postoperative Pain Management After Total Knee/Hip Arthroplasty: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e32339. [PMID: 36628043 PMCID: PMC9826532 DOI: 10.7759/cureus.32339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) or total hip arthroplasty (THA) are frequent procedures used to relieve the symptoms of hip or knee joint dysfunction, enhance disease recovery, and boost patients' quality of life. Nevertheless, postoperative pain has been a significant disadvantage since it strongly impacts patients' postoperative recovery. Parecoxib has been demonstrated to be useful in the management of postoperative pain in a variety of surgical procedures. While parecoxib can help with postoperative pain, its analgesic and unfavourable effects in TKA/THA patients have not been well studied. METHODS A systematic search of peer-reviewed articles was conducted through the PubMed database, Google Scholar, and Cochrane library to retrieve related studies published in the English language that met inclusion and exclusion criteria. The publication date was restricted to the past 10 years (2012-2022). Results were analyzed using Review Manager software (RevMan version 5.4.1, The Cochrane Collaboration, 2020). The quality of the studies included was assessed using Jadad scores. Risk ratios (RR) standard mean difference (SMD) and 95% confidence intervals (CI) were calculated to analyze the primary and secondary endpoints. RESULTS Eleven randomized controlled trials covering 1911 patients who underwent TKA/THA were selected. The pooled results indicated that the parecoxib group has lower visual analogue scale (VAS) scores than the placebo group. However, there was no significant difference in the secondary endpoint. The Jadad scores ranged from 3 to 5 and most of the studies were of high quality. CONCLUSION The results of our meta-analysis indicate that parecoxib has a better analgesic effect compared to placebo. It alleviates postoperative orthopaedic pain without raising the risk of adverse events.
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Gao Z, Li M, Yao F, Xia X, Duan T, Meng J, Huang Y, He Y, Saro A, Huang J. Valdecoxib Protects against Cell Apoptosis Induced by Endoplasmic Reticulum Stress via the Inhibition of PERK-ATF4-CHOP Pathway in Experimental Glaucoma. Int J Mol Sci 2022; 23:12983. [PMID: 36361772 PMCID: PMC9657191 DOI: 10.3390/ijms232112983] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/15/2022] [Accepted: 10/20/2022] [Indexed: 07/30/2023] Open
Abstract
The purpose of this study was to investigate the effects of valdecoxib on the retina in retinal ischemia-reperfusion injury (IRI) and R28 cells following oxygen-glucose deprivation/recovery (OGD/R) injury, as well as the underlying mechanisms. Immunofluorescence and Cell Counting Kit-8 (CCK-8) analyses were used to identify the proper timepoint and concentration of valdecoxib's protective effect on the R28 cells in the OGD/R model. Hematoxylin-eosin (HE) staining and immunofluorescence were used to explore valdecoxib's effect on the retina and retina ganglion cell (RGC) in IRI. Cell apoptosis was determined by a TUNEL Apoptosis Detection Kit and Annexin V-FITC/PI flow cytometry. The expression levels of p-PERK, transcription factor 4 (ATF4), GRP78, CHOP, cleaved caspase 3, bax and bcl-2 were measured by Western blot analyses. The valdecoxib protected the R28 cells from OGD/R injury by decreasing the cell apoptosis rate, and it exerted a protective effect on retinas in I/R injury by inhibiting RGC apoptosis. The valdecoxib pretreatment reversed the expression of p-PERK, ATF4, CHOP, GRP78, cleaved caspase 3 and bax induced by the glaucomatous model. Meanwhile, the CCT020312 reversed the valdecoxib's anti-apoptosis effect by activating PERK-ATF4-CHOP pathway-mediated endoplasmic reticulum (ER) stress. These findings suggest that valdecoxib protects against glaucomatous injury by inhibiting ER stress-induced apoptosis via the inhibition of the PERK-ATF4-CHOP pathway.
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Affiliation(s)
- Zhaolin Gao
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
- Hunan Key Laboratory of Ophthalmology, Central South University, Changsha 410008, China
| | - Min Li
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
| | - Fei Yao
- Hunan Key Laboratory of Ophthalmology, Central South University, Changsha 410008, China
| | - Xiaobo Xia
- Hunan Key Laboratory of Ophthalmology, Central South University, Changsha 410008, China
| | - Tianqi Duan
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
| | - Jingzhuo Meng
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
| | - Yanxia Huang
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
| | - Ye He
- Hunan Key Laboratory of Ophthalmology, Central South University, Changsha 410008, China
| | - Adonira Saro
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
| | - Jufang Huang
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha 410013, China
- Hunan Key Laboratory of Ophthalmology, Central South University, Changsha 410008, China
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Fillingham YA, Hannon CP, Roberts KC, Hamilton WG, Della Valle CJ. Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2020; 35:2704-2708. [PMID: 32571593 DOI: 10.1016/j.arth.2020.05.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Karl C Roberts
- Department of Orthopaedic Surgery, Michigan State University, Grand Rapids, MI
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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5
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Fillingham YA, Hannon CP, Roberts KC, Mullen K, Casambre F, Riley C, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2739-2758. [PMID: 32690428 DOI: 10.1016/j.arth.2020.05.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) have become widely used to manage perioperative pain following total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of NSAIDs in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS Databases including MEDLINE, EMBASE, and the Cochrane Central Registry of Controlled Trials were searched for studies published prior to November 2018 on NSAIDs in TJA. Studies included after a systematic review evaluated through direct comparisons and/or meta-analysis, including qualitative and quantitative heterogeneity testing, to evaluate effectiveness and safety of NSAIDs. RESULTS After critical appraisal of 2921 publications, 25 articles represented the best available evidence for inclusion in the analysis. Oral selective cyclooxygenase (COX)-2 and non-selective NSAIDs and intravenous ketorolac safely reduce postoperative pain and opioid consumption during the hospitalization for primary TJA. Administration of an oral selective COX-2 NSAID reduced postoperative opioid consumption after discharge from TKA. CONCLUSION Strong evidence supports the use of an oral selective COX-2 or non-selective NSAID and intravenous ketorolac as adjunctive medications to manage postoperative pain during the hospitalization for TJA. Although no safety concerns were observed, prescribers need to remain vigilant when prescribing NSAIDs.
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Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Karl C Roberts
- Department of Orthopaedic Surgery, Michigan State University, Grand Rapids, MI
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Connor Riley
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Zhou ZJ, Tang J, Li WH, Tao WD. Preoperative intravenous flurbiprofen reduces postoperative pain and inflammatory cytokines in elderly patients after hip arthroplasty. Exp Ther Med 2018; 17:354-358. [PMID: 30651803 PMCID: PMC6307351 DOI: 10.3892/etm.2018.6911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 10/11/2018] [Indexed: 12/29/2022] Open
Abstract
Effect of flurbiprofen on the postoperative cognition and inflammatory cytokines in elderly patients after hip arthroplasty was investigated. Elderly patients undergoing replacement of total hip were randomly divided into three groups of equal size (n=60). A control group (control) received no treatment before or at the end of surgery. The other two groups, PRE and INTRA, received 50 mg flurbiprofen intravenously 15 min before the surgery and 30 min before the end of surgery, respectively. The pain score was evaluated by a visual analog scale (VAS) at the following time-points: 24 h before surgery (T0), and 3 h (T1), 12 h (T2) and 24 h (T3) after surgery. Peripheral venous blood was collected at T0, T1, T2 and T3. Cognitive function was assessed by mini-mental state examination (MMSE) at the time of T0, T1, T2 and T3. The serum concentration of tumor necrosis factor α (TNF-α), interleukin-1β (IL-1β), IL-6, and Cox-2 were measured using enzyme linked immunosorbent assay (ELISA). The VAS scores and the release of pro-inflammatory cytokines in the PRE and INTRA groups were less than those in the control group at T1, T2 and T3. The MMSE scores in PRE and INTRA groups were significantly higher than those in the control group at T1, T2 and T3. The PRE group showed a lower VAS score, release of pro-inflammatory cytokines and higher MMSE scores at T1, T2 and T3 than the control and INTRA groups. Intravenous flurbiprofen administration reduces postoperative pain and flammatory response after hip arthroplasty. Moreover, flurbiprofen is more effective when given preoperatively than intraoperatively.
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Affiliation(s)
- Zhi-Jun Zhou
- The Second People's Hospital of Nantong, Nantong, Jiangsu 226002, P.R. China
| | - Jian Tang
- The Second People's Hospital of Nantong, Nantong, Jiangsu 226002, P.R. China
| | - Wei-Hua Li
- The Second People's Hospital of Nantong, Nantong, Jiangsu 226002, P.R. China
| | - Wei-Dong Tao
- The Second People's Hospital of Nantong, Nantong, Jiangsu 226002, P.R. China
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Videla S, Lahjou M, Vaqué A, Sust M, Escriche M, Soler L, Sans A, Sicard E, Gascón N, Encina G, Plata-Salamán C. Pharmacokinetics of multiple doses of co-crystal of tramadol-celecoxib: findings from a four-way randomized open-label phase I clinical trial. Br J Clin Pharmacol 2017; 84:64-78. [PMID: 28888220 PMCID: PMC5736845 DOI: 10.1111/bcp.13428] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/19/2017] [Accepted: 09/03/2017] [Indexed: 01/01/2023] Open
Abstract
Aim We compared the pharmacokinetic (PK) profiles of co‐crystal of tramadol–celecoxib (CTC) vs. each reference product (alone and in open combination) after single (first dose) and multiple dosing. Methods Healthy adults aged 18–50 years received, under fasted conditions, 15 twice‐daily doses of the following treatments (separated by ≥14‐day washout): 200 mg immediate‐release (IR) CTC (equivalent to 88 mg tramadol and 112 mg celecoxib; treatment 1); 100 mg IR tramadol (treatment 2), 100 mg celecoxib (treatment 3); and 100 mg IR tramadol and 100 mg celecoxib (treatment 4). The treatment sequence was assigned by computer‐generated randomization. PK parameters were calculated using non‐compartmental analysis. Parameters for CTC were adjusted according to reference product dose. Results A total of 30 subjects (20 males, mean age 35 years) were included. Multiple‐dose tramadol PK parameters for treatments 1, 2 and 4, respectively, were 551, 632 and 661 ng ml−1 [mean maximum plasma concentration (Cmax)]; 4796, 4990 and 5284 ng h ml−1 (area under the plasma concentration–time curve over the dosing interval at steady state); and 3.0, 2.0 and 2.0 h (median time to Cmax at steady state). For treatments 1, 3 and 4, multiple‐dose celecoxib PK parameters were 445, 536 and 396 ng ml−1; 2803, 3366 and 2897 ng h ml−1; and 2.0, 2.0 and 3.0 h. Single‐dose findings were consistent with multiple‐dose data. Types of adverse events were consistent with known reference product safety profiles. Conclusion After single (first dose) and multiple dosing, PK parameters for each active pharmaceutical ingredient in CTC were modified by co‐crystallization compared with reference products alone or in open combination.
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Affiliation(s)
| | | | - Anna Vaqué
- Laboratorios del Dr. Esteve, S.A.U., Barcelona, Spain
| | - Mariano Sust
- Laboratorios del Dr. Esteve, S.A.U., Barcelona, Spain
| | | | - Lluis Soler
- Laboratorios del Dr. Esteve, S.A.U., Barcelona, Spain
| | - Artur Sans
- Laboratorios del Dr. Esteve, S.A.U., Barcelona, Spain
| | | | - Neus Gascón
- Laboratorios del Dr. Esteve, S.A.U., Barcelona, Spain
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Jahr JS, Bergese SD, Sheth KR, Bernthal NM, Ho HS, Stoicea N, Apfel CC. Current Perspective on the Use of Opioids in Perioperative Medicine: An Evidence-Based Literature Review, National Survey of 70,000 Physicians, and Multidisciplinary Clinical Appraisal. PAIN MEDICINE 2017; 19:1710-1719. [DOI: 10.1093/pm/pnx191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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9
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Camu F, Borgeat A, Heylen RJ, Viel EJ, Boye ME, Cheung RY. Parecoxib, propacetamol, and their combination for analgesia after total hip arthroplasty: a randomized non-inferiority trial. Acta Anaesthesiol Scand 2017; 61:99-110. [PMID: 27900763 DOI: 10.1111/aas.12841] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 10/27/2016] [Accepted: 10/31/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study assessed non-inferiority of parecoxib vs. combination parecoxib+propacetamol and compared the opioid-sparing effects of parecoxib, propacetamol, and parecoxib+propacetamol vs. placebo after total hip arthroplasty. METHODS In this randomized, placebo-controlled, parallel-group, non-inferiority study, patients received one of four IV treatments after surgery: parecoxib 40 mg bid (n = 72); propacetamol 2 g qid (n = 71); parecoxib 40 mg bid plus propacetamol 2 g qid (n = 72); or placebo (n = 38) with supplemental IV patient-controlled analgesia (morphine). Patients and investigators were blinded to treatment. Pain intensity at rest and with movement was assessed regularly, together with functional recovery (modified Brief Pain Inventory-Short Form) and opioid-related side effects (Opioid-Related Symptom Distress Scale) questionnaires up to 48 h. RESULTS After 24 h, cumulative morphine consumption was reduced by 59.8% (P < 0.001), 38.9% (P < 0.001), and 26.8% (P = 0.005) in the parecoxib+propacetamol, parecoxib, and propacetamol groups, respectively, compared with placebo. Parecoxib did not meet criteria for non-inferiority to parecoxib+propacetamol. Parecoxib+propacetamol and parecoxib significantly reduced least-squares mean pain intensity scores at rest and with movement compared with propacetamol (P < 0.05). One day after surgery, parecoxib+propacetamol significantly reduced opioid-related symptom distress and decreased pain interference with function compared with propacetamol or placebo. CONCLUSION Parecoxib and parecoxib+propacetamol provided significant opioid-sparing efficacy compared with placebo; non-inferiority of parecoxib to parecoxib+propacetamol was not demonstrated. Opioid-sparing efficacy was accompanied by significant reductions in pain intensity on movement, improved functional outcome, and less opioid-related symptom distress. Study medications were well tolerated.
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Affiliation(s)
- F. Camu
- Department of Anesthesiology; University of Brussels; Brussels Belgium
| | - A. Borgeat
- Department of Anesthesiology; Uniklinik Balgrist; Zurich Switzerland
| | - R. J. Heylen
- Department of Anesthesia, Intensive Care, Emergency Care and the Multidisciplinary Pain Centre; Ziekenhuis Oost-Limburg; Genk Belgium
| | - E. J. Viel
- Department Anesthesiology-Intensive Care, Emergency Medicine and Pain Management; Pain Clinic; Regional University Hospital Caremeau Nîmes and Faculty of Medicine of Montpellier-Nîmes; Montpellier-Nîmes France
| | - M. E. Boye
- Outcomes Research; Pfizer Inc; Ann Arbor MI USA
| | - R. Y. Cheung
- Global Medical Team; Pfizer Inc; New York NY USA
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Gan TJ, Singla N, Daniels SE, Hamilton DA, Lacouture PG, Reyes CR, Carr DB. Postoperative opioid sparing with injectable hydroxypropyl-β-cyclodextrin-diclofenac: pooled analysis of data from two Phase III clinical trials. J Pain Res 2016; 10:15-29. [PMID: 28053554 PMCID: PMC5191619 DOI: 10.2147/jpr.s106578] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose Use of nonopioid analgesics (including nonsteroidal anti-inflammatory drugs) for postoperative pain management can reduce opioid consumption and potentially prevent opioid-related adverse events. This study examined the postoperative opioid-sparing effect of repeated-dose injectable diclofenac formulated with hydroxypropyl-β-cyclodextrin (HPβCD)-diclofenac. Patients and methods Pooled data from two double-blind, randomized, placebo- and active comparator-controlled Phase III trials were analyzed. Patients received HPβCD-diclofenac, placebo, or ketorolac by intravenous injection every 6 hours for up to 5 days following abdominal/pelvic or orthopedic surgery. Rescue opioid use was evaluated from the time of first study drug administration to up to 120 hours following the first dose in the overall study population and in subgroups defined by baseline pain severity, age, and HPβCD-diclofenac dose. Results Overall, 608 patients received ≥1 dose of study medication and were included in the analysis. While 93.2% of patients receiving placebo required opioids, the proportion of patients requiring opioids was significantly lower for patients receiving HPβCD-diclofenac (18.75, 37.5, or 50 mg) or ketorolac (P<0.005 for all comparisons). Mean cumulative opioid dose and number of doses were significantly lower among patients receiving HPβCD-diclofenac versus placebo for the 0–24 through 0–120 hour time periods (P<0.0001), as well as versus ketorolac for the 0–72 through 0–120 hour time periods (P<0.05). HPβCD-diclofenac significantly reduced opioid consumption versus placebo in subgroups based on baseline pain severity (moderate, severe) and age (<65 years, ≥65 years) from the 0–24 hour period onward. When compared to ketorolac, HPβCD-diclofenac also significantly reduced cumulative opioid consumption among patients with moderate baseline pain (0–72 through 0–120 hours) and opioid dose number among patients ≥65 years old (0–24 through 0–120 hours). Conclusion HPβCD-diclofenac can reduce postoperative opioid requirements. As this analysis was not powered to compare opioid-related adverse event rates, follow-up studies examining the clinical impact of HPβCD-diclofenac’s opioid sparing are warranted.
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Affiliation(s)
- Tong J Gan
- Department of Anesthesiology, Stony Brook University, NY
| | | | | | - Douglas A Hamilton
- Javelin Pharmaceuticals, Inc., Cambridge, MA; New Biology Ventures, LLC, San Mateo, CA
| | - Peter G Lacouture
- Magidom Discovery, LLC, St Augustine, FL; Department of Emergency Medicine, Brown University School of Medicine, Providence, RI
| | | | - Daniel B Carr
- Javelin Pharmaceuticals, Inc., Cambridge, MA; Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
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Abstract
Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.
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Affiliation(s)
- Peter J. S. Koo
- Departments of Clinical Pharmacy and Pharmaceutical Services, University of California, San Francisco, San Francisco, California
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12
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Loxoprofen sodium and celecoxib for postoperative pain in patients after spinal surgery: a randomized comparative study. J Orthop Sci 2015; 20:617-23. [PMID: 25911562 DOI: 10.1007/s00776-015-0726-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/07/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to treat inflammation, pain, and fever, but no criterion standard exists for the management of postoperative pain following spinal surgery. In the present study, we compared the analgesic efficacy of loxoprofen sodium (loxoprofen) and celecoxib for the management of postoperative pain following spinal surgery. METHODS One-hundred forty-one patients (mean age 62.2 years) were randomly assigned to two groups before spinal surgery: a loxoprofen group (n = 73, 180 mg/day) and a celecoxib group (n = 68, 200 mg/day). The drugs were administered from 1 day until 7 days after surgery. A numeric rating scale (NRS) was used to evaluate pain at nine predefined times every day and the findings were compared between the two groups. Laboratory data and adverse events were also recorded. RESULTS There was no significant difference in the maximum and mean NRS scores on each day between loxoprofen and celecoxib, suggesting a comparable analgesic effect for these two NSAIDs. Greater improvement in the NRS score between preadministration (baseline) and 30 min or 2 h after administration was obtained for loxoprofen. This tendency was shown for both slight (NRS score <5 at baseline) and severe pain (NRS score ≥ 5 at baseline). Loxoprofen was discontinued in one patient on day 4 because of renal dysfunction. Celecoxib was discontinued in one patient on day 2 at the patient's request. CONCLUSIONS Both loxoprofen sodium and celecoxib were well tolerated for the relief of acute postoperative pain after spinal surgery. A single administration of loxoprofen showed superior and rapid effectiveness compared with celecoxib for both slight and severe postoperative pain.
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Højer Karlsen AP, Geisler A, Petersen PL, Mathiesen O, Dahl JB. Postoperative pain treatment after total hip arthroplasty. Pain 2015; 156:8-30. [DOI: 10.1016/j.pain.0000000000000003] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Perioperative analgesia outcomes and strategies. Best Pract Res Clin Anaesthesiol 2014; 28:105-15. [DOI: 10.1016/j.bpa.2014.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 04/16/2014] [Accepted: 04/28/2014] [Indexed: 11/18/2022]
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Singla NK, Desjardins PJ, Chang PD. A comparison of the clinical and experimental characteristics of four acute surgical pain models: Dental extraction, bunionectomy, joint replacement, and soft tissue surgery. Pain 2014; 155:441-456. [DOI: 10.1016/j.pain.2013.09.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/27/2013] [Accepted: 09/02/2013] [Indexed: 11/30/2022]
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16
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Inal S, Kabay S, Cayci MK, Kuru HI, Altikat S, Akkas G, Deger A. Comparison of the effects of dexketoprofen trometamol, meloxicam and diclofenac sodium on fibular fracture healing, kidney and liver: an experimental rat model. Injury 2014; 45:494-500. [PMID: 24246878 DOI: 10.1016/j.injury.2013.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 08/08/2013] [Accepted: 10/04/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Nonsteroidal anti-inflammatory drugs (NSAIDs) are particularly used in patients with bone fractures, but there are limited studies on whether one NSAID is superior to another. In this study, we used histopathological and biochemical parameters to determine whether there are differences between the effects of the administration of clinical doses of dexketoprofen trometamol (DEXT), meloxicam (MEL) and diclofenac sodium (DIC) on the healing of closed fibular fractures and the toxicity of both the liver and kidney. METHODS Twenty-eight male Sprague-Dawley rats were randomly divided into four groups of seven each. Closed diaphyseal fractures were formed in the left fibulas of all of the rats. The NSAIDs dexketoprofen trometamol (DEXT) (Arveles(®)), meloxicam (MEL) (Melox(®)) and diclofenac sodium (DIC) (Voltaren(®)) were intramuscularly administered to Groups I, II, and III, respectively, for a period of 10 days after the fibular fractures were performed. No pharmacological agents were administered to Group IV (Control group). Blood samples were collected from all of the rats after the fractures were performed, and the rats were sacrificed on day 28. The histopathological findings were compared, and the blood samples were evaluated to determine any differences between the levels of superoxide dismutase (SOD), catalase (CAT), and malondialdehyde (MDA). RESULTS Our results suggest that DEXT and MEL impair the healing of bone fractures and that DIC does not histopathologically affect the healing process of bone fractures. We also found that DEXT, MEL, and DIC impaired the renal histopathology compared with the control group. However, the liver histopathological analysis showed that DEXT and MEL caused a higher degree of parenchymal necrosis compared with DIC. CONCLUSION Based on our results, DIC can be considered a relatively safe medication in patients with fractures.
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Affiliation(s)
- Sermet Inal
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - Sahin Kabay
- Department of Urology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - M Kasim Cayci
- Department of Biology, Faculty of Arts and Science, Dumlupinar University, Kutahya, Turkey.
| | - H Isa Kuru
- Department of Medical Laboratory Techniques, Simav Vocational High School, Dumlupinar University, Turkey.
| | - Sayit Altikat
- Department of Biochemistry, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - Gizem Akkas
- Department of Pathology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - Aysenur Deger
- Department of Pathology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
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Abstract
Cyclooxygenase-2 specific inhibitors have anti-inflammatory and analgesic properties, and are effective in managing a wide range of chronic and acute painful conditions such as adult rheumatoid arthritis, osteoarthritis, migraine, primary dysmenorrhea and postoperative pain. Valdecoxib, an orally administered cyclooxygenase-2 specific inhibitor, provides effective pain relief for both chronic and acute conditions, and reduces postoperative opioid use, with a concomitant reduction in opioid-related adverse events. Valdecoxib also has superior gastrointestinal safety compared with nonspecific nonsteroidal anti-inflammatory drugs, and at therapeutic doses, it is generally safe and well tolerated in terms of renal and cardiovascular events. This drug profile reviews the efficacy, safety and tolerability of valdecoxib for the management of chronic and acute pain.
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Affiliation(s)
- Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 9068, USA.
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Atukorala I, Hunter DJ. Valdecoxib: the rise and fall of a COX-2 inhibitor. Expert Opin Pharmacother 2013; 14:1077-86. [DOI: 10.1517/14656566.2013.783568] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Leese PT, Recker DP, Kent JD. The COX-2 Selective Inhibitor, Valdecoxib, Does Not Impair Platelet Function in the Elderly: Results of a Randomized Controlled Trial. J Clin Pharmacol 2013. [DOI: 10.1177/0091270003252234] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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20
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Abstract
Chronic instability of the ankle and anterolateral impingement syndrome are abnormalities that present as a result of inversion and forced plantar-flexion traumas of the foot, despite strict conservative management in the ER and in rehabilitation. A conservative approach is always the first choice of treatment, including anti-inflammatory medications, rehabilitation and proprioception, infiltration with steroids in impingement cases, and use of orthotics, whose true effectiveness is the subject of multiple studies and much debate. Good to excellent results can be obtained surgically with a minimally invasive approach, such as the arthroscopic technique presented herein. Such an approach is useful in managing a combination of conditions such as anterolateral impingement, synovitis, and osteochondral lesions of the talus. The method is easily reproducible, its learning curve is rapid, and it has the advantage of not preventing the use other arthroscopic methods, or open anatomic or nonanatomic methods (tendon transfers), in the case of failure. No nerve lesion was recorded, probably owing to the use of the security zone, and neither was there any arthrofibrosis, possibly related to the use of nonsteroidal anti-inflammatory medications in the immediate postsurgical period coupled with aggressive rehabilitation from the fourth week. The success of the technique is due to multidisciplinary team work leading to the ultimate achievement of patient satisfaction. This technique is not indicated for patients with a high sports demand or for sport professionals, until further biomechanical studies on its use and success are completed.
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Abstract
BACKGROUND Periprocedural analgesic therapy is an often overlooked, but critical component of ensuring adequate surgical patient care and overall satisfaction with surgical outcomes. Adequate pain management requires thorough assessment of pain and complete knowledge and understanding of the various therapeutic agents available. OBJECTIVES To further the knowledge and understanding of current strategies in pain management. METHODS A literature review was conducted through PubMed to define current pain assessment and management strategies. RESULTS AND CONCLUSIONS Appropriate pain assessment leads to the selection of optimal pharmacologic options for pain control in the acute postoperative setting.
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Affiliation(s)
- Lana N Kashlan
- Department of Dermatology, Boston University, Boston, Massachusetts 02118, USA.
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22
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Desai VN, Cheung EV. Postoperative pain associated with orthopedic shoulder and elbow surgery: a prospective study. J Shoulder Elbow Surg 2012; 21:441-50. [PMID: 22192767 DOI: 10.1016/j.jse.2011.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 09/20/2011] [Accepted: 09/24/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the last 2 decades, extensive research in postoperative pain management has been undertaken to decrease morbidity. Orthopedic procedures tend to have increased pain compared with other procedures, but further research must be done to manage pain more efficiently. Postoperative pain morbidities and analgesic dependence continue to adversely affect health care. MATERIALS AND METHODS The study assessed the pain of 78 elbow and shoulder surgery patients preoperatively and postoperatively using the Short-Form McGill Pain Questionnaire (SF-MPQ). Preoperatively, each patient scored their preoperative pain (PP) and anticipated postoperative pain (APP). Postoperatively, they scored their 3-day (3dpp) and 6-week postoperative pain (6wpp). The pain intensities at these 4 intervals were then compared and analyzed using Pearson coefficients. RESULTS APP and PP were strong predictors of postoperative pain. The average APP was higher than the average postoperative pain. The 6wpp was significantly lower than the 3dpp. Sex, chronicity, and type of surgery were not significant factors; however, the group aged 18 to 39 years had a significant correlation with postoperative pain. CONCLUSION PP and APP were both independent predictors of increased postoperative pain. PP was also predictive of APP. Although, overall postoperative pain was lower than APP or PP due to pain management techniques, postoperative pain was still significantly higher in patients with increased APP or PP than their counterparts. Therefore, surgeons should factor patient's APP and PP to better manage their patient's postoperative pain to decrease comorbidities.
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Affiliation(s)
- Vimal N Desai
- Department of Orthopedic Surgery, Stanford University Medical Center, Redwood City, CA 94063, USA
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23
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Abdulla S, Netter U, Abdulla W. Efficacy of Non-Opioid Analgesics on Opioid Consumption for Postoperative Pain Relief After Abdominal Hysterectomy. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Susanne Abdulla
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Bernburg Teaching Hospital, Martin Luther University Halle-Wittenberg, Bernburg, Germany
| | - Ute Netter
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Bernburg Teaching Hospital, Martin Luther University Halle-Wittenberg, Bernburg, Germany
| | - Walied Abdulla
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Bernburg Teaching Hospital, Martin Luther University Halle-Wittenberg, Bernburg, Germany
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Chandrakantan A, Glass PSA. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth 2012; 107 Suppl 1:i27-40. [PMID: 22156268 DOI: 10.1093/bja/aer358] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.
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Affiliation(s)
- A Chandrakantan
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA.
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25
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Pountos I, Georgouli T, Calori GM, Giannoudis PV. Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. ScientificWorldJournal 2012; 2012:606404. [PMID: 22272177 PMCID: PMC3259713 DOI: 10.1100/2012/606404] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 10/18/2011] [Indexed: 12/21/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) play an essential part in our approach to control pain in the posttraumatic setting. Over the last decades, several studies suggested that NSAIDs interfere with bone healing while others contradict these findings. Although their analgesic potency is well proven, clinicians remain puzzled over the potential safety issues. We have systematically reviewed the available literature, analyzing and presenting the available in vitro animal and clinical studies on this field. Our comprehensive review reveals the great diversity of the presented data in all groups of studies. Animal and in vitro studies present so conflicting data that even studies with identical parameters have opposing results. Basic science research defining the exact mechanism with which NSAIDs could interfere with bone cells and also the conduction of well-randomized prospective clinical trials are warranted. In the absence of robust clinical or scientific evidence, clinicians should treat NSAIDs as a risk factor for bone healing impairment, and their administration should be avoided in high-risk patients.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS1 3EX, UK
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26
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27
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Langford RM, Joshi GP, Gan TJ, Mattera MS, Chen WH, Revicki DA, Chen C, Zlateva G. Reduction in Opioid-Related Adverse Events and Improvement in Function with Parecoxib followed by Valdecoxib Treatment after Non-Cardiac Surgery. Clin Drug Investig 2009; 29:577-90. [DOI: 10.2165/11317570-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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28
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Abstract
Multimodal analgesia incorporates the use of analgesic adjuncts with different mechanisms of action to enhance postoperative pain management. Acetaminophen, anti-inflammatories, and gabapentinoids provide effective analgesia while reducing opioid requirements and opioid-related side effects. Intrathecal morphine and periarticular local anesthetic infiltration further enhance dynamic analgesia and improve postoperative mobilization. Epidural analgesia, peripheral nerve blocks, tramadol, ketamine, and/or clonidine can be added for improved benefit in opioid-tolerant individuals.
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29
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Agnihotri SM, Vavia PR. Pharmacokinetics of intramuscular microparticle depot of valdecoxib in an experimental model. Drug Dev Ind Pharm 2009; 35:1043-7. [PMID: 19365783 DOI: 10.1080/03639040902762979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM We did a prospective study to investigate pharmacokinetics of a single intramuscularly (i.m.) administered Valdecoxib (VC) polymeric microparticles in New Zealand white rabbits. METHOD Poly[lac(glc-leu)] microparticles encapsulating a potent cyclooxygenase-2- selective inhibitor, VC, were prepared by emulsion and solvent evaporation technique and administered i.m. to rabbits for pharmacokinetic study. RESULTS A single i.m. dose of drug-loaded poly[lac(glc-leu)] microparticles resulted in sustained therapeutic drug levels in the plasma for 49 days. The relative bioavailability was increased severalfold as compared with unencapsulated drug. CONCLUSIONS Injectable poly[lac(glc-leu)] microparticles hold promise for increasing drug bioavailability and reducing dosing frequency for better management of rheumatoid arthritis.
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Affiliation(s)
- Sagar M Agnihotri
- Pharmaceutical Division, Institute of Chemical Technology, University of Mumbai, Matunga, Mumbai, India.
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30
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Abstract
Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. Surgical options that adequately reduce pain are intra-articular injection of local anaesthetics alone or in combination with opioids and cooling and physiotherapeutic treatment regimens after joint procedures. There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.
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Affiliation(s)
- C J P Simanski
- Klinik für Unfallchirurgie, Orthopädie und Sporttraumatologie Köln-Merheim, Lehrstuhl für Unfallchirurgie und Orthopädie der Universität Witten-Herdecke, Ostmerheimer Strasse 200, 51109, Köln, Deutschland.
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31
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Cardiovascular safety of the cyclooxygenase-2 selective inhibitors parecoxib and valdecoxib in the postoperative setting: an analysis of integrated data. Anesth Analg 2009; 108:299-307. [PMID: 19095866 DOI: 10.1213/ane.0b013e31818ca3ac] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Studies of parecoxib, the inactive prodrug of the cyclooxygenase-2 selective inhibitor valdecoxib, and valdecoxib for postoperative pain relief in patients undergoing coronary artery bypass graft surgery revealed an increased risk of cardiovascular (CV) adverse events compared with placebo. We conducted this study to address whether parecoxib and valdecoxib increased CV risk in noncardiac surgery patients. METHODS A pooled post hoc analysis was conducted using 2 large datasets: 17 controlled trials of parecoxib for noncardiac studies and 32 studies, including the 17 noncardiac parecoxib studies plus 15 studies of valdecoxib. The 32-study dataset provided 95% power to detect a twofold increase in the incidence of CV adverse events assuming a placebo group incidence of 1% (estimated from previous study data), and 69% power to detect a twofold increase from a 0.5% incidence. RESULTS The incidence of total CV events for the 17 parecoxib studies was 0.44% (13 of 2966) in patients who received parecoxib and 0.37% (7 of 1915) in those receiving placebo (P > 0.20). In the analysis of 32 studies, the incidence of total CV events was 0.40% (21 of 5285) in the parecoxib/valdecoxib group compared with 0.50% (16 of 3226) in the placebo group (P > 0.20). No significant differences in the incidence of total or any individual CV event category were observed between the parecoxib or parecoxib/valdecoxib and placebo groups in the two analyses. When patients were stratified by number of baseline CV risk factors, no significant difference in CV events was detected in parecoxib/valdecoxib patients compared with placebo. CONCLUSIONS In the largest analysis of the CV risk of cyclooxygenase selective inhibitors or nonsteroidal antiinflammatory drugs for perioperative pain management, parecoxib and valdecoxib were not found to increase the risk of CV adverse events after noncardiac surgery.
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Chou LB, Wagner D, Witten DM, Martinez-Diaz GJ, Brook NS, Toussaint M, Carroll IR. Postoperative pain following foot and ankle surgery: a prospective study. Foot Ankle Int 2008; 29:1063-8. [PMID: 19026197 PMCID: PMC2743476 DOI: 10.3113/fai.2008.1063] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic procedures have been reported to have the highest incidence of pain compared to other types of operations. There are limited studies in the literature that investigate postoperative pain. MATERIALS AND METHODS A prospective study of 98 patients undergoing orthopedic foot and ankle operations was undertaken to evaluate their pain experience. A Short-Form McGill Pain Questionnaire (SF-MPQ) was administered preoperatively and postoperatively. RESULTS The results showed that patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. Patients, on average, experienced higher pain intensity 3 days after the operation than anticipated. The postoperative pain intensity at 3 days was the most severe, while postoperative pain intensity at 6 weeks was the least severe. Age, gender and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced. Six weeks following the operation, the majority of patients felt no pain. In addition, the severity of preoperative pain was highly predictive of their anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predict higher immediate postoperative pain. CONCLUSION The intensity of patients' preoperative pain was predictive of the anticipated postoperative pain. Patients' preoperative pain and anticipated postoperative pain were independently predictive of the 3-day postoperative pain. The higher pain intensity a patient experienced preoperatively suggested that their postoperative pain severity would be greater. Therefore, surgeons should be aware of these findings when treating postoperative pain after orthopaedic foot and ankle operations.
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Ranawat CS, Ranawat AS, Parvataneni HK. How I Manage Pain After Total Knee Replacement. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.sart.2008.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pountos I, Georgouli T, Blokhuis TJ, Pape HC, Giannoudis PV. Pharmacological agents and impairment of fracture healing: what is the evidence? Injury 2008; 39:384-94. [PMID: 18316083 DOI: 10.1016/j.injury.2007.10.035] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 10/31/2007] [Accepted: 10/31/2007] [Indexed: 02/08/2023]
Abstract
Bone healing is an extremely complex process which depends on the coordinated action of several cell lineages on a cascade of biological events, and has always been a major medical concern. The use of several drugs such as corticosteroids, chemotherapeutic agents, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, anticoagulants and drugs which reduce osteoclastic activity have been shown to affect bone healing. This review article presents our current understanding on this topic, focusing on data illustrating the effect of these drugs on fracture healing and bone regeneration.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK
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Abstract
Minimally invasive hip surgery has stimulated a new process in hip arthroplasty. There is consensus among surgeons about the benefits of anesthesia, pain management, and rapid recovery protocols. The benefits of the surgical technique for small incision surgery remain controversial. Some patients influence this controversy because they prefer minimally invasive hip surgery: they associate less body violation and better cosmesis with smaller incisions. Small incision surgery is associated with a learning curve and requires specialized instruments for favorable outcomes. Despite being a more difficult operation to perform, in skilled hands it is a safe procedure that does not increase complication rates as shown by recent prospective, randomized studies. Correct component positioning has been achieved consistently with these procedures and short-term results of small incision surgery are the same as with long incisions. New anesthesia and pain management techniques have led to remarkable early functional results, making same-day surgery possible. With improved instrumentation such as computer navigation, minimally invasive total hip arthroplasty will become more prevalent.
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Affiliation(s)
- Aamer Malik
- Arthritis Institute, 501 E. Hardy Street, Inglewood, CA 90301, USA
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36
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Desjardins PJ, Black PM, Daniels SE, Bird SR, Petruschke RA, Chang DJ, Smugar SS, Tershakovec AM. A double-blind randomized controlled trial of rofecoxib and multidose oxycodone/acetaminophen in dental impaction pain. J Oral Maxillofac Surg 2007; 65:1624-32. [PMID: 17656293 DOI: 10.1016/j.joms.2006.06.268] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2005] [Revised: 05/22/2006] [Accepted: 06/09/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Paul J Desjardins
- Clinical Research and Clinical Site Operations, SCIREX Clinical Research Centers, Austin, TX 78705, USA.
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Martinez V, Belbachir A, Jaber A, Cherif K, Jamal A, Ozier Y, Sessler DI, Chauvin M, Fletcher D. The influence of timing of administration on the analgesic efficacy of parecoxib in orthopedic surgery. Anesth Analg 2007; 104:1521-7, table of contents. [PMID: 17513652 PMCID: PMC2564988 DOI: 10.1213/01.ane.0000262039.69513.9d] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Parecoxib, a selective cyclooxygenase-2 inhibitor, may reduce postoperative pain without increasing bleeding when administered before surgery. METHODS We randomly assigned 62 patients scheduled for total hip arthroplasty to the following IV dosing schedule: 1) placebo at induction, at wound closure, and 12 h after induction (control); 2) parecoxib 40 mg at induction, placebo at wound closure, and parecoxib 40 mg 12 h after induction (pre); or, 3) placebo at induction, parecoxib 40 mg at wound closure, and parecoxib 40 mg 12 h after induction (post). Pain scores at rest and with movement were recorded every 4 h for 24 h using a visual analog scale. Treatment side effects were recorded every 4 h. Red cell loss for 5 days after surgery was calculated. RESULTS Postoperative pain scores were less in the pre and post groups than in the control group. Postoperative bleeding was similar in the three groups. There were no significant differences between the pre and post groups, nor was their any trend suggesting a preemptive analgesic efficacy from preincision administration of parecoxib. Morphine use in the Postanesthesia Care Unit was reduced in the pre and post groups compared with the control group (14.2 +/- 2.0, and 15.7 +/- 2.0, vs 20.4 +/- 2.3 mg), although the trend was only significant (P < 0.05) in the pre group. The first pain score was also reduced in the pre and post groups compared to the control group (56.1 +/- 7.5 and 64.2 +/- 7.0 vs 78.3 +/- 5), but this was also only significant for the pre group (P = 0.001). The delay for first analgesic demand was increased for both the pre and post group compared to the control group (38 +/- 9 and 28.2 +/- 6.6 vs 18 +/- 6 min) but, again, this was only significant for the pre group (P = 0.05). Twenty-four hour consumption of morphine was similar in the pre (26 +/- 12 mg) and post groups (25 +/- 13 mg); both were significantly less than in the control group (47 +/- 27 mg, P < 0.001). CONCLUSIONS Administration of parecoxib before hip arthroplasty did not provide preemptive analgesia. There was a trend towards improved analgesia immediately after surgery with preincision administration, consistent with the expected time course of nonsteroidal antiinflammatory drug's effect. Perioperative parecoxib administration, consisting of two injections spaced 12 h apart, improved postoperative analgesia over the first 24 h without increasing bleeding.
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Affiliation(s)
- Valéria Martinez
- Service d'anesthésie
AP-HPHôpital Raymond Poincaré92380 Garches,FR
| | - Anissa Belbachir
- Service de réanimation médicale polyvalente
AP-HPHôpital CochinUniversité Paris Descartes - Paris V27 rue du Faubourg St Jacques
75014 Paris,FR
| | - Aithem Jaber
- Service d'anesthésie
AP-HPHôpital Raymond Poincaré92380 Garches,FR
| | - Kamel Cherif
- Service d'anesthésie
AP-HPHôpital Raymond Poincaré92380 Garches,FR
| | - Adel Jamal
- Service d'anesthésie
AP-HPHôpital Raymond Poincaré92380 Garches,FR
| | - Yves Ozier
- Service de réanimation médicale polyvalente
AP-HPHôpital CochinUniversité Paris Descartes - Paris V27 rue du Faubourg St Jacques
75014 Paris,FR
| | - Daniel I. Sessler
- Department of OUTCOMES RESEARCH
OUTCOMES RESEARCH InstituteUniversity of LouisvilleThe Cleveland ClinicUS
| | - Marcel Chauvin
- Service d'anesthésie
AP-HPHôpital Raymond Poincaré92380 Garches,FR
| | - Dominique Fletcher
- Service d'anesthésie
AP-HPHôpital Raymond Poincaré92380 Garches,FR
- * Correspondence should be adressed to: Dominique Fletcher
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Diaz JA, Cuervo C, Valderrama AM, Kohles J. Valdecoxib provides effective pain relief following acute ankle sprain. J Int Med Res 2007; 34:456-67. [PMID: 17133774 DOI: 10.1177/147323000603400502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We sought to determine whether valdecoxib is as effective as diclofenac in treating acute ankle sprain. Patients (n=202) with acute first- and second-degree ankle sprain were randomized to valdecoxib (40 mg twice daily on day 1 followed by 40 mg once daily on days 2-7) or diclofenac (75 mg twice daily). The primary efficacy end-point was the Patient's Assessment of Ankle Pain visual analogue scale (VAS, 0-100 mm) value on day 4. Valdecoxib was as efficacious as diclofenac in treating the signs and symptoms of acute ankle sprain. The mean VAS reduction in ankle pain on day 4 was not different between groups; the two-sided 95% confidence interval for the between-group difference was within the prespecified limit for non-inferiority (10 mm). There were no significant differences between groups for all secondary efficacy end-points. The two treatments were similarly effective and well tolerated for treatment of acute ankle sprain.
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Affiliation(s)
- J A Diaz
- Clínica de Fracturas de Medellín, Medellin, Colombia
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Ximenes A, Robles M, Sands G, Vinueza R. Valdecoxib Is as Efficacious as Diclofenac in the Treatment of Acute Low Back Pain. Clin J Pain 2007; 23:244-50. [PMID: 17314584 DOI: 10.1097/ajp.0b013e31802f67c6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the efficacy of valdecoxib 40 mg q.d. (with a second dose on day 1) with diclofenac 75 mg b.i.d. in the treatment of acute low back pain. METHODS This was a multicenter, randomized, double-blind study. Patients with acute low back pain, class 1a or 2a (Quebec Task Force), with a visual analog scale score >/=50 mm (on a 100-mm scale) and moderate to severe pain on a categorical scale, were randomized to valdecoxib 40 mg q.d. (with a second dose on day 1) or diclofenac 75 mg b.i.d. for 7 days (170 patients per group). The primary efficacy end point was change in pain intensity (visual analog scale, mm) from baseline to day 3 for the per-protocol population. RESULTS Least squares mean reductions in pain intensity from baseline to day 3 were similar for valdecoxib (-42.02 mm) and diclofenac (-41.43 mm). Valdecoxib was comparable to diclofenac as the lower limit of the 95% confidence interval of the estimated difference (0.59 mm; 95% confidence interval, -3.40 to 4.59 mm) was within the prespecified noninferiority margin of -10 mm. The overall incidence of adverse events was similar for valdecoxib (28%) and diclofenac (26%). No statistically different moderate or severe upper gastrointestinal adverse events were reported, although they were numerically greater for diclofenac (8) than for valdecoxib (3). DISCUSSION Valdecoxib 40 mg q.d. (with a second dose on day 1) provides effective relief for acute low back pain, and was at least as efficacious as diclofenac 75 mg b.i.d., with a nonsignificant but numerically lower incidence of gastrointestinal adverse events.
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Affiliation(s)
- Antonio Ximenes
- Department of Internal Medicine, Division of Rheumatology, Hospital Geral de Goiânia, Goiânia, GO, Brazil
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Moskowitz RW, Sunshine A, Hooper M, Olson NZ, Cawkwell GD. An analgesic model for assessment of acute pain response in osteoarthritis of the knee. Osteoarthritis Cartilage 2006; 14:1111-8. [PMID: 16784879 DOI: 10.1016/j.joca.2006.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 05/09/2006] [Indexed: 02/02/2023]
Abstract
BACKGROUND Osteoarthritis (OA) is frequently treated only during periods of flare, in which rapid onset of analgesia is the outcome target. OBJECTIVE To assess an acute pain model of knee OA in flare. METHODS In a multicenter, randomized, double-blind, controlled study, 530 patients aged >or=50 years received valdecoxib 10 mg qd (n=212), rofecoxib 2 5 mg qd (n=208), or placebo (n=110). Pain intensity (PI) was measured on a visual analog scale (VAS) at baseline after a 10-min walk. Patients took their first dose of study medication, rested for 20 min, then measured their PI VAS at 0.5, 1, 1.5, 2, 3, 4, 5, and 6h, each time following a 10-min walk. RESULTS PI VAS differences (PID) were significantly greater vs placebo both with valdecoxib and rofecoxib (P<0.05) beginning as early as 3h (intent-to-treat population). The percentage of patients with analgesia onset from 4h was significantly higher with both valdecoxib (55%) and rofecoxib (56%) relative to placebo (40%). Median time to first onset of analgesic was shorter with both valdecoxib and rofecoxib compared with placebo (P=0.104 vs valdecoxib; P=0.036 vs rofecoxib). CONCLUSIONS This acute pain model of knee OA flare detected significant pain relief with agents known to relieve pain in OA and placebo within hours after the first treatment dose, allowing assessment of pain relief within hours rather than days or weeks when evaluating analgesic efficacy in OA. This model is undergoing further study to determine optimal walk times, distances, and rates to maximize its sensitivity.
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Affiliation(s)
- R W Moskowitz
- Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals, Cleveland, OH 44122, USA.
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Bainbridge D, Cheng DC, Martin JE, Novick R. NSAID-analgesia, pain control and morbidity in cardiothoracic surgery. Can J Anaesth 2006; 53:46-59. [PMID: 16371609 DOI: 10.1007/bf03021527] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE While narcotics remain the backbone of perioperative analgesia, the adjunctive role of other analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), is being recognized increasingly. This meta-analysis sought to determine whether adjunctive NSAIDs improve postoperative analgesia and reduce cumulative narcotic requirements. METHODS A comprehensive search was undertaken to identify all randomized trials, in cardiothoracic patients, of NSAIDs plus narcotics vs narcotics without NSAIDs. Medline, Cochrane Library, EMBASE, and abstract databases were searched up to September 2005. The primary outcome was visual analogue scale (VAS) pain score. Secondary outcomes included 24-hr cumulative morphine-equivalents, rescue medications required, mortality, myocardial infarction, atrial fibrillation, stroke, renal failure, hospital readmissions, and in-hospital costs. RESULTS Twenty randomized trials involving 1,065 patients were included. A significant reduction in 24-hr VAS pain score was found in patients receiving NSAIDs [weighted mean difference (WMD) -0.91 points, 95% confidence interval (CI) -1.48 to -0.34 points]. In addition, patients required significantly less morphine-equivalents in the first 24 hr (WMD -7.67 mg, 95% CI -8.97 to -6.38 mg). No significant difference was found with respect to mortality [odds ratio (OR) 0.19, 95% CI 0.01 to 4.22], myocardial infarction (OR 0.71, 95% CI 0.09 to 5.71), renal dysfunction (OR 0.95, 95% CI 0.37 to 2.46), or gastrointestinal bleeding (OR 0.96, 95% CI 0.13 to 7.09). CONCLUSION In patients less than 70 yr of age undergoing cardiothoracic surgery, the adjunctive use of NSAIDs with narcotic analgesia reduces 24-hr VAS pain score and narcotic requirements.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, University Hospital, Main Building, Room C3-172, 339 Windermere Road, London, Ontario N6A 5A5, Canada
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Ekman EF, Wahba M, Ancona F. Analgesic efficacy of perioperative celecoxib in ambulatory arthroscopic knee surgery: a double-blind, placebo-controlled study. Arthroscopy 2006; 22:635-42. [PMID: 16762702 DOI: 10.1016/j.arthro.2006.03.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine whether celecoxib, administered perioperatively, reduces opioid consumption and opioid-related adverse effects, and provides effective analgesia, in patients undergoing ambulatory arthroscopic knee meniscectomy. METHODS Patients (> or = 18 years) with diagnosed knee meniscus disease were given celecoxib (400 mg; n = 99) or placebo (n = 101) 1 hour before they underwent arthroscopic knee surgery; this was followed by celecoxib (200 mg) or placebo given postoperatively at their first request for pain medication. Surgery was performed with patients under general anesthesia (fentanyl, 1 to 3 microg/kg plus 0.25% intra-articular bupivacaine, 10 to 20 mL) administered at the index joint. Every 4 to 6 hours, patients were allowed 1 to 2 tablets of hydrocodone bitartrate 5 mg/acetaminophen 500 mg (and optional opioids as needed). All efficacy analyses were conducted in the modified intent-to-treat population. RESULTS In the 24 hours following surgery, total opioid consumption was significantly reduced in the celecoxib group (3.6 tablets) compared with the placebo group (4.6 tablets; P = .009). Celecoxib was associated with significant reductions in opioid consumption compared with placebo at 10 to 12 hours (P = .005) and at 12 to 24 hours (P = .012). The percentage of placebo-treated patients (41%) who required opioid analgesics was significantly greater than the percentage of celecoxib-treated patients who required opioids (22%; P = .008) at 10 to 12 hours. Adverse events (AEs) were experienced by more patients in the placebo group (37%) than in the celecoxib group (18%). Incidences of opioid-related events, such as central nervous system disorders (12% v 3%, respectively) and constipation (5% v 1%, respectively), were higher in placebo-treated patients than in those given celecoxib. CONCLUSIONS Perioperative administration of celecoxib plus optional opioids reduces the use of opioids and the occurrence of opioid-related AEs compared with treatment with placebo plus optional opioids given to patients undergoing arthroscopic knee meniscectomy. LEVEL OF EVIDENCE Level I, randomized, double-blind, placebo-controlled, parallel-group study.
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Affiliation(s)
- Evan F Ekman
- Southern Orthopedic Sports Medicine, Columbia, South Carolina 29204, USA.
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Ekman EF, Ruoff G, Kuehl K, Ralph L, Hormbrey P, Fiechtner J, Berger MF. The COX-2 specific inhibitor Valdecoxib versus tramadol in acute ankle sprain: a multicenter randomized, controlled trial. Am J Sports Med 2006; 34:945-55. [PMID: 16476920 DOI: 10.1177/0363546505283261] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The cyclooxygenase-2 specific inhibitor valdecoxib has not been approved in the United States for treatment of acute pain. HYPOTHESIS Valdecoxib 20 mg twice daily or once daily (both with a 40-mg loading dose) is not clinically inferior to tramadol for treating the signs and symptoms of acute ankle pain. STUDY DESIGN Randomized, controlled clinical trial; Level of evidence, 1. METHODS Patients (N = 829) with acute first- or second-degree ankle sprain received 7 days' treatment with valdecoxib 20 mg either twice daily or once daily (both with 40-mg loading dose), tramadol 50 mg 4 times daily, or placebo. The primary end point was Patient's Assessment of Ankle Pain visual analog scale on day 4; a test of noninferiority compared valdecoxib with tramadol. RESULTS On day 4, both valdecoxib doses were significantly better versus placebo and were comparable with tramadol in relieving ankle pain. On day 7, valdecoxib, but not tramadol, significantly reduced pain versus placebo. On days 4 and 7, more patients resumed normal walking with valdecoxib (45%-47% and 73%-79%, respectively) than with placebo (35% and 64%, respectively) or tramadol (38% and 67%, respectively). In contrast to valdecoxib, the number of withdrawals due to adverse events was significantly higher in the tramadol group (12.2% vs 3.4%; P = .0005). CONCLUSIONS Valdecoxib was comparable with tramadol and was significantly better than placebo in treating acute ankle sprain, and it enabled more patients to resume normal walking on days 4 and 7. Both valdecoxib and tramadol were well tolerated.
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Affiliation(s)
- Evan F Ekman
- Southern Orthopedic Sports Medicine, 1718 St. Julian Place, Columbia, SC 29204, USA.
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Fischer HBJ, Simanski CJP. A procedure-specific systematic review and consensus recommendations for analgesia after total hip replacement. Anaesthesia 2005; 60:1189-202. [PMID: 16288617 DOI: 10.1111/j.1365-2044.2005.04382.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Total hip replacement is a major surgical procedure usually associated with significant pain in the early postoperative period. Several anaesthetic and analgesic techniques are in common clinical use for this procedure but, to date, clinical studies of pain after total hip replacement have not been systematically assessed. Using the Cochrane protocol, we have conducted a systematic review of analgesic, anaesthetic and surgical interventions affecting postoperative pain after total hip replacement. In addition to the review, transferable evidence from other relevant procedures and clinical practice observations collated by the Delphi method were used to develop evidence-based recommendations for the treatment of postoperative pain. For primary total hip replacement, PROSPECT recommends either general anaesthesia combined with a peripheral nerve block that is continued after surgery or an intrathecal (spinal) injection of local anaesthetic and opioid. The primary analgesic technique should be combined with a step-down approach using paracetamol plus conventional non-steroidal anti-inflammatory drugs, with strong or weak opioids as required.
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Affiliation(s)
- H B J Fischer
- Anaesthesia and Pain Management, Department of Anaesthesia, Alexandra Hospital, Redditch, Worcestershire, UK.
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Hill K, Berlet GC, Philbin TM, Lee TH. The role of cyclooxygenase-2 inhibition in foot and ankle arthrodesis. Foot Ankle Clin 2005; 10:729-42, x. [PMID: 16297830 DOI: 10.1016/j.fcl.2005.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cyclooxygenase-2 (COX-2) inhibitors are an important adjunct in controlling postoperative pain. Concerns exist regarding the use of NSAIDs for postoperative pain management because of the possible deleterious impact on bone healing in patients undergoing hindfoot arthrodesis. Orthopedic surgeons are concerned with: (1) a multimodal approach for postoperative pain control, and (2) bone healing following arthrodesis, fracture repair with rigid internal fixation, and cementless implants. The use of COX-2 inhibitors has been shown to be an important component of a pain control strategy but questions about their effects on bone healing have inhibited their use. This article discusses the laboratory and clinical data available on the use of COX-2 inhibitors on bone healing and their effects on foot and ankle arthrodesis procedures.
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Affiliation(s)
- Keith Hill
- Orthopedic Foot and Ankle Center, Inc., 6200 Cleveland Ave, Suite 100, Columbus, OH 43231, USA
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Abstract
To prevent patient pain, the clinician may chose from opioid and nonopioid analgesics. It is rational for the practitioner to combine drugs from these classes when managing moderate to severe pain. To select combination regimens wisely, it is necessary to understand the significant pharmacological features of each category alone. Careful selection of an effective analgesic regimen based on the type and amount of pain the patient is expected to have can prevent the stress and anxiety associated with breakthrough pain. The clinician can and should develop a variety of effective, safe analgesic regimens, based on estimates of anticipated pain intensity that use sound pharmacological principles.
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Affiliation(s)
- Daniel E Becker
- Professor of Allied Health Sciences, Sinclair Community College, and Associate Director of Education, Miami Valley Hospital, Dayton, Ohio
| | - James C Phero
- Professor of Clinical Anesthesia, Pediatrics, and Surgery, and Faculty UC Physicians Pain Center, Anesthesia Department, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Address correspondence to James C. Phero, Anesthesia Department, College of Medicine, University of Cincinnati, Cincinnati, OH;
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Abstract
Cyclooxygenase (COX)-2 inhibitors are as efficacious as nonselective nonsteroidal anti-inflammatory drugs for the treatment of postoperative pain but have the advantages of a better gastrointestinal side-effect profile as well as a lack of antiplatelet effects. There have been recent concerns regarding the cardiovascular side effects of COX-2 inhibitors. Nonetheless, they remain a valuable option for postoperative pain management. The pharmacology of these agents and available studies are reviewed.
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Affiliation(s)
- Noor M Gajraj
- Baylor Center for Pain Management, Baylor University Medical Center, 5575 Warren Parkway # 220, Frisco, TX 75034, USA.
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Delarge J, Dogné JM, Julémont F, Leval XD, Pirotte B, Sanna V. Advances in the field of COX-2 inhibition. Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.12.7.969] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rømsing J, Møiniche S, Mathiesen O, Dahl JB. Reduction of opioid-related adverse events using opioid-sparing analgesia with COX-2 inhibitors lacks documentation: a systematic review. Acta Anaesthesiol Scand 2005; 49:133-42. [PMID: 15715611 DOI: 10.1111/j.1399-6576.2005.00614.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND We have reviewed opioid-related adverse events in studies of opioid sparing with cyclooxygenase-2 (COX-2) inhibitors compared with placebo in postoperative pain. METHODS Randomized, controlled trials were evaluated. Outcome measures were significant reduction in consumption of supplementary opioids with the COX-2 inhibitors and reported opioid-related adverse events (nausea, vomiting, constipation, dizziness, sedation, pruritus and/or urinary retention) 0-24 h after surgery. RESULTS Nineteen studies including 26 comparisons of four COX-2 inhibitors (rofecoxib, celecoxib, parecoxib and valdecoxib) were evaluated, in which significant opioid-sparing averaging about 35% with COX-2 inhibitors and opioid-related adverse events were reported. The trials were in general of high quality (median Oxford quality score 4) but the reporting quality of adverse events was poor. Opioid-related adverse events, i.e. vomiting, constipation and pruritus, were only significantly reduced with COX-2 inhibitors in four of the 26 comparisons. Quantitative analysis of combined data revealed a significantly reduced risk for only dizziness; the clinical relevance was minor as the number needed to treat (NNT) was about 33. CONCLUSION The limitation of this review is the lack of quality of data of adverse events from the original trials. Although supplementary opioid consumption in all trials was significantly reduced by on average 35% with the COX-2 inhibitors, it was only sporadically possible to demonstrate a clinically important reduction in opioid-related adverse events. Data did not support the common opinion that opioid-sparing with COX-2 inhibitors provides much clinical beneficial effect with respect to opioid-related adverse events. Future studies have to increase the awareness and proper reporting of adverse events in the postoperative period.
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Affiliation(s)
- J Rømsing
- Department of Pharmaceutics, The Danish University of Pharmaceutical Sciences, Copenhagen, Denmark.
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Chelly JE, Ben-David B, Joshi RM, Kandel A, Merman RB, Rest CC, Yennam S, Uskova AA. Minimally Invasive Total Hip Replacement as an Ambulatory Procedure. Int Anesthesiol Clin 2005; 43:161-5. [PMID: 15970753 DOI: 10.1097/01.aia.0000166333.23510.0a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jacques E Chelly
- Department of Anesthesiology, UPMC Presbyterian Shadyside Hospital, Pittsburgh, PA 15232, USA
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