The analgesic efficacy of intramuscular parecoxib sodium in postoperative dental pain

Postoperative administration of ketorolac compared to other drugs for pain control after third molar surgery: A meta-analysis of double-blind, randomized, clinical trials

AIMS

The aim of this study was to evaluate the analgesic effectiveness and adverse reactions of ketorolac in comparison with other drugs when administered postoperatively after third molar surgery.

METHODS

PubMed and Google Scholar were utilized to search for articles comparing the efficacy and safety of ketorolac and other analgesic agents after third molar surgery. Data from papers with a lower risk of bias were recorded. The overall evaluation of analgesia onset, general and subgroup evaluation of the number of patients requiring rescue analgesic medication, general and subgroup assessment of the study medication (satisfaction on the study drugs), and the overall estimation of adverse effects were performed using the Review Manager Software 5.3 to analyse the data and obtain the meta-analysis plot.

RESULTS

The subgroup evaluation of the study medication showed that patients who received ketorolac 30 mg were more satisfied than those who were given parecoxib 1 mg (odds ratio [OR] = 8.57, 95% confidence interval [CI] = 3.66-20.08, P = .00001), parecoxib 2 mg (OR = 7.17, 95% CI = 2.88-17.86, P = .0001), parecoxib 5 mg (OR = 3.03, 95% CI = 1.69-5.41, P = .0002), and parecoxib 10 mg (OR = 2.42, 95% CI = 1.36-4.32, P = .003). Moreover, patients who received ketorolac reported fewer adverse reactions compared with those who had received opioid analgesics (OR = 0.14, 95% CI = 0.32-1.76, P = .0001).

CONCLUSIONS

The data from this study demonstrates that the postoperative administration of ketorolac 30 mg presents better results on patient satisfaction when compared to parecoxib 1 mg to 10 mg, and presents a similar satisfaction to parecoxib 20 mg following third molar removal.

The safety profile of parecoxib for the treatment of postoperative pain: a pooled analysis of 28 randomized, double-blind, placebo-controlled clinical trials and a review of over 10 years of postauthorization data

Background

Nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 (COX-2) inhibitors are associated with safety issues including cardiovascular, renal, and gastrointestinal (GI) events.

Objective

To examine the safety of parecoxib, a COX-2 inhibitor, for the management of postoperative pain.

Design

Pooled analysis of 28 placebo-controlled trials of parecoxib and review of postauthorization safety data.

Main outcome measures

Prespecified safety events commonly associated with COX-2 inhibitors and/or NSAIDs. In the clinical trial analysis, the frequency of each event was compared between treatment groups using a chi-square test. In the postauthorization review, the number of confirmed cases, along with outcome, was presented for each event.

Results

In the clinical trial analysis, GI-related events occurred in ~0.2% of patients in the parecoxib and placebo groups. Renal failure and impairment was similar between parecoxib (1.0%) and placebo (0.9%). The occurrence of arterial (parecoxib=0.3%; placebo=0.2%) and venous (parecoxib=0.2%; placebo=0.1%) cardiovascular embolic and thrombotic events was similar between groups. Hypersensitivity reactions including anaphylactic reactions (parecoxib=8.7%; placebo=8.6%), hypotension (parecoxib=2.6%; placebo=2.1%), angioedema (parecoxib=2.5%; placebo=2.8%), and severe cutaneous adverse reactions (0% in both groups) were similar between groups. Incision site or other skin/tissue infections occurred in <0.1% of patients in both groups. The occurrence of these events (total reports/serious reports) in the postauthorization database, based on 69,567,300 units of parecoxib, was as follows: GI ulceration-related events (35/35), renal failure and impairment (77/68), cardiovascular embolic and thrombotic events (66/64), hypersensitivity reactions including hypotension-related events (32/25) and severe cutaneous adverse events (17/17), and masking signs of inflammation (18/18). A majority of reported outcomes were classified as recovered or recovering.

Conclusions

Potentially serious safety events occur infrequently with parecoxib, which high-lights its safety in patients with postoperative pain.

Comparing parecoxib and ketorolac as preemptive analgesia in patients undergoing posterior lumbar spinal fusion: a prospective randomized double-blinded placebo-controlled trial

Background

Poor postoperative pain control is frequently associated with complications and delayed discharge from a hospital. Preemptive analgesia is one of the methods suggested for reducing postoperative pain. Opioids are effective for pain control, but there known addictive properties make physicians cautious about using them. Parecoxib and ketorolac are potent non-opioid NSAIDs that are attractive alternative drugs to opioids to avoid opioid-related side effects. However, there are no good head-to-head comparisons between these two drugs in the aspect of preemptive analgesic effects in lumbar spinal fusion surgery. This study aimed to compare the efficacy in terms of postoperative pain control and safety of parecoxib with ketorolac as preemptive analgesia in posterior lumbar spinal fusion patients.

Methods

A prospective, double-blinded randomized controlled trial was carried out in patients undergoing posterior lumbar spinal fusion, who were randomized into 3 groups (n = 32). Parecoxib, ketorolac or a placebo was given to each patient via injection around 30 minutes prior to incision. The efficacy of postoperative pain control was assessed by a verbal numerical rating score (0–10). And various postoperative things were monitored for analysis, such as total opioid consumption, complications, and estimated blood loss.

Results

Both the ketorolac and parecoxib groups showed significantly better early postoperative pain reduction at the postanesthesia care unit (PACU) than the control group (p < 0.05). There were no differences between the pain scores of ketorolac and parecoxib at any time points. Complications and bleeding were not significantly different between all three groups.

Conclusions

Preemptive analgesia using both ketorolac and parecoxib showed a significantly better early postoperative pain control in the PACU than the control group in patients undergoing lumbar spinal fusion.

Trial registration

ClinicalTrials.gov NCT01859585. Registered 15 May 2013.

Comparative evaluation of efficacy and safety of etodolac and diclofenac sodium injection in patients with postoperative orthopedic pain

OBJECTIVE

The objective of this study was to compare the analgesic efficacy of etodolac injection and diclofenac injection in patients with postoperative orthopedic pain.

METHODS

This was multicentric, randomized, assessor-blind and parallel-group study. A group of 158 patients with moderate to severe pain following orthopedic surgery were randomly assigned to receive either etodolac 400 mg twice a day (n = 78) or diclofenac 75 mg thrice a day (n = 80).

MAIN OUTCOME MEASURES

The primary efficacy outcome measures were pain intensity difference, sum of pain intensity differences and pain relief whereas secondary efficacy variables included maximum fall in pain intensity, number of doses of study medication consumed, number of patients who required rescue medication and overall response to therapy.

RESULTS

Mean pain intensity differences assessed on 10 cm VAS were significantly better for etodolac arm compared to diclofenac arm at 4, 8, 20 and 24 hours (p < 0.05). Sum of pain intensity differences over the first 8 hours (-21.31 ± 6.26 for etodolac vs. -19.13 ± 6.98 for diclofenac; p = 0.041) and over the 24 hours (-39.83 ± 10.70 for etodolac vs. -35.25 ± 12.00 for diclofenac; p = 0.012) for the etodolac group was significantly superior than diclofenac group. Assessment of pain relief showed that etodolac injection was significantly more effective than diclofenac injection (p < 0.0001) over the 24 hour assessment period. Maximum fall in pain intensity score, number of doses of study medication consumed and patients' and investigators' overall response to the drug at the end of treatment period were also significantly superior in the etodolac arm as compared to the diclofenac arm (p < 0.05). However, the number of patients who were rescued was comparable in both the treatment arms. A change in emotional functioning of the patients was not captured in this study. Both the study medications were well tolerated with no incidence of SAE throughout the study.

CONCLUSION

Etodolac can be considered as an effective alternative to traditional NSAIDS in the treatment of post operative pain.

A randomised comparison of parecoxib versus placebo for pain management following minor day stay gynaecological surgery

At therapeutic concentrations, parecoxib selectively inhibits the cyclo-oxygenase-2 enzyme. We investigated the impact of a single preoperative dose of parecoxib on pain relief following minor gynaecological surgery. Ninety women undergoing uterine dilatation and curettage, with or without hysteroscopy, were randomised to receive either 40 mg of parecoxib intravenously or a saline placebo prior to induction of standardised general anaesthesia. Exclusion criteria included a preoperative history of renal dysfunction or hypertension and the preoperative use of anti-inflammatory or opioid medication. The primary endpoint was the pain score during recovery. There was no difference in global pain scores or area under the curve for pain scores in the recovery area. Pain scores with coughing one hour after surgery were low in both groups but significantly lower after parecoxib (median 2 [interquartile range 0 to 4] parecoxib group vs. 2 [interquartile range 0 to 6] placebo group, P = 0.037). The 24 hour Quality of Recovery score did not differ significantly between groups but the parecoxib group was less likely to experience headache at 24 hours postoperatively (12 vs. 38%, P = 0.007) and reported complete satisfaction more frequently (78 vs. 57%, P = 0.042). The preoperative administration of parecoxib was associated with a significant but small decrease in dynamic pain scores one hour postoperatively. Women who received preoperative parecoxib had a lower incidence of postoperative headache and higher satisfaction.

Intravenous or intramuscular parecoxib for acute postoperative pain in adults

BACKGROUND

Parecoxib was the first COX-2 available for parenteral administration, and may, given intravenously or intramuscularly, offer advantages over oral medication when patients have nausea and vomiting or are unable to swallow, such as in the immediate postoperative period.

OBJECTIVES

Assess the efficacy of single dose intravenous or intramuscular parecoxib in acute postoperative pain, the requirement for rescue medication, and any associated adverse events.

SEARCH STRATEGY

We searched Cochrane CENTRAL, MEDLINE, EMBASE in November 2008.

SELECTION CRITERIA

Randomised, double-blind, placebo-controlled clinical trials of parecoxib compared with placebo for relief of acute postoperative pain in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. The area under the "pain relief versus time" curve was used to derive the proportion of participants with parecoxib and placebo experiencing at least 50% pain relief over 6 hours, using validated equations. The number-needed-to-treat-to-benefit (NNT) was calculated using 95% confidence intervals (CI). The proportion of participants using rescue analgesia over a specified time period, and time to use of rescue analgesia, were sought as additional measures of efficacy. Information on adverse events and withdrawals were also collected.

MAIN RESULTS

Seven studies (1446 participants) were included. There was no significant difference between doses, or between intravenous and intramuscular administration for 50% pain relief over 6 hours: NNTs compared with placebo were 3.1 (2.4 to 4.5), 2.4 (2.1 to 2.8), and 1.8 (1.5 to 2.3) for 10, 20, and 40 mg parecoxib respectively. Fewer participants required rescue medication over 24 hours with parecoxib than placebo: parecoxib 40 mg was significantly better than parecoxib 20 mg (NNTs to prevent use of rescue medication 7.5 (5.3 to 12.8) and 3.3 (2.6 to 4.5) respectively; P < 0.0007). Median time to use of rescue medication was 3.1 hours, 6.9 hours and 10.6 hours with parecoxib 10 mg, 20 mg and 40 mg respectively, and 1.5 hours with placebo. Adverse events were generally mild to moderate, rarely led to withdrawal, and did not differ in frequency between groups. No serious adverse events were reported with parecoxib or placebo.

AUTHORS' CONCLUSIONS

A single dose of parecoxib 20 mg or 40 mg provided effective analgesia for 50 to 60% of those treated compared to about 15% with placebo, and was well tolerated. Duration of analgesia was longer, and significantly fewer participants required rescue medication over 24 hours with the higher dose.

Safety of parecoxib in patients with nonsteroidal anti-inflammatory drug-induced urticaria or angioedema

BACKGROUND

Parecoxib is the first injectable cyclooxygenase 2 selective inhibitor indicated for the treatment of acute postoperative pain.

OBJECTIVE

To describe the results of a challenge with parecoxib in patients with a history of urticaria or angioedema to 1 or more nonsteroidal anti-inflammatory drugs (NSAIDs).

METHODS

The study was performed from October 1, 2006, through March 31, 2007, with 79 patients who historically had experienced urticaria or angioedema after use of NSAIDs. The patients underwent a single-blind challenge with parecoxib, 40 mg.

RESULTS

No reaction to placebo was observed in any patient. Similarly, no reaction to parecoxib was observed in any patients in the single-class or multiple-class intolerance group.

CONCLUSION

Our report demonstrates that parecoxib does not induce cross-reactivity in patients with a history of urticaria or angioedema. Hence, this finding suggests that this drug could be safely proposed as an alternative (but only after a prior challenge) in patients with previous hypersensitive reactions to NSAIDs, even if there are added risk factors such as atopy and antimicrobial allergy, who require an analgesic drug perioperatively.

Effect of parecoxib on postoperative pain after lumbar spine surgery: a bicenter, randomized, double-blinded, placebo-controlled trial

STUDY DESIGN

A bicenter randomized, patients, healthcare providers, and data collectors blind placebo-controlled trial in multimodal analgesia for postoperative lumbar spine surgery was conducted.

OBJECTIVE

To assess the efficacy and safety of parecoxib on postoperative pain management after posterior lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Systematic reviews suggest that cyclo-oxygenase-2 inhibitors are an effective treatment for acute postoperative pain. However, previous trials on lumbar spine surgery showed equivocal efficacy of cyclo-oxygenase-2 inhibitors for postoperative pain relief.

METHODS

In this study, 120 patients undergoing posterior lumbar discectomy, spinal decompression, or spinal fusion were stratified based on the surgical procedure to 3 groups (n = 40) and randomly allocated to receive multidoses of parecoxib 40 mg/dose or placebo. Efficacy was assessed by total morphine used from patient-controlled analgesic pump, pain intensity, pain relief, and the patient's subjective rating of the medication.

RESULTS

Parecoxib 40 mg reduced the total amount of morphine required over 48 hours by 39% relative morphine reduction compared with placebo (P = 0.0001). Pain at rest was reduced by 30% (P = 0.0001). Ninety percent of patients given parecoxib experienced at least 50% maximum total pain relief compared with 58% treated with placebo. The number-needed-to-treat for 1 patient to have at least half pain relief was 3.1 (2.0-4.6). Patients' subjective rating of the medication was described as "excellent, good, and fair" by 48%, 43%, and 8% in the parecoxib group, respectively, compared with 21%, 50%, and 28% of placebo patients (P = 0.004). Overall adverse effects of patients receiving parecoxib and morphine were comparable to those receiving morphine alone.

CONCLUSION

The present study demonstrates that the perioperative administration of parecoxib with patient-controlled analgesic morphine after lumber spine surgery resulted in significantly improved postoperative analgesic management as defined by reduction in opioid requirement, lower pain scores, and higher patients' subjective rating of the medication.

Intravenous Parecoxib Rapidly Leads to COX-2 Inhibitory Concentration of Valdecoxib in the Central Nervous System

Evidence in animal studies supports widespread induction of cyclooxygenase-2 (COX-2) in the central nervous system (CNS) following tissue injury, probably mediated by cytokines, transducing the signal across the blood-brain barrier. CNS COX-2 blockade is a possible therapeutic target for drugs that are able to reach adequate CNS levels and abolish the prostaglandin E2-induced central sensitization. This human pharmacokinetic study investigated valdecoxib cerebrospinal fluid (CSF) and plasma concentrations over time in 37 patients following 40 mg of single-dose intravenous parecoxib. High-performance liquid chromatography/tandem mass spectrometry analysis was performed. Valdecoxib was first detectable in the CSF at 15 min postdosing, increased rapidly until 50 min, and thereafter remained between 6 and 14 ng/ml. This is the first human study demonstrating CNS COX-2 inhibitor penetration as early as 15 min. CSF valdecoxib concentration rapidly reached in vitro IC50 (inhibitory concentration 50) (1.57 ng/ml) by 17 min and remained consistently higher thereafter.

Constitutive cyclooxygenase-2 is involved in central nociceptive processes in humans

BACKGROUND

Prostaglandins play a major role in inflammation and pain. They are synthesized by the two cyclooxygenase (COX) isoforms: COX-1, which is expressed constitutively in many cell types, and COX-2, which is induced at the site of inflammation. However, unlike peripheral tissues, COX-2 is expressed constitutively in the central nervous system and may play a role in nociceptive processes. The current study aimed to investigate the role of constitutive COX-2 in the spinal transmission of nociceptive signals in humans.

METHODS

The authors used 12 healthy volunteers to compare the effects of the specific COX-2 inhibitor sodium parecoxib (1 mg/kg) or placebo, administered intravenously in a double-blind and crossover fashion, on the electrophysiologic recordings of the nociceptive flexion (RIII) reflex. The RIII reflex is an objective psychophysiologic index of the spinal transmission of nociceptive signals and was recorded from the biceps femoris after electrical stimulation of the sural nerve. Two experiments, 7 days apart, were conducted in each volunteer. On each experimental day, the effects of parecoxib or placebo were tested on (1) the RIII reflex threshold, (2) the stimulus-response curves of the reflex up to the tolerance threshold (frequency of stimulation: 0.1 Hz), and (3) the progressive increase of the reflex and pain sensations (i.e., "windup" phenomenon) induced by a series of 15 stimulations at a frequency of 1 Hz (intensity 20% above RIII threshold).

RESULTS

Parecoxib, but not placebo, significantly reduced the slope of the stimulus-response curve, suggesting a reduction in the gain of the spinal transmission of nociceptive signals. By contrast, the windup phenomenon was not significantly altered after administration of parecoxib or placebo.

CONCLUSIONS

This study shows that constitutive COX-2 modulates spinal nociceptive processes and that the antiinflammatory and antinociceptive actions of COX-2 inhibitors are not necessarily related.

Perioperative pain management

The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively. The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption. The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge. The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to achieve an effective and successful perioperative pain management regimen.

The Efficacy of the Non-Opioid Analgesics Parecoxib, Paracetamol and Metamizol for Postoperative Pain Relief After Lumbar Microdiscectomy

In this prospective, double-blind, randomized, placebo-controlled study we compared the efficacy of three IV non-opioid analgesics for postoperative pain relief after lumbar microdiscectomy. Eighty healthy patients were randomly divided into 4 treatment groups (n = 20 each) to receive either parecoxib 40 mg, paracetamol 1 g, metamizol 1 g, or placebo IV 45 min before the end of surgery. In the postanesthesia care unit (PACU) patients were treated using patient-controlled analgesia (PCA) with piritramide. In the metamizol group the pain score at arrival in the PACU was significantly lower compared with the paracetamol, parecoxib, and placebo groups. In addition, in the metamizol group significantly fewer patients required additional PCA compared with the other groups studied. However, in those patients who required additional pain therapy in the four treatment groups, there was no significant difference in time to first request for piritramide and cumulative consumption of piritramide as assessed by the PCA data in the PACU. The incidence of adverse side effects was infrequent in all groups. These results suggest that in patients undergoing lumbar microdiscectomy, metamizol is superior to parecoxib, paracetamol, and placebo for immediate postoperative pain relief with minimal side effects.