A Risk-Benefit Appraisal of Injectable NSAIDs in the Management of Postoperative Pain

Abstract

The inadequacy of pain treatment has been demonstrated in many patient groups suffering from acute pain. The injectable nonsteroidal anti-inflammatory drugs (NSAIDs), including indomethacin, diclofenac, ketoprofen and ketorolac, provide relief from the pain associated with several different conditions. When administered alone or in combination with low doses of opioids, NSAIDs provide good pain relief after musculoskeletal trauma or operation. The main advantage of these agents is that they may form the first-line therapy for pain relief and thus decrease the need of opioids. This avoids respiratory depression which can be associated with opioids. In contrast to opioids, NSAIDs do not cause respiratory depression or have marked adverse effects on the central nervous system. However, they may be associated with adverse effects of the gastrointestinal tract, liver and kidneys, and may increase pre- and postoperative bleeding and cause allergic reactions. These effects are related to the ability of NSAIDs to inhibit prostaglandin synthesis. Use of NSAIDs has to be considered carefully in patients with asthma, allergy to aspirin and NSAIDs, atopy, peptic ulcer or bleeding disorders (such as abnormalities in blood coagulation or coagulation deficits). These considerations are especially important in elderly patients. Having taken these contraindications into account, many clinical studies have demonstrated that NSAIDs are at least as safe as opioids when administered in the short term. However, few studies have specifically monitored adverse effects or included patients over 65 to 70 years of age. In addition, patients with risk factors have often been excluded from the trials. Therefore, the risk-benefit ratio of NSAIDs requires further assessment.

Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery

“…4 Previous investigators have reported no important gastrointestinal ulceration or hemorrhage with short-term (<48 hr) therapy. 3,4 Our results showed no deterioration in renal function following the use of NSAIDs. Clinical trials evaluating the effects of NSAID therapy on renal function in healthy patients have previously documented transient, but clinically insignificant increases in creatinine following NSAID use.…”

“…3 Although the use of opioids can provide excellent analgesia, the doses necessary to provide effective pain relief may lead to undesirable side effects such as respiratory depression, sedation and nausea. 4 Non-steroidal anti-inflammatory drugs (NSAIDs) are potent analgesics 4,s but are inadequate for postoperative analgesia after major surgery when used alone. 3,5 However, NSAIDs in conjunction with opioids for postoperative analgesia have been shown to improve pain scores and reduce opioid consumption.…”

Effect of Intravenous Methylprednisolone on Pain after Intertrochanteric Femoral Fracture Surgery

“…Eighty two patients with stable intertrochanteric unilateral fracture were selected and divided into two groups: one received Methylprednisolone (MP) 125 mg and the other received placebo. Pain was evaluated at rest and 45° flexion of the hip in times 4,6,8,12,24,36, and 48 hours and during walking in times 24, 36, and 48 hours after the surgery.…”

“…Pain control using NSAIDs and anticonvulsants has also been investigated in some studies, although their overdose may have such complications as GI bleeding or sedation [10][11][12]. Invasive ways of pain control also requires appropriate equipment and clinical conditions that suit the patient.…”

Postoperative analgesia after lumbar disc surgery: A comparison between ketorolac and opioid

“…Although opioids are the traditional first-line treatment, 1 the potential adverse effects often make physicians reluctant to increase the dosage to achieve adequate analgesia. 2 Nonsteroidal anti inflammatory drugs (NSAIDs) provide effective analgesia for acute pain after minor and major surgery as a substitute for or as an adjunct to opioid analgesia and reduces opioid requirement during postoperative period. [3][4][5][6][7][8][9][10][11] The most recent parental non-steroidal antiinflammatory drug available for control of postoperative pain is ketorolac, a pyrolizine carboxylic acid derivative, structurally related to indomethacin.…”