Perioperative Intravenous Acetaminophen and NSAIDs

Abstract

The i.v. formulation of APAP represents a safe and effective first-line analgesic agent for the treatment of acute mild-to-moderate pain in the perioperative setting when oral agents may be impractical or when rapid onset with predictable therapeutic dosing is required.

OFIRMEV: An Old Drug Becomes New Again

“…29 IV ketorolac, a preferential COX-1 inhibitor, is currently the IV nonopioid analgesic of choice in the US due to its efficacy and low cost. 5 Due to its high degree of COX-1 selectivity, IV ketorolac is only approved for use in adult patients for the short-term (5 days or fewer) management of moderate to severe pain requiring analgesia at the opioid level; its use prior to major surgery and intraoperatively is contraindicated. 5 IV ibuprofen is indicated for use only in adults for the management of mild to moderate pain, management of moderate to severe pain as an adjunct to opioid analgesics, and reduction of fever.…”

“…4 The primary analgesic effect of acetaminophen is thought to be due to a central nervous system site of action involving cyclooxygenase (COX) inhibition. 5,10 Passive diffusion of acetaminophen into the central nervous system appears to be enhanced by a high plasma to cerebrospinal fluid (CSF) concentration gradient, with acetaminophen concentrations in the CSF being linearly dose proportional with plasma levels. 19 IV acetaminophen has been shown to achieve higher maximum concentrations and earlier time to maximum concentration compared to bioequivalent oral doses with less intrasubject variability.…”

“…28,29 Nevertheless, all NSAIDs carry risks of serious gastrointestinal, cardiovascular, renal, and bleeding adverse effects. 5 In situations where IV NSAIDs are not approved (ie, pediatric patients) or not clinically appropriate (ie, patients with history of peptic ulcer disease, renal disease, or surgeries with a high risk of postoperative bleeding), IV acetaminophen can serve as a viable alternative when an IV route of administration is needed. 10,28,29 For many outpatient dental procedures performed under general anesthesia or IV sedation, IV acetaminophen administered in the immediate postoperative period may provide sufficient analgesia to address mild to moderate pain, obviating the need for or decreasing NSAID and opioid dosing and their associated side effects.…”

“…4 Although IV acetaminophen is relatively new in the US, the same formulation has been used extensively in over 80 countries since 2002. 5 Evidence from randomized clinical trials has found IV acetaminophen to be a safe, effective, and well-tolerated analgesic agent in the treatment of acute postoperative pain associated with a number of surgical procedures, including third-molar extraction and orthognathic surgery. 6,7 The goal of this paper is to examine the potential role of IV acetaminophen in dentistry.…”

“…6,7,10 Until the introduction of IV acetaminophen, the only other nonopioid injectable analgesics available in the US were NSAIDs: IV ketorolac and IV ibuprofen (Caldolor, Cumberland Pharmaceuticals Inc). 5,28 The pathogenesis of dental pain is primarily inflammation. Thus, NSAIDs have been described as being more effective analgesics in treating dental pain than acetaminophen and opioids, which lack anti-inflammatory action.…”