Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial

Pharmacological bases of combining nonsteroidal antiinflammatory drugs and paracetamol

Paracetamol and nonsteroidal antiinflammatory drugs (NSAIDs), particularly ibuprofen, are frequently administered together. A systematic review of clinical studies using combined or alternating regimes of NSAIDs was performed up to May 2023. Clinical evidence (77 studies) confirms that in many cases efficacy is enhanced by paracetamol + NSAID combinations, but quite a few studies show no added benefit. Synergism is more commonly found with combined regimens in analgesia for surgery, and with alternating regimes in antipyresis. In some instances the advantage may be related to the short duration of the effect of paracetamol. Mechanistically, central and peripheral actions associated with inhibition of cyclooxygenase have been documented for both paracetamol and NSAIDs, which are relevant for analgesia, antipyresis and closure of patent ductus arteriosus in neonates. In addition, paracetamol may achieve analgesia via different central pathways independently of cyclooxygenase. Hence, increased analgesia may result from NSAID and paracetamol acting at least partly via different mechanisms, while enhancement of antipyresis probably is explained simply by augmented or more prolongued inhibition of cyclooxygenase. Because of the inconsistencies found in the available evidence, added benefit should not be assumed for paracetamol/NSAID combinations. In addition, combining paracetamol and NSAIDs may lead to increased dosing errors, and may result in increased toxicity as a result of enhanced cyclooxygenase interference, a possibility that has barely been scrutinized. We conclude that combining paracetamol and NSAIDs may be justified in analgesia, but further studies are warranted to establish when and how an enhanced effect is achieved with this strategy.

Pain control following impacted mandibular third molar surgery: a comparison of the effectiveness of two different protocols

The use of multimodal analgesia is a common practice in clinical settings, where a combination of drugs with different mechanisms of action is used to enhance the effectiveness of an analgesic and reduce its adverse effects. This study aimed to compare the efficacy of concurrent ibuprofen and paracetamol with alternate administration in the management of postoperative pain after the surgical removal of impacted mandibular third molars. A single-center, double-masked, parallel-group, randomized controlled clinical trial involved 56 patients undergoing scheduled surgical extraction of impacted mandibular third molars. Patients were randomly assigned to either Group A (Control), where they were instructed to take one tablet of ibuprofen 400 mg and two tablets of paracetamol 500 mg together every 8 h for 48 h, or Group B (Study), where they were instructed to take one tablet of ibuprofen 400 mg and two tablets of paracetamol 500 mg alternatively every 4 h for 48 h. The primary outcome measure was the intensity of postoperative pain, which was evaluated using a Visual Analogue Scale (VAS) ranging from 0 to 10. The secondary outcome measure was the timing of the onset of the analgesic effect, the duration of pain relief, the frequency of rescue drug administration, and the time interval between taking the recommended medication and the need for rescue medication. Investigators involved in analyzing the patients' responses were blinded to the pain control regime used by the participants. Pain intensity during the first 48 h after the extractions showed that most participants experienced "some pain," including 50% in Group A and 35.7% in Group B. The percentage of patients reporting "no pain" was higher in group B than in group A, although the difference was not statistically significant (p = 0.495). More than half of the participants (53%) in group A reported needing an extra dose in the 48-hour follow-up period, while 85% in group B reported pain relief (p = 0.002). When correlating the mean pain score to the complexity level, in patients with moderate complexity of extraction, higher pain scores were recorded in group B. The findings of this study show that the combination of Paracetamol and Ibuprofen are well-tolerated and effective option for post operative pain after surgical removal of mandibular third molars. Use of Paracetamol and Ibuprofen alternatively in the first 48 h showed a more effective pain control compared to concurrent use of these medications. However given the small sample size and patients recruited from a single center, multicenter studies with a bigger sample size and stratified complexity groups would enhance the generalizability of the findings.This trial protocol was registered with ClinicalTrials.gov (Registration No: NCT06514222 dated 23/07/2024).

The Effectiveness of Bromelain on Oedema, Subconjunctival Haemorrhage, and Ecchymosis After Rhinoplasty: A Randomised, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To evaluate the effectiveness of bromelain on periorbital oedema, subconjunctival haemorrhage, and ecchymosis after preservation rhinoplasty.

STUDY DESIGN

Randomised, double-blind, placebo-controlled trial SETTING: Tertiary referral centre METHODS: In this double-blind clinical trial, participants aged 18-45 who were scheduled for open preservation rhinoplasty using the push-down technique and lateral osteotomy were recruited. Twenty-three cases were assigned to the placebo group and twenty-three to the experimental group Bromelain.

RESULTS

Regarding gender, 17.39% (8 cases) were male, and 82.61% (38 cases) were female. Comparing the severity of left and right eye ecchymosis between groups at different times showed that bromelain was significantly effective on both sides on the 7th day (p = 0.012). Like ecchymosis, the results demonstrated that bromelain was also considerably effective on subconjunctival haemorrhage on the seventh day post-operatively (p = 0.015). However, the intensity of oedema between groups at different times did not significantly differ.

CONCLUSION

Bromelain increases serum fibrinolytic activity and decreases plasma fibrinogen levels. It is significantly more effective on subconjunctival haemorrhage and ecchymosis compared with the placebo on the seventh day in both eyes after rhinoplasty. Hence, this study indicates that bromelain is remarkably more effective than a placebo in reducing subconjunctival haemorrhage and ecchymosis.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials ID: IRCT20180519039720N2 LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evolving Toward Non-narcotic Perioperative Enhanced Recovery After Surgery and Opioid-Free Analgesia in the Management of Postoperative Pain

Opioid medications are commonly employed for perioperative and postoperative pain management. However, these medications can negatively impact the body's innate pain management system, specifically the action of beta-endorphins. By impairing the function of mu-opioid receptors and inhibiting the release of beta-endorphin, opioids may exacerbate and prolong postoperative pain. Additionally, opioid use is associated with numerous side effects, including nausea, vomiting, constipation, excessive sedation, clouded sensorium, dizziness, respiratory depression, and addiction, all of which may impede postoperative patient recovery and outcome quality. The purpose of this article is to explore the intricate relationship between opioid medications and endogenous beta-endorphins, examine nonopioid modalities for postoperative pain control, and elucidate the applications of non-narcotic perioperative enhanced recovery after surgery protocols in improving patient outcomes.

Pain Management in Surgical Treatment of Facial Fractures: Alternative Approaches to Opioid Use

Study Design

Literature review.

Objective

This review aims to explore current opioid use trends for surgical management of facial fractures, as well as methods and alternative treatments to decrease opioid use.

Methods

Review of selected literature from Medline and Google Scholar.

Results

Despite the devastating effects of the opioid epidemic and recent policy changes aimed at reducing unnecessary opioid prescription, opioids remain commonly used for pain management after facial fracture repair. Recently, use of multimodal analgesic therapy has been suggested to decrease opioid dosage utilized for post-operative pain control. Alternatives to medication therapies have been proposed for pain management; however, standardized recommendations for pain management in facial fracture patients remain unclear.

Conclusions

Further research is required to establish evidence-based recommendations for pain management in craniofacial fracture repair.

Postoperative pain management using an intravenous combination of ibuprofen and acetaminophen compared with acetaminophen alone after thyroidectomy: A prospective randomized controlled trial

BACKGROUND

Multiple medications are more effective than single agents for postoperative pain management. We investigated the analgesic effects of an intravenous combination of acetaminophen and ibuprofen immediately after thyroidectomy.

METHODS

In this double-blind clinical trial, 62 patients who underwent thyroidectomies were randomized to either the treatment (1000 mg acetaminophen, 300 mg ibuprofen) or control (1000 mg acetaminophen) group. Postoperative pain intensity was assessed using the visual analog scale (VAS) 0, 15, and 30 min after recovery room admission. Opioid rescue consumption was also recorded.

RESULTS

The VAS scores were significantly lower in the treatment than in the control group 15 [3 (2-4.3) vs. 5 (3-6); p = 0.015] and 30 [3 (2-4.3) vs. 4 (3-5); p = 0.018] min after recovery room admission, as were the opioid rescue dose requirements (p = 0.033).

CONCLUSIONS

Combined intravenous acetaminophen and ibuprofen may be better than acetaminophen alone for immediately acute postoperative pain after thyroidectomy.

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

Effectiveness of low-intensity laser photobiomodulation in reducing inflammatory events (pain, edema, and trismus) after orthognathic surgery: a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

This systematic review aimed to answer whether, in (P) individuals undergoing orthognathic surgery, (I) low-level laser therapy (LLLT) during or shortly after the surgical procedure compared to (C) pharmacologic therapy alone or no therapy for improvement of post-intervention complications relieves (O) postoperative inflammatory events in (S) randomized clinical trials.

MATERIAL AND METHODS

A preliminary electronic search was conducted for references with language following a Latin (Roman) alphabet in seven databases index, and gray literature without restriction on language or publication period. Risk of bias was performed by RoB 2.0 tool, and meta-analysis used mean differences (MD) for edema and mouth opening and standardized mean differences (SMD) for pain scores (p < 0.05, Revman®).

RESULTS

A total of 91 control patients and 114 LLLT patients were included. The wavelengths ranged from 660 to 940 nm, and the applied energy density was between 5 and 100 J/cm2 at mostly extraoral distributed points. LLLT significantly reduced edema (MD =  - 4.27, CI95% - 5.13 to - 3.41 mm) in the period from 5 days to 2 weeks postoperatively (p < 0.001) and showed strongly reduced pain scores (SMD =  - 1.37, I95% =  - 1.99 to - 0.75) between 1 day and 5 weeks (p < 0.001), without significantly interfering with mouth opening (p = 0.110). Despite the low risk of bias, high heterogeneity among studies (I2 > 70%) and small sample sizes made the certainty of GRADE evidence low.

CONCLUSION

This SR demonstrated that LLLT effectively controls pain and edema after orthognathic surgery.

CLINICAL RELEVANCE

Systematic review that summarizes the use of photobiomodulation on orthognathic surgery.

Use of Photobiomodulation to Reduce Postoperative Pain, Edema, and Trismus After Third Molar Surgery: A Systematic Review and Meta-Analysis

PURPOSE

Third molar extraction can cause surgical trauma, which is associated with pain, edema, trismus, and functional limitations. The aim of the present systematic review was to investigate the effects of photobiomodulation (PBM) following the extraction of impacted mandibular third molars.

METHODS

An electronic search was conducted in 10 databases from inception up to October 2021 and the grey literature, with no restrictions regarding language or year of publication. Randomized controlled clinical trials (RCT) were included. Studies that were not RCTs were excluded. Reviewers independently analyzed titles and abstracts, followed by full-text analysis. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The exposure variable was the use of PBM and the outcomes were pain, edema, and trismus. Meta-analysis was performed using a random-effects model. The estimate was calculated considering standardized mean differences (SMD) and respective 95% confidence intervals (CI) obtained for each outcome on the first, second, third and seventh postoperative days. The level of evidence was assessed using the GRADE approach.

RESULTS

The search resulted in the 3,324 records. Thirty-three RCTs were included in the systematic review and 23 of these were included in the meta-analyses. The studies involved a total of 1,347 participants (56.6% female and 43.4% male) between 16 and 44 years of age. A greater reduction in pain was found in the PBM group compared to the control group on the third postoperative day (SMD: -1.09; 95% CI: -1.63; -0.55; P < .001; low certainty). Edema was discretely lower in the PBM group on the second postoperative day (SMD: -0.61; 95% CI: -1.09; -0.13; P < .001; low certainty) and trismus was discretely lower in the PBM group on the seventh postoperative day (SMD: 0.48; 95% CI: 0.00; 0.96; P < .001; very low certainty).

CONCLUSION

The evidence of the effect of PBM regarding the control of pain, edema, and trismus following third molar extractions is low or very low.

Parenteral Ready-to-Use Fixed-Dose Combinations Including NSAIDs with Paracetamol or Metamizole for Multimodal Analgesia-Approved Products and Challenges

The combination of non-steroidal anti-inflammatory drugs (NSAIDs) with non-opioid analgesics is common in clinical practice for the treatment of acute painful conditions like post-operative and post-traumatic pain. Despite the satisfactory results achieved by oral analgesics, parenteral analgesia remains a key tool in the treatment of painful conditions when the enteral routes of administration are inconvenient. Parenteral ready-to-use fixed-dose combinations of non-opioid analgesics combinations, including NSAIDs and paracetamol or metamizole, could play a central role in the treatment of painful conditions by combining the advantages of multimodal and parenteral analgesia in a single formulation. Surprisingly, only in 2020, a parenteral ready-to-use fixed-dose combination of ibuprofen/paracetamol was launched to the market. This review aims to investigate the current availability of combinations of NSAIDs with paracetamol or metamizole in both European and American markets, and how the combination of such drugs could play a central role in a multimodal analgesia strategy. Also, we explored how the parenteral formulations of NSAIDs, paracetamol, and metamizole could serve as starting elements for the development of new parenteral ready-to-use fixed-dose combinations. We concluded that, despite the well-recognized utility of combining NSAIDs with paracetamol or metamizole, several randomized clinical trial studies demonstrate no clear advantages concerning their efficacy and safety. Future clinical trials specifically designed to assess the efficacy and safety of pre-formulated fixed-dose combinations are required to generate solid evidence about their clinical advantages.

Post-operative pain management using two drugs following dental implant surgery among Indians

It is of interest to assess two drug regimens for managing pain and swelling in 40 dental implant surgery patients. Visual analogue scale readings were taken at 24 hours, 72 hours and 1 week. Data shows that a combination of acetaminophen and aceclofenac with trypsin - chymotrypsin was found to be more effective than acetaminophen alone.

Oxadiazole: A highly versatile scaffold in drug discovery

As a pharmacologically important heterocycle, oxadiazole paved the way to combat the problem associated with the confluence of many commercially available drugs with different pharmacological profiles. The present review focuses on the potential applications of five-membered heterocyclic oxadiazole derivatives, especially 1,2,4-oxadiazole, 1,2,5-oxadiazole, and 1,3,4-oxadiazole, as therapeutic agents. Designing new hybrid molecules containing the oxadiazole moiety is a better solution for the development of new drug molecules. The designed molecules may accumulate a biological profile better than those of the drugs currently available on the market. The present review will guide the way for researchers in the field of medicinal chemistry to design new biologically active molecules based on the oxadiazole nucleus. Antitubercular, antimalarial, anti-inflammatory, anti-HIV, antibacterial, and anticancer activities of various oxadiazoles have been reviewed extensively here.

Paracetamol for multimodal analgesia

Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.

Population Pharmacokinetic Modelling of Acetaminophen and Ibuprofen: the Influence of Body Composition, Formulation and Feeding in Healthy Adult Volunteers

BACKGROUND AND OBJECTIVE

Combined acetaminophen and ibuprofen are common antipyretic and analgesic drugs. Formulation and feeding affect drug absorption. Drug clearance has a nonlinear relationship with total body weight. The covariate effect of fat mass on acetaminophen and ibuprofen pharmacokinetics remains unexplored. This study sought to quantify acetaminophen and ibuprofen pharmacokinetics with intravenous, tablet, sachet and oral suspension formulations in fed and fasted states.

METHODS

Pooled time-concentration data for acetaminophen and ibuprofen were available from fasting and fed healthy adults. Data from intravenous, tablet, sachet and suspension formulations were analysed using nonlinear mixed-effects models. Body composition was considered as a covariate on clearances and volumes of distribution (V_d). Size metrics investigated were total body weight, fat and fat-free mass. Theory-based allometry was used to scale pharmacokinetic parameters to a 70 kg individual. A factor on absorption half-life and lag time quantified delays due to feeding for oral formulations. Pharmacokinetic-pharmacodynamic simulations were used to explore the time courses of pain response for acetaminophen and ibuprofen for each formulation.

RESULTS

Pooled data included 116 individuals (18-49 years, 49-116 kg) with 6095 acetaminophen and 6046 ibuprofen concentrations available for analysis. A two-compartment pharmacokinetic model with first-order elimination described disposition for both drugs. Normal fat mass was the best covariate to describe acetaminophen clearance (CL), with a factor for fat contribution (FFATCL) of 0.816. Acetaminophen volume of distribution was described using total body weight. Normal fat mass was the best covariate to describe ibuprofen clearance (FFATCL = 0.863) and volume of distribution: (FFATV = 0.718). Clearance and central volume of distribution were 24.0 L/h/70 kg and 43.5 L/h/70 kg for acetaminophen. Ibuprofen clearance and central volume of distribution were 3.79 L/h/70 kg and 10.5 L/h/70 kg. Bioavailability and absorption half-life were 86% and 12 min for acetaminophen and 94% and 27 min for ibuprofen. Absorption lag times were 5.3 min and 6.7 min for acetaminophen and ibuprofen, respectively. Feeding increased both absorption half-life and absorption lag time when compared to the tablet formulation under fasting conditions. Feeding had the most pronounced effect on the lag time associated with tablet formulation for both drugs. Time to a pain score reduction of 2 points (visual analogue score, 0-10) differed by only 5-10 min across all formulations for acetaminophen and ibuprofen.

CONCLUSION

Fat mass was an important covariate to describe acetaminophen and ibuprofen pharmacokinetics. The absorption half-lives of acetaminophen and ibuprofen were increased in fed states. The delay in absorption, quantified by a lag time, was protracted for both drugs.

Gender Variations in Pharmacokinetics of Paracetamol in Hausa/Fulani Ethnic group in Northwest Nigeria - A Two-stage Approach

Background:

Paracetamol is one of the most commonly used drugs worldwide and has been linked to drug-related liver damage, even when taken at recommended doses. Ingesting the upper limit of recommended doses of the drug produced a doubling of mortality when compared to not taking the drug. Acetaminophen ingestion has been implicated in the development of angioedema, the exasperation of asthma, and urticaria in patients with aspirin intolerance.

Aim:

This study aimed at assessing gender variations in the pharmacokinetics of paracetamol in Hausa/Fulani, the most populous ethnic group in Nigeria and determines a possibility of toxicity in the group.

Methods:

It was an exploratory study involving twenty participants selected by criterion sampling who satisfied inclusion criteria. They were fasted 11-h preceding acetaminophen administration to 3 h after administration. A single dose of acetaminophen, 1 g orally with 300 ml of distilled water, was administered at 8 A. M. Blood was obtained before the administration and 15, 30, and 45 min, and 1, 2, 3, 4, 5, and 6 h after the administration. Acetaminophen plasma concentrations were determined by validated reverse-phase high-performance liquid chromatography Food and Drug Administration guidelines.

Results:

Six out of 19 (31.6%) participants have higher than maximum therapeutic plasma concentration (>20 μg/ml). Pharmacokinetics parameters were higher in males except for clearance and volume of distribution.

Conclusion:

Clearance from the plasma tends to be more for females than their male counterparts. A good proportion of Hausa/Fulani is prone to acetaminophen toxicity at a therapeutic dose.

Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management

BACKGROUND

Dentists commonly prescribe opioids and are the highest prescribers of opioids to patients 18 years and younger. Little is known about dentists' beliefs regarding opioids and other analgesics.

METHODS

The authors conducted a national survey of dentists about their opioid prescribing habits, perceptions regarding opioid effectiveness, beliefs about patient behaviors, and relationships with drug and equipment manufacturers.

RESULTS

The authors received 291 responses from 30 states and 2 territories and analyzed 269 completed surveys. Although 84% of respondents reported believing that nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are equally as effective or more effective than opioids, 43% of respondents also reported regularly prescribing opioid medications. Of those who reported prescribing opioids, 9 of 10 reported they were less likely to prescribe opioids to adolescents aged 11 through 18 years, but only 48% reported they were less likely to prescribe opioids to young adults aged 19 through 25 years. One-half of those who reported prescribing opioids reported prescribing in amounts that would result in unused medication, and 69% reported having had patients divert or misuse opioids. Few dentists reported industry interactions.

CONCLUSIONS

The continued prescription of opioids contradicts mounting evidence about the superiority of NSAIDs over opioids in dentistry. Continuing dental education, increased use of prescription drug monitoring programs, and the development of national guidelines are necessary to align clinical practice with current evidence.

PRACTICAL IMPLICATIONS

Dentists should seek to minimize opioid prescribing and pill counts and instead opt for safer, more effective NSAID-acetaminophen combinations. Dentists also should refrain from prescribing opioids to patients younger than 25 years because of the high risk of experiencing addiction in this population.

An Analgesic Regimen for Opioid Reduction in Elective Plastic Surgery: A Randomized Prospective Study

BACKGROUND

Prescription opioid misuse has been recognized as a national epidemic. The implications of this problem are especially important to consider, as postoperative opioid abuse can give rise to true addiction for surgical patients. The concept of enhanced recovery after surgery is increasingly used across various specialties to decrease the overabundance of postoperative opioid use.

METHODS

This study prospectively examined 143 patients undergoing cosmetic elective surgery. Patients were randomized into one of two groups based on postoperative pain management regimen: multimodal (enhanced recovery after surgery) analgesia or traditional opioid analgesia. Data regarding postoperative pain scores, amount of postoperative opioids consumed, and duration of postoperative pain pill use were analyzed.

RESULTS

Multimodal (enhanced recovery after surgery) regimen patients experienced a 13.0 percent reduction in their pain scores after admission to the postanesthesia care unit and a 34.2 percent reduction in pain score at discharge, compared with traditional opioid patients (p = 0.049 and p = 0.0036, respectively). Enhanced recovery after surgery patients experienced a 35 percent reduction in the number of pills taken in the postoperative period and an 18.4 percent reduction in the duration of consumption (p = 0.0007 and p = 0.0539, respectively).

CONCLUSIONS

The results demonstrate that multimodal postoperative pain management is an important tool for decreasing the amount of opioids prescribed and needed in the postoperative period. The overprescribing of opioids after surgery is a precursor to abuse and the increase in the national opioid reservoir.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Extending the safety profile of the post-operative administration of an intravenous acetaminophen/ibuprofen fixed dose combination: An open-label, multi-center, single arm, multiple dose study

PURPOSE

Postoperative pain is typically treated with multimodal analgesia, using systemic acetaminophen and/or nonsteroidal anti-inflammatory drugs in conjunction with opioids as required. The present study aimed to determine the safety and tolerability of repeated doses of an intravenous fixed-dose combination (FDC) of acetaminophen and ibuprofen.

METHODS

This multicenter, open-label, single arm, multiple dose study was conducted at 4 centers across New Zealand and the United States between July 2019 and July 2020. Adults (>18 years) requiring multiple doses of parenteral nonopioid analgesics over multiple days following non-laparoscopic general, plastic or orthopedic surgery were eligible. The study drug (acetaminophen 1000 mg+ibuprofen 300 mg) was administered 6-hourly as a 5 min infusion for between 48 h and 5 days. Adverse event data was collected throughout the study, in addition to scheduled vital sign assessments, laboratory tests and electrocardiograms. Participants completed a global evaluation of the FDC at the end of the treatment period.

FINDINGS

232 participants received ≥ 1 dose of the FDC. Most were female (62.1%), White (56.5%) or Black or African American (39.2%), and had undergone orthopedic surgery (85.3%). There was a broad age range (19-87 years), with a mean age of 53.4 years, and 26.3% of participants aged ≥ 65 years. The FDC was safe when used for 48 h to 5 days. Treatment-emergent adverse events (TEAEs) affected 56.0% of participants, the most common were infusion site pain, nausea, infusion site extravasation, constipation, and headache. Minimal changes in vital signs were observed at scheduled timepoints. No clinically significant changes in electrocardiogram assessments occurred. Transient elevations in the hepatic enzymes ALT and AST to < 3 times the upper limit of normal (ULN) affected 10.5% and 9.6% of subjects, elevations to ≥ 3 times the ULN affected 2.6% and 2.2% of subjects, respectively. There were no apparent differences in the safety profile of the FDC in older participants. The FDC was well tolerated; most TEAEs were mild or moderate in severity. Five participants discontinued treatment due to TEAEs, none were considered treatment-related. The FDC was perceived well by study participants; the majority rated their experience as 'excellent' (40.1%) or 'very good' (35.3%).

IMPLICATIONS

The safety profile was comparable to previous studies with no novel safety concerns. The FDC was safe, well tolerated, and perceived positively by participants treated for acute pain between 48 h and 5 days following orthopedic or plastic surgery, supporting a favorable risk benefit profile.

Efficacy and Safety of Ibuprofen Plus Paracetamol in a Fixed-Dose Combination for Acute Postoperative Pain in Adults: Meta-Analysis and a Trial Sequential Analysis

BACKGROUND

Ibuprofen and paracetamol (acetaminophen) are very commonly used for analgesia and pain. In 2020, the US FDA gave its first approval of a fixed-dose combination (FDC) of the two drugs in the same tablet for postoperative pain. There has been no quantitative, summative analysis of the FDC effect size measures against postoperative pain in adults. Similar analyses exist, but only in pediatric patients.

OBJECTIVE

This was the first meta-analysis to compare the efficacy and safety outcomes of the ibuprofen/paracetamol FDC against placebo, administered postoperatively, for moderate to severe pain relief in adults.

METHODS

The MEDLINE, EMBASE, and Cochrane CENTRAL databases, in addition to the grey literature, were searched for clinical trials until April 2020, to identify comparative literature studies of the ibuprofen/paracetamol FDC in acute postoperative pain in adults. No restrictions on doses, formulations (oral, intravenous), and underlying type of surgery were applied. Independent reviewers performed the study selection, data extraction, and the risk-of-bias and quality-of-evidence assessments based on the Cochrane criteria. The outcome measures of interest in the meta-analysis were ≥ 50% pain relief , need for rescue medications, and occurrence of adverse drug events. Statistical analyses using a random-effects model were performed, at a statistical significance of p < 0.05. The RevMan software was used for analysis. A trial sequential analysis (TSA) was conducted to assess how precise and conclusive the meta-analysis outcomes are.

RESULTS

Seven double-blind, randomized controlled trials with 2947 participants were included. The FDC dose was at three different levels: 75-100 mg ibuprofen/250 mg paracetamol, 150-200 mg ibuprofen/500 mg paracetamol (FDA-approved dose level), and 292.5-400 mg ibuprofen/975-1000 mg paracetamol. The ≥ 50% pain relief outcome was more achieved with the FDC compared to placebo (risk ratio [RR] 2.60, 95% confidence interval [CI] 2.11-3.20, p < 0.00001), as was the reduced need for rescue medications (RR 0.51, 95% CI 0.37-0.71, p < 0.0001). While inconclusive based on TSA, the FDC was at the highest doses at least as well tolerated as placebo regarding the occurrence of adverse events, including severe, common, and treatment-related adverse events, as well as those that lead to discontinuation, but it was also significantly associated with lower rates of headache and nausea. Subgroup analyses confirmed that the efficacy and safety of the FDC were maintained regardless of doses and formulations. The sensitivity analysis confirmed outcomes against potential publication bias and identified sources of heterogeneity in analyses.

CONCLUSION

The ibuprofen plus paracetamol FDC is conclusively an effective analgesic against placebo in acute postoperative, moderate to severe pain in adults. It is also superiorly well tolerated, including at the higher dose of 292.5-400 mg ibuprofen/975-1000 mg paracetamol; however, safety outcomes were inconclusive. Future studies need to confirm the safety of FDC and its benefits against other marketed analgesics in postoperative pain.

Does Low-Level Laser Photobiomodulation Improve Neurosensory Recovery After Orthognathic Surgery? A Clinical Trial With Blink Reflex

PURPOSE

Evidence shows that low-level laser therapy (LLLT) may shorten the recovery time of healing wounds. This study sought to assess the effect of LLLT on the recovery time of neurosensory deficits after Le Fort I osteotomy and bilateral sagittal split osteotomy using the blink reflex.

METHODS

This randomized double-blind clinical trial evaluated 12 patients undergoing orthognathic surgery of the maxilla/mandible. One random quadrant of the maxilla/mandible underwent 810 nm gallium-aluminum-arsenide laser (infrared spectrum, 200 mW, 12 J/cm², 60-second irradiation time of each point, continuous-wave mode), while the laser handpiece was used in off mode for the other quadrant, postoperatively. The patients underwent LLLT at 1, 5, 10, and 14 days, postoperatively. The blink test was performed to assess the function of the trigeminal nerve, and the 2-point discrimination (TPD) test was performed to assess the recovery of the inferior alveolar nerve (IAN) and the infraorbital nerves at 30 and 90 days, postoperatively. Data were analyzed using the Mann-Whitney U test (alpha = 0.05).

RESULTS

Six women and 6 men were evaluated (mean age = 23.41 ± 5.03 years). Both groups showed significant improvement in function of the IAN and infraorbital nerves, postoperatively in blink reflex test (P < .05). In the TPD test, although both groups showed significant improvement of the IAN compared with the baseline (P < .05), the IAN showed significantly greater improvement by 1.1% in the laser group (P = .036). The percentage of change was significantly smaller in the laser group in R1 (by 14%; P = .025) and R2C wavelengths of the IAN and in the TPD test of the IAN (by 20%; P = .021), showing significantly greater improvement in laser group.

CONCLUSIONS

LLLT with 810-nm diode laser can accelerate the recovery from paresthesia after orthognathic surgery. The blink reflex can be used as a quantitative index for neurosensory assessment in line with subjective clinical tests such as the TPD test.

Pediatric Post-Tonsillectomy Opioid Prescribing Practices

OBJECTIVE

To evaluate the effect of discharge order sets on prescribing patterns of opioids after pediatric tonsillectomy. Secondary outcomes included encounters for postoperative pain, dehydration, and bleeding.

METHODS

Retrospective chart review of pre- and post-intervention in pediatric post-tonsillectomy patients, 0-18 years old (n = 1486). Order sets were installed with age-specific analgesic medication defaults and recommendation of concurrent alternating scheduled ibuprofen and acetaminophen. Time-balanced pre- and post-intervention cohorts were established. Opioid outcomes calculated in morphine milligram equivalents per kilogram (MME/kg) per dosage and total prescribed.

RESULTS

Discharge order set intervention resulted in 17% reduction of opioid dose prescribed (0.095 MME/kg [95% CI, 0.092-0.099] vs. 0.079 [95% CI, 0.076-0.083], P < .001). Total number of opioid doses prescribed was reduced after order set implementation (46.4 [95% CI, 43.6-49.1] to 20.3 [95% CI, 19.1-21.5], P < .001). Patients <7 years old prescribed opioids remained rare in pre- and post-intervention groups (1.6% and 1.8%, respectively, P = .86). Admissions and emergency department visits for postoperative dehydration and pain were significantly reduced. Post-intervention group showed an increase in readmissions for post-tonsillectomy hemorrhage (9.2% vs. 5.2%, P = .003) which was isolated to an increase in the older post-intervention group after stratification by age.

CONCLUSION

Utilization of order sets with standardized analgesic medication regimen of acetaminophen, ibuprofen, and opioid helped effectively reduce opioid amount per dose, total opioid amount dispensed, and variability in the total opioid amount dispensed while maintaining pain control. An increase in post-tonsillectomy hemorrhage was recognized following this implementation which did not persist after the study period despite continuation of intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1386-1391, 2021.

Effect of Diclofenac Potassium Premedication on Postendodontic Pain in Mandibular Molars with Symptomatic Irreversible Pulpitis: A Randomized Placebo-Controlled Double-Blind Trial

INTRODUCTION

The aim of this prospective, randomized, double-blind clinical trial was to evaluate the effect of a preoperative, single, oral dose of diclofenac potassium (DFK) on postoperative pain and rescue analgesic intake in patients with symptomatic irreversible pulpitis in mandibular molars treated in 1 visit.

METHODS

Seventy emergency patients with moderate to severe preoperative pain randomly received either 50 mg DFK or placebo tablets 1 hour before starting endodontic treatment (n = 35 per group). Patients recorded their pain level 6, 12, 24, and 48 hours after treatment on a 170-mm Heft-Parker visual analog scale. The incidence of rescue analgesic intake was also recorded. Outcome data were statistically analyzed using Mann-Whitney U, Friedman, Wilcoxon signed rank, and chi-square tests. Binary logistic regression assessed the association of predisposing factors with postoperative pain. The significance level (α) was set at 0.05.

RESULTS

Of the 70 patients, 68 were analyzed (n = 34 per group). Both groups had similar baseline characteristics (P > .05). DFK showed significantly less pain incidence and intensity than the placebo at 48 hours only (P < .05). A significant decrease occurred from 24 to 48 hours with DFK (P < .05), which was not recorded with the placebo (P > .05). No difference in the incidence of rescue analgesic intake was reported between groups (P > .05). Food intake timing, sex, and rescue analgesic intake were associated with postoperative pain (P < .05).

CONCLUSIONS

Premedication by a single, oral dose of 50 mg DFK could be effective in reducing postendodontic pain at 48 hours after 1-visit endodontic treatment in mandibular molars with symptomatic irreversible pulpitis.

Anti-Inflammatory and Anticoagulant Activities of Synthesized NSAID Prodrug Esters

Paracetamol with ibuprofen or with naproxen are frequently prescribed by doctors in combination. It was found that patients using a combination of NSAID like acetaminophen and ibuprofen experienced less pain. Patients are more compliant if these two drugs are combined in an ester form and given in one dosage form. The esterified prodrugs are hydrolyzed in humans to their active forms. In this study, two esters of paracetamol combined with ibuprofen and naproxen were synthesized as prodrugs. The physiochemical properties of these products were identified. Moreover, the bioactivities of these prodrugs were tested for its anti-inflammatory and anticoagulant activities. The results showed an improved COX inhibition and anticoagulant activity compared with their parent drugs. The synthesized drugs are expected to improve patient's compliance in terms of administration frequency and will have better pharmacokinetic properties with fewer side effects.

A target concentration strategy to determine ibuprofen dosing in children

BACKGROUND

Ibuprofen is widely used for ductus arteriosus closure in premature neonates and for analgesia in children and adults. There are no maturation descriptors of clearance. This lack of maturation understanding limits dosing recommendations from premature neonates to adulthood.

METHODS

Published clearance estimates from different aged patients determined after administration from time-concentration profiles were used to construct a maturation model based on size and age. Curve fitting was performed using nonlinear mixed-effects models. A target concentration strategy was used to estimate maintenance dose at different ages.

RESULTS

There were three publications reporting an estimate of individual clearance estimates in premature neonates, three reporting population clearances in infants, 11 in children 2-15 years (1 with individual and 9 with population clearances), and 13 adult studies (1 with individual and 12 with population clearances). Clearance maturation, standardized to a 70 kg person was described using the Hill equation. Mature clearance was 3.81 (CV 15.5%, 95%CI 3.72, 3.92) L/h/70 kg. The maturation half-time was 36.8 (CV 9.2%, 95%CI 34.7, 40.9) weeks postmenstrual age and the Hill coefficient 11.5 (95%CI 8.1, 15). A target effect of four units (visual analogue scale 0-10) correlated with an effect site concentration of 6.3 mg/L: a concentration achieved at trough after 400 mg 8 hourly in adults.

CONCLUSION

Previously published pharmacokinetic parameters can be used to develop maturation models that address gaps in current knowledge regarding the influence of age on a drug's disposition. Maturation of ibuprofen clearance was rapid and was 90% of adult values by the first month of life in term neonates (ie, 44 weeks postmenstrual age) and 98% of standardized adult estimates by 3 months of age (53 weeks postmenstrual age). Clearance informed dosing predictions in all ages (premature neonate to adult) and matched those doses in common use in children older than 3 months.

Optimizing opioid prescribing and pain treatment for surgery: Review and conceptual framework

Purpose

Millions of Americans who undergo surgical procedures receive opioid prescriptions as they return home. While some derive great benefit from these medicines, others experience adverse events, convert to chronic opioid use, or have unused medicines that serve as a reservoir for potential nonmedical use. Our aim was to investigate concepts and methods relevant to optimal opioid prescribing and pain treatment in the perioperative period.

Methods

We reviewed existing literature for trials on factors that influence opioid prescribing and optimization of pain treatment for surgical procedures and generated a conceptual framework to guide future quality, safety, and research efforts.

Results

Opioid prescribing and pain treatment after discharge from surgery broadly consist of 3 key interacting perspectives, including those of the patient, the perioperative team, and, serving in an essential role for all patients, the pharmacist. Systems-based factors, ranging from the organizational environment’s ability to provide multimodal analgesia and participation in enhanced recovery after surgery programs to other healthcare system and macro-level trends, shape these interactions and influence opioid-related safety outcomes.

Conclusions

The severity and persistence of the opioid crisis underscore the urgent need for interventions to improve postoperative prescription opioid use in the United States. Such interventions are likely to be most effective, with the fewest unintended consequences, if based on sound evidence and built on multidisciplinary efforts that include pharmacists, nurses, surgeons, anesthesiologists, and the patient. Future studies have the potential to identify the optimal amount to prescribe, improve patient-focused safety and quality outcomes, and help curb the oversupply of opioids that contributes to the most pressing public health crisis of our time.

Efficacy and Safety of an Intravenous Acetaminophen/Ibuprofen Fixed-dose Combination After Bunionectomy: a Randomized, Double-blind, Factorial, Placebo-controlled Trial

PURPOSE

Multimodal analgesia with acetaminophen and/or nonsteroidal anti-inflammatory drugs is recommended for the treatment of postoperative pain. Although oral fixed-dose combinations (FDCs) are available, parenteral administration may be clinically justified. The goal of this study was to investigate the clinical efficacy and safety of an intravenous FDC of ibuprofen and acetaminophen after bunionectomy.

METHODS

This study was a prospective, randomized, double-blind, multicenter, placebo-controlled factorial clinical trial conducted at 2 clinical research centers in the United States between November 2016 and June 2017. Eligible patients (male and female subjects, aged 18-65 years, reporting pain intensity levels ≥40 mm on a 100-mm visual analog scale (VAS) after distal, first metatarsal bunionectomy) were randomized (3:3:3:2) to receive the FDC (ibuprofen 300 mg + acetaminophen 1000 mg), ibuprofen 300 mg, acetaminophen 1000 mg, or placebo (vehicle), administered as 15-minute intravenous infusions every 6 hours for 48 hours. The primary efficacy end point was the time-adjusted sum of pain intensity differences from baseline over 48 hours (SPID₄₈). In addition to VAS pain intensity scores, pain relief scores, time to perceptible and meaningful pain relief, the use of rescue medication, and participant's global evaluations of the study drug were recorded. Adverse events occurring during the 48-hour treatment period were included in the safety analysis.

FINDINGS

A total of 276 participants were enrolled; most were female (82%), the mean age was 42.4 years, and the median baseline VAS was 67 mm, indicating moderate to severe pain. SPID₄₈ was significantly higher for the FDC (23.4 [2.5] mm) than for ibuprofen (9.5 [2.5] mm), acetaminophen (10.4 [2.5] mm), and placebo (-1.3 [3.1] mm; all, P < 0.001). The superior analgesic effect of the FDC was supported by a range of secondary end points, including reduced opioid usage rates (75% for FDC, 92% for ibuprofen, 93% for acetaminophen, and 96% for placebo; all, P < 0.005). The safety profile of the FDC was comparable to that of intravenous ibuprofen or acetaminophen alone. Three participants withdrew from the study due to adverse events: 2 in the ibuprofen group and 1 in the acetaminophen group.

IMPLICATIONS

The study found that repeated administration of an intravenous FDC of ibuprofen and acetaminophen provided statistically significant improvement in SPID₄₈ over comparable doses of either monotherapy without an increase in adverse events. ClinicalTrials.gov identifier: NCT02689063.

Synthesis and Evaluation of Glycyrrhetic Acid-aromatic Hybrids as Antiinflammatory Agents

BACKGROUND

Inflammation is a biological response of body tissues to harmful stimuli, so it is desirable to search for novel anti-inflammatory agents with improved pharmaceutical profiles and reduced adverse effects.

OBJECTIVE

This study was to explore natural anti-inflammatory agents and improve therapeutic application of glycyrrhetic acid (GA) through molecular hybridization with active aromatics.

METHODS

Fourteen novel GA-aromatic hybrids were synthesized and evaluated for their antiinflammatory activities by inhibiting LPS-induced nitric oxide (NO) release in RAW264.7 cells. The synthesized compounds were characterized by single-crystal X-ray diffraction, 1H NMR, 13C NMR and HRMS.

RESULTS

The structure-activity relationship (SAR) study indicated that compounds with styryl displayed better NO inhibitory activity. Among them, compounds 2a and 3c exhibited the most promising activity with IC50 values of 9.93 μM and 12.25 μM, respectively. In addition, X-ray singlecrystal diffraction data for compounds 2e and 3c showed that the absolute configuration of GA skeleton was consistent with that of natural 18 β-glycyrrhetic acid.

CONCLUSION

The results showed that GA-aromatic hybrids were a new class of anti-inflammatory agents and this study provided useful information on further optimization.

An integrated safety analysis of combined acetaminophen and ibuprofen (Maxigesic /Combogesic®) in adults

INTRODUCTION

Acetaminophen (APAP) and ibuprofen (IBP) are two analgesic compounds with a long history of use. Both are considered safe at recommended over-the-counter daily doses. Chronic use, high doses, or concomitant medication can produce safety risks for both drugs. APAP is associated with increased risk of hepatic injury, while IBP can produce gastric bleeding and thromboembolic events. Using a combination of APAP and IBP provides superior analgesia without transgressing daily dose limits of each individual drug.

METHODS

The present study aimed to determine if treatment with a fixed-dose combination (FDC) containing APAP and IBP results in any unexpected adverse events (AEs) and/or changes in the safety profiles of its two ingredients compared to monotherapy. The analysis will examine clinical safety data obtained from either single dose trials, multiple dose trials, a long-term exposure trial, and post-marketing surveillance data of APAP/IBP FDC tablets (Maxigesic®/Combogesic®, AFT Pharmaceuticals Ltd). The largest dataset was obtained by pooling the four randomized-controlled, multiple-dose clinical studies with either APAP 325 mg + IBP 97.5 mg (FDC 325/97.5, three tablets per dose) or APAP 500 mg + IBP 150 mg (FDC 500/150, two tablets per dose). At maximum doses, the two FDCs are bioequivalent, permitting the pooling of data for the analysis of safety.

RESULTS

A safety population of 922 patients who received full doses of either FDC, APAP alone, IBP alone, or placebo was compiled from the four studies. A total of 521 AEs were experienced with the incidence of FDC AEs similar to or below either monotherapy group or placebo. The FDC did not alter the incidence and percentage of the most common AEs, including gastrointestinal events and postoperative bleeding.

CONCLUSION

Overall, the FDC is well tolerated and has a strong safety profile at single and multiple doses with improved efficacy over monotherapy.

Novel immediate/sustained-release formulation of acetaminophen-ibuprofen combination (Paxerol®) for severe nocturia associated with overactive bladder: A multi-center, randomized, double blinded, placebo-controlled, 4-arm trial

Aim

To determine short‐term efficacy and safety of Paxerol®, novel immediate:sustained (50%:50%) release tablets containing 325 mg acetaminophen and 150 mg ibuprofen per tablet.

Methods

One of three dose levels, corresponding to the amounts in 1, 2, and 3 tablets, of Paxerol and placebo were administered for 14 consecutive days to patients with severe nocturia (defined in this study as an average nocturnal voids [NV] ≥2.5) associated with overactive bladder (OAB). Changes in NV, as well as Nocturia Quality of Life (NQOL), duration of first uninterrupted sleep (DFUS), and total hours of nightly sleep (THNS) associated with treatment were assessed. Short‐term safety/tolerability was assessed throughout the study and for at least 30 days post‐treatment.

Results

Paxerol at all three doses reduced NV to a greater degree than placebo (average NV −1.1, −1.4, −1.3 voids for low, mid, and high doses, respectively, vs −0.3 void for placebo). NQOL and THNS were similar between baseline and treatment values in all four groups. There were also no between‐group differences. Paxerol at high dose tended to (although not statistical significantly) increase DFUS to a greater degree than placebo (1.2 vs 0.4 h, P = 0.057). There were no treatment related adverse events in any of the four groups.

Conclusions

This study demonstrates short‐term efficacy and short‐term safety of Paxerol in patients with severe nocturia associated with OAB. The results warrant further investigation of the long‐term efficacy and safety of Paxerol in larger patient populations.

Analgesic effectiveness, pharmacokinetics, and safety of a paracetamol/ibuprofen fixed-dose combination in children undergoing adenotonsillectomy: A randomized, single-blind, parallel group trial

BACKGROUND

Pain following tonsillectomy is often poorly managed in the home setting. Multimodal analgesia with acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs offers superior analgesia over monotherapy but may be difficult for caregivers to manage. A fixed-dose combination oral suspension product containing paracetamol and ibuprofen has been developed to facilitate pediatric dosing.

AIMS

The aims of this study are to determine the analgesic effectiveness, pharmacokinetics, and safety of the fixed-dose combination at two doses in the pediatric population.

METHODS

In this prospective, multicenter, randomized, single-blind, parallel group trial, 251 children aged 2-12 years undergoing day-stay (adeno)tonsillectomy were randomized to two dose groups of the fixed-dose combination. A doubled loading dose was given preoperatively, followed by treatment for up to 11 days (Higher dose: paracetamol 15 mg/kg + ibuprofen 4.5 mg/kg, Lower dose: paracetamol 12 mg/kg + ibuprofen 3.6 mg/kg). Blood samples were collected for pharmacokinetic analysis for up to 6 hours after the loading dose. The analgesic effectiveness was examined on the first day after surgery using both Parents Postoperative Pain Measurement and modified Wong-Baker Faces pain scales. Rescue medication consumption was recorded throughout the study.

RESULTS

Differences in maximum plasma concentration (C_max ) and total exposure (AUC_0→t ) between the treatment groups for both analytes were consistent with a 25% increase in dose; there was no difference in time to peak concentration (T_max ). On the first postoperative day, there was no difference in pain scores or rescue medication use between treatment groups (approximately 30% in both groups). The combination was well tolerated by both groups. The most common adverse events were vomiting and nausea. The incidence of postoperative bleeding was 4.4%.

CONCLUSION

The shallow dose-response relationship and good tolerability of the fixed-dose combination over an extended study period supports the utility of both doses of the fixed-dose combination in the home setting.

Acetaminophen, ibuprofen, and tramadol analgesic interactions after adenotonsillectomy

BACKGROUND

The impact of tramadol in children given acetaminophen-ibuprofen combination therapy is uncertain in acute pediatric pain management. A model describing the interaction between these three drugs would be useful to understand the role of supplemental analgesic therapy.

METHODS

Children undergoing tonsillectomy were given oral paracetamol and ibuprofen perioperatively. Blood was taken for paracetamol and ibuprofen drug assay on up to six occasions over 6 h after the initial dose. Tramadol was administered by caregivers for unacceptable postoperative pain. Pain was measured using the Parent's Postoperative Pain Measurement rating two hourly on the first postoperative day. A first-order absorption, one-compartment linear model with first-order elimination was used to describe acetaminophen and ibuprofen disposition. Analgesia was described using an E_MAX model extended for three drugs, assuming additive effects. Curve fitting was performed using nonlinear mixed effects models.

RESULTS

Pharmacodynamic parameter estimates, expressed using fractional Hill equation, were maximum effect (E_MAX ) 0.65 (95%CI 0.54, 0.74), the concentration of acetaminophen associated with 50% of the maximal drug effect (C_50,ACET ) 7.06 (95%CI 7.03, 7.72) mg/L, and the ibuprofen C₅₀ (C_50,IBU ) 3.95 (95%CI 2.57, 7.53) mg/L. The Hill coefficient was 1.48 (95%CI 0.92, 2.62) and an interaction term was fixed at zero (additivity). The half-time (t_1/2 keo) for equilibration between the plasma and effect site was 0.34 hour (95%CI 0.23, 1.98) for acetaminophen and 1.04 hour (95%CI 0.75, 1.77) for ibuprofen. Tramadol had a C_50,TRAM of 0.07 (95%CI 0.048, 1.07) mg/L with a t_1/2 keo,_TRAM 1.78 hour (95%CI 1.06, 1.96).

CONCLUSION

Ibuprofen has an EC₅₀ for analgesia in children similar to that of adults (3.95 mg/L; 95%CI 2.57-7.53, vs 5-10 mg/L adults). The maximum effect from combination therapy (ie, 65% reduction in pain score) achieves satisfactory analgesia with commonly used doses but increased dose adds little additional benefit. The addition of tramadol to this analgesic mixture prolongs analgesia duration.

Analgesic Efficacy of an Acetaminophen/Ibuprofen Fixed-dose Combination in Moderate to Severe Postoperative Dental Pain: A Randomized, Double-blind, Parallel-group, Placebo-controlled Trial

PURPOSE

Acute pain is a significant burden to the individual and to society. There is a clear need for a pain medication that provides improved analgesia over common analgesics, without compromising tolerability. The goal of this study was to determine the efficacy of a new fixed-dose combination of acetaminophen 975 mg and ibuprofen 292.5 mg (FDC 975/292.5) relative to acetaminophen or ibuprofen monotherapy, or placebo.

METHODS

This prospective, multicenter, randomized, double-blind, placebo-controlled, Phase III trial included 408 adult volunteers aged 18 to 60 years experiencing moderate to severe pain after surgical removal of at least 2 impacted third molars. Subjects were randomized in a 3:3:3:2 ratio to the following interventions: FDC 975/292.5, acetaminophen 975 mg, ibuprofen 292.5 mg, and placebo. Self-reported pain intensity scores were recorded over a 48-hour double-blind treatment period using a 100-mm visual analog scale. In addition, time to perceptible and meaningful pain relief was assessed by using the two-stopwatch method; use of rescue medication (oxycodone) was recorded; and patients rated their pain relief on a 5-point categorical scale. All adverse events during the 30-day study period were assessed.

FINDINGS

The majority of participants were female (67.4%) and white (90.0%), with a mean age of 24.8 years. Demographic and baseline characteristics were balanced across treatment groups, with a mean baseline pain score of 56.4 mm. The primary end point was the time-adjusted sum of pain intensity differences over 48 hours, which was found to be significantly greater for FDC 975/292.5 than for both monotherapies and placebo (all, P < 0.001). The robustness of the procedures used in the calculation of the primary end point was confirmed in a series of sensitivity analyses. Statistical superiority of the combination was evident in all secondary end points (time to meaningful pain relief, maximum pain score, response rate, participants using supplementary analgesia, time to rescue, oxycodone consumption, and categorical pain relief score) with the exception of time to perceptible pain relief versus monotherapies and the time to peak response versus ibuprofen. The percentage of patients reporting adverse events was 37.3% in the FDC 975/292.5 group, with no significant differences between treatment groups. Nausea was the most common adverse event across all groups.

IMPLICATIONS

Overall, the fixed-dose combination of acetaminophen and ibuprofen provided greater and more rapid analgesia than comparable doses of either agent alone or placebo in adults after removal of impacted third molars. ClinicalTrials.gov identifier: NCT01420653.

Effects of low-level laser therapy following surgical extraction of the lower third molar with objective measurement of swelling using a three-dimensional system

The aim of the present study was to evaluate and compare the effects of single- and two-dose low-level laser therapy (LLLT) on the postoperative swelling, trismus and pain of patients undergoing extraction of impacted mandibular third molars. In addition, edema was volumetrically measured with a 3dMD face system. A total of 45 patients were randomly divided into three treatment groups (15 patients in each group) as follows: Group 1, receiving routine management with ice application and serving as the control group; Group 2, receiving a single dose of LLLT immediately following surgery; and Group 3, receiving two doses of LLLT, immediately following surgery and on day 2 after surgery. In the present study, a gallium-aluminum-arsenide (0.3 W, 40 sec, 4 J/cm²) diode laser device was applied extraorally at the insertion point of the masseter muscle. The trismus, pain level and facial swelling of the patients were evaluated. The visual analog scale (VAS) was used to examine the pain degree, while a 3dMD face photogrammetric system was used to evaluate the volumetric alterations of the swelling. The results indicated no statistically significant differences in the mean swelling or trismus among the three groups. The mean VAS measurements did not differ significantly among the groups at postoperative day 2; however, significantly reduced VAS values were observed in Group 2 compared with Group 1 at postoperative day 7 (P<0.05). The present study demonstrated that, although single-dose or two-dose LLLT had beneficial effects on the swelling, trismus and pain level, a significant reduction was only observed in the pain level at postoperative day 7.

Low-level laser therapy for treatment of neurosensory disorders after orthognathic surgery: A systematic review of randomized clinical trials

BACKGROUND

Low-level laser has been widely used in Dentistry and many studies have focused on its application in oral surgeries. This study was conducted with the aim of searching for scientific evidence concerning the effectiveness of laser to reduce pain or paresthesia related to orthognathic surgery.

MATERIAL AND METHODS

An electronic search was performed in PubMed, Scopus, Science Direct, LILACS, SciELO, CENTRAL, Google Scholar, OpenGrey, and ClinicalTrials.gov, up to November 2016, with no restrictions on language or year of publication. Additionally, a hand search of the reference list of the selected studies was carried out. The PICOS strategy was used to define the eligibility criteria and only randomized clinical trials were selected.

RESULTS

Out of 1,257 identified citations, three papers fulfilled the criteria and were included in the systematic review. The risk of bias was assessed according to the Cochrane Guidelines for Clinical Trials and results were exposed based on a descriptive analysis. One study showed that laser therapy was effective to reduce postoperative pain 24 hours (P=0.007) and 72 hours (P=0.007) after surgery. Other study revealed the positive effect of laser to improve neurosensory recovery 60 days after surgery, evaluated also by the two-point discrimination (P=0.005) and sensory (P=0.008) tests. The third study reported an improvement for general sensibility of 68.75% for laser group, compared with 21.43% for placebo (P=0.0095), six months after surgery.

CONCLUSIONS

Individual studies suggested a positive effect of low-level laser therapy on reduction of postoperative pain and acceleration of improvement of paresthesia related to orthognathic surgery. However, due to the insufficient number and heterogeneity of studies, a meta-analysis evaluating the outcomes of interest was not performed, and a pragmatic recommendation about the use of laser therapy is not possible. This systematic review was conducted according to the statements of PRISMA and was registered at PROSPERO under the number CRD42016043258.

Effect of prophylactic administration of Novafen for periodontal surgery on postoperative pain relief

Pain is a subjective feeling and one of the defense and alerting mechanisms of the body, which is distinguished from the body senses, including touch sensation and perception of heat, cold, pressure, etc. Pain, discomfort, and edema are very common after dental procedures, especially after periodontal surgeries, usually occurring during the first 24 hours after surgery; such pains are classified as medium to severe pains. Generally, medications are used to manage patients' pain and discomfort. One of the most commonly used medications for pain control is Ibuprofen, which is one of the NSAIDs and is a simple derivative of phenylpropionic acid. There is evidence that caffeine alone or in association with Acetaminophen, Ibuprofen, or Aspirin can increase their analgesic effects. Novafen is a new drug which consists of Acetaminophens, Ibuprofen and caffeine and has been marketed in Iran in recent years. 70 subjects referring to the Department of Oral and Maxillofacial Surgery, Tabriz Faculty of Dentistry, who were candidates for crown lengthening procedure, were randomly selected and included in the present study, based on inclusion and exclusion criteria. No significant differences were detected in pain severity between the two groups either clinically or statistically at 30-minutes postoperative interval. Pain, discomfort, and edema are very common after dental procedures, especially after periodontal surgeries. Such conditions usually occur during the first 24-hours postoperative interval and are considered moderate to severe pains. Although in the present study, the administration of Novafen before periodontal surgery resulted in the relief of postoperative pain, further studies are recommended on the subject, The administration of Novafen before periodontal surgeries resulted in pain relief after surgery.

Nonsteroidal Anti-inflammatory Drugs for Managing Postoperative Endodontic Pain in Patients Who Present with Preoperative Pain: A Systematic Review and Meta-analysis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been commonly used to treat endodontic postoperative pain. The purpose of this study was to address the following Population, Intervention, Comparator, Outcome, Timing, Study design and setting question: in patients with preoperative pain who undergo initial orthograde endodontic treatment, what is the comparative efficacy of NSAIDS compared with non-narcotic analgesics or placebo in reducing postoperative pain and the incidence of adverse events.

METHODS

Ovid MEDLINE (1946-December 15, 2015), the Cochrane Database of Systematic Reviews (2005-December 15, 2015), and the Cochrane Central Register of Controlled Trials (to December 15, 2015) were searched using included drugs, indications, and study designs as search terms. Hand searches in texts were also conducted. Two independent reviewers assessed eligibility for inclusion, extracted data, and assessed quality using the risk of bias tool. L'Abbe plots were used for qualitative review. Where applicable, meta-analysis was conducted on the pooled effect size (ES).

RESULTS

Two thousand two hundred eighty-four studies were identified through the database searches; 405 full-text articles were assessed. Fifteen articles met the inclusion criteria; qualitative analysis revealed all studies had a moderate to high risk of bias. Ibuprofen was the most studied NSAID. The L'Abbe plots showed that NSAIDS are effective at relieving postoperative endodontic pain overall. Meta-analysis showed that ibuprofen 600 mg is more effective than placebo at 6 hours postoperatively (ES = 10.50, P = .037), and ibuprofen 600 mg + acetaminophen 1000 mg combination is more effective than placebo (ES = 34.89, P = .000) but not significantly different than ibuprofen (ES = 13.94, P = .317). Five studies reported patients experiencing adverse events such as drowsiness, dizziness, nausea, and emesis; 2 studies reported that patients experienced no adverse events.

CONCLUSIONS

A combination of ibuprofen 600 mg and acetaminophen 1000 mg is more effective than placebo but not significantly different than ibuprofen 600 mg at 6 hours postoperatively. Ibuprofen 600 mg is more effective than placebo at 6 hours postoperatively; however, there are insufficient data to recommend the most effective NSAID, dose amount, or dose interval for the relief of postoperative endodontic pain of longer duration in patients with preoperative pain.

Pharmacokinetics and Bioavailability of a Fixed-Dose Combination of Ibuprofen and Paracetamol after Intravenous and Oral Administration

Background and Objectives

Previously published studies have suggested the lack of a pharmacokinetic interaction between ibuprofen and paracetamol when they are delivered as a fixed-dose oral combination. The aim of this study was to determine the pharmacokinetic profile and safety of a fixed-dose intravenous (IV) combination, containing 3 mg/mL ibuprofen and 10 mg/mL paracetamol, in comparison with its individual components. The study also assessed the relative bioavailability of the same doses of the active ingredients when they were administered as an oral formulation.

Methods

A single-dose, open-label, randomized, five-period cross-over sequence pharmacokinetic study was undertaken in 30 healthy volunteers. Serial plasma samples were assayed for both paracetamol and ibuprofen concentrations, using validated liquid chromatography–tandem mass spectrometry methods. Pharmacokinetic parameters were computed using standard non-compartmental analyses. Adverse events were also assessed. The ratios of the maximum measured plasma concentration (C_max), the area under the plasma concentration–time curve (AUC) from time zero to the time of the last measurable plasma concentration (AUC_t) and AUC from time zero to infinity (AUC_∞) were analysed for bioequivalence as determined by 90 % confidence intervals.

Results

The pharmacokinetic parameters of ibuprofen and paracetamol were very similar for the combination and monotherapy IV preparations; the ratios of the C_max, AUC_t and AUC_∞ values fell within the 80–125 % acceptable bioequivalence range. Precise dose proportionality for both compounds was also determined for the half dose of the IV formulation in comparison with the full dose. The relative bioavailability of paracetamol (93.78 %) and ibuprofen (96.45 %) confirmed the pharmacokinetic equivalence of the oral and IV formulations of the fixed-dose combination.

Conclusion

Concomitant administration of 3 mg/mL ibuprofen and 10 mg/mL paracetamol in a fixed-dose IV combination does not alter the pharmacokinetic profiles of either drug. The IV and oral dose forms of such a combination are pharmacokinetically equivalent.

Consumer concerns about paracetamol: a retrospective analysis of a medicines call centre

OBJECTIVES

To identify consumer information needs about paracetamol, the most commonly used analgesic and antipyretic worldwide.

DESIGN

Retrospective analysis of medicines questions from the public.

SETTING

Australian consumer medicines call centre.

PARTICIPANTS

Callers to National Prescribing Service Medicines Line between September 2002 and June 2010 (n=123 217).

MAIN OUTCOME MEASURES

Enquiry profile: demographics, enquiry type and concurrent medicines included in paracetamol calls; question themes derived from subset of call narratives.

RESULTS

Paracetamol comprised part of the enquiry in 5.2% of calls (n=6367). The caller age distribution for paracetamol calls was skewed towards a younger cohort, with 45.2% made by those aged 25-44 vs 37.5% in 'rest of calls'. Significantly more paracetamol-related calls were made for a child (23.7%) compared with 'rest of calls' (12.7%, p<0.001). The most frequent concurrently asked about medicines were codeine (11%, n=1521) and ibuprofen (6.4%, n=884). Questions underpinned by paracetamol risk (interaction, use in pregnancy/lactation or other safety concerns) predominated (55.8%). When individual paracetamol enquiry types were compared with 'rest of calls', efficacy was most frequent (24.9% vs 22.8%); however, interaction (21.5% vs 14.8%), administration (15.5% vs 11%) and pregnancy/lactation (13.8% vs 8.3%) categories were more prevalent for paracetamol calls (all p<0.001). Enquiry type frequency also varied by patient age group, with questions about administration more common in younger groups and efficacy dominating in those over 45. Narrative analysis of over-represented paracetamol enquiry types showed specific concerns relevant to life stages: young children, those of reproductive age and the elderly.

CONCLUSIONS

Consumers have many concerns about the use of paracetamol that may be under-recognised by healthcare providers, with the nature of enquiries differing across life stages. These concerns are not adequately addressed by available consumer information. Improving access to targeted information about paracetamol would promote the safe and effective use of this common medicine.

A Randomized Controlled Trial of Oral Versus Intravenous Administration of a Nonnarcotic Analgesia Protocol Following Pediatric Craniosynostosis Corrections on Nausea and Vomiting Rates

BACKGROUND

The authors' center uses a nonnarcotic postoperative regimen following craniosynostosis corrections. Despite opioid avoidance, the authors noted that some children still experienced nausea and vomiting following the oral administration of either acetaminophen or ibuprofen. This study sought to evaluate whether intravenous administration of these medications might reduce nausea and vomiting rates.

METHODS

A total of 50 children undergoing craniosynostosis corrections were prospectively randomized to a control group given only oral ibuprofen (10 mg/kg) and acetaminophen (15 mg/kg), or a treatment group given only intravenous ketorolac (0.5 mg/kg) and acetaminophen (15 mg/kg). All patients were assessed for postoperative nausea and vomiting by a blinded research nurse.

RESULTS

Twenty-eight patients randomized to the oral control group, and 22 to the intravenous treatment group. No statistically significant differences were identified between groups, including: age, weight, sex, before history of severe postoperative nausea and vomiting, or procedure. With similar anesthesia times there was significantly more vomiting episodes in the oral group (71% versus 41%). Using a multivariate logistic regression, controlling for age, weight and procedure, the odds ratio for vomiting in the oral control versus intravenous experimental groups was 3.61 (95% CI 1.11-1.76; P = 0.033), and for postoperative nausea was 14.0 (95% CI 1.40-71.69, P = 0.010).

CONCLUSIONS

The authors found a significant reduction in nausea and vomiting among children randomized to receive intravenous medications. In addition, the intravenous delivery of medications has the theoretical advantage of insuring an effective full dose delivery. Based on these findings, our standard process is to preferentially manage all children following craniosynostosis corrections with intravenous nonnarcotics.

Current concepts in management of pain in children in the emergency department

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Oral pregabalin for postoperative pain relief after third molar extraction: a randomized controlled clinical trial

OBJECTIVES

The aim of this randomized controlled clinical trial was to evaluate the efficacy and safety of pregabalin administered pre- and postoperatively in patients with pain and swelling due to the surgical removal of impacted lower third molars.

MATERIALS AND METHODS

The final study sample comprised 60 volunteers (23 males and 37 females). Group 1 (n = 30) received 75 mg oral pregabalin 1 h before surgery and 1 h after surgery. Group 2 (n = 30) served as a control group and received no pregabalin. Both groups were administered with 650 mg paracetamol every 8 h for 2 days. Postoperative pain intensity and swelling were measured using a visual analog scale (VAS); pain relief experienced was reported using a four-point verbal rating scale (VRS); the rescue medication requirement, adverse effects, and global impression of the medication were also recorded.

RESULTS

No significant difference in pain intensity (VAS) was observed between the groups. However, fewer rescue medication tablets were needed by pregabalin-treated patients than by controls (p = 0.021). The frequency and intensity of adverse effects were significantly higher in pregabalin-treated patients (p < 0.001), although no serious adverse events occurred. No significant difference in the degree of swelling was observed in any measurement except that from mandibular angle to lip junction, which showed lesser inflammation in the pregabalin group at 24 h post-surgery (p = 0.011). The global opinion on the medication received was more positive in the pregabalin group (p = 0.042).

CONCLUSIONS

The administration of pregabalin reduces the requirement for rescue medication after third molar surgery and results in a more constant pain level, with fewer peaks of pain intensity.

CLINICAL RELEVANCE

These findings suggest that pregabalin may be useful to control acute postoperative pain. Adverse effects are known to be reduced at the low pregabalin dose used in our study.

A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars

Pain after third molar extraction has been considered the most suitable pharmaceutical model to evaluate acute pain. This study aimed to evaluate the pre-emptive analgesic/anti-inflammatory efficacy of etoricoxib 120 mg following mandibular third molar surgery. A split-mouth, randomized, triple-blind, placebo-controlled study was conducted with patients undergoing the surgical removal of mandibular third molars. All volunteers were allocated randomly to receive either etoricoxib 120 mg or placebo 1h preoperatively, and inflammatory events were evaluated. An estimated sample of 18 surgical units per group was required based on a pilot study (95% confidence level and 80% statistical power). Rescue medication was analyzed by Kaplan-Meier method through log-rank Mantel-Cox test and Pearson linear correlation (P<0.05). Pre-emptive etoricoxib reduced postoperative pain scores significantly in comparison to placebo (P<0.001), with a pain score peak at 6h after surgery (P<0.001). The mean rescue medication consumption was lower in the etoricoxib group compared to the placebo group over the study period (P<0.05). There was no statistically significant difference between groups related to swelling and trismus. The pre-emptive administration of etoricoxib 120 mg significantly reduced the postoperative pain intensity and the need for rescue medication, but did not reduce swelling or trismus.