Etoricoxib pre-medication for post-operative pain after laparoscopic cholecystectomy

Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery.

METHODS

We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence.

RESULTS

We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042).

CONCLUSION

In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.

Nationwide Etoricoxib Injection Clinical Experience (NICE): Real-World Evidence in Indian Patients

Introduction Pain is a major health issue globally. Etoricoxib, a highly selective COX-2 inhibitor, given orally, has been found to be efficacious and safe in the management of acute and chronic pain. Oral etoricoxib has been extensively studied; however, there is a lack of research exploring the use of etoricoxib via alternative routes, specifically intramuscular (IM) injection. This study aimed to evaluate the effectiveness and safety of an innovative and novel formulation of IM etoricoxib injection 90 mg/mL in the management of patients with acute pain in India. Method This was a real-world, multicenter, retrospective, observational study to investigate the effectiveness and safety of IM etoricoxib injection in the management of patients with acute pain in India (outpatient setting). The clinical data of 383 patients from 42 centers across India were collected from November 2022 to April 2023. Following approval from the site investigator, comprehensive patient-level information encompassing demographic and clinical variables as well as comorbidities was collected and entered into a case report form. Approval from the Independent Ethics Committee (IEC) and Institutional Review Board (IRB) was sought. The safety and effectiveness at 30 minutes and 60 minutes of IM etoricoxib injection were then analyzed. Results Among the studied patients, etoricoxib was used for the management of knee arthritis, fracture, post-traumatic pain, postoperative cases, acute back pain, back injury, torn ligament, and muscle strain and sprain. Of 383 patients, 98.17% had moderate-to-severe pain at baseline on the visual analogue scale (VAS) (0 being no pain and 10 being severe unbearable pain). The percentage of patients with severe pain reduced to only 6.78% and 4.17% at 30 minutes and 60 minutes, respectively. The improvement in the VAS score was statistically significant from baseline to 30 minutes and 60 minutes, and at 60 minutes compared to 30 minutes (p < 0.0001). More than half the patients (56.91%) had no pain at the site of the injection. Most of the doctors (70.23%) opined that the IM etoricoxib injection was better than their currently used NSAID injections for pain relief. Only 12.79% of patients required rescue analgesia post-IM etoricoxib injection. IM etoricoxib injection was well tolerated as 98.69% of the patients did not experience or report any adverse events post-IM injection. Conclusion This real-world, multicenter, retrospective, observational study across India demonstrated that the innovative and novel formulation of etoricoxib (90 mg/mL IM injection) was effective and well-tolerated in the management of acute pain. Overall, this study provides valuable insights into the real-world effectiveness and safety of IM etoricoxib injections, suggesting it could be a promising therapy for the management of acute pain for optimal patient benefit.

Clinical effect of preoperative intravenous non-steroidal anti-inflammatory drugs on relief of postoperative pain in patients after laparoscopic cholecystectomy: Intravenous ibuprofen vs. intravenous ketorolac

Backgrounds/Aims

Postoperative pain management is a key to enhanced recovery after surgery. The aim of this study was to evaluate clinical effect of preoperative intravenous (IV) non-steroidal anti-inflammatory drugs (NSAIDs) on relief of postoperative pain in patients after laparoscopic cholecystectomy.

Methods

This single center, retrospective study was conducted between September 2019 and May 2020. A total of 163 patients were divided into two groups: Ibuprofen group (preoperative IV ibuprofen, n = 77) and Ketorolac group (preoperative IV ketorolac, n = 86). The primary outcome was postoperative pain score measured immediately in the recovery room.

Results

There was no difference in demographic characteristics between the two groups of patients. Postoperative pain score measured immediately in the recovery room was significantly higher in the Ibuprofen group than in the Ketorolac group (mean value: 5.09 vs. 4.61; p = 0.027). The number of patients who needed analgesics immediately in the recovery room was also higher in the Ibuprofen group than in the Ketorolac group (28 [36.4%] vs. 18 [20.9%]; p = 0.036).

Conclusions

In this study, preoperative IV injection with ketorolac reduced postoperative pain and analgesic requirement in the recovery room more effectively than that with ibuprofen. However, both showed similar effects on peak pain and pain at discharge. Numbers of patients requiring additional analgesics were also similar between the two groups.

Comparative Evaluation of Two Doses of Etoricoxib (90 mg and 120 mg) as Pre-Emptive Analgesic for Post-Operative Pain Relief in Mandibular Fracture Surgery Under General Anaesthesia: A Prospective, Randomised, Double-Blinded, Placebo-Controlled Trial

Objective

This trial investigated the post operative analgesic efficacy of oarl etoricoxib 90 mg and 120 mg and a placebo in mandibular fracture pain model.

Methods

A total of 63 adult patients with mandibular fractures who were scheduled to undergo maxillofacial surgery were randomly allocated to receive etoricoxib 90 mg, etoricoxib 120 mg and a placebo 1 hour before the surgery. Patients were followed-up till 24 hours after the surgery. Duration of analgesia, intra-operative and post-operative analgesic requirement, pain score, post-operative patient satisfaction and adverse effects were measured.

Results

The baseline demographic parameters were similar in all the groups. Duration of analgesia was longer in both the E120 (6.00±0.816 hours) and E90 (4.37±1.008 hours) groups (p<0.05) as compared to the placebo group (2.60±0.821 hours). Mean difference of duration of analgesia between E120 and E90 was 1.62 (95% confidence interval: 0.234–3.484; p>0.05). Post-operative pain intensity was significantly lower in both the E120 and E90 groups as compared to the C group. Both the etoricoxib groups required less intra-operative (p=0.002) and post-operative (p=0.001) analgesic supplementation as compared to the placebo group. The patient satisfaction score and rate of occurrence of significant adverse effects were similar among all the three groups.

Conclusion

Etoricoxib 90 mg is equally efficacious to etoricoxib120 mg with a similar side effect profile in a severely acute setting.

The Influence of Etoricoxib on Pain Control for Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The efficacy of etoricoxib on pain control for laparoscopic cholecystectomy remains controversial. We conduct a systematic review and meta-analysis to explore the impact of etoricoxib on pain intensity after laparoscopic cholecystectomy.

MATERIALS AND METHODS

We searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2018 for randomized controlled trials assessing the effect of etoricoxib versus placebo on pain management after laparoscopic cholecystectomy. This meta-analysis was performed using the random-effect model.

RESULTS

Four randomized controlled trials involving 351 patients are included in the meta-analysis. Overall, compared with control group for laparoscopic cholecystectomy, etoricoxib has no important impact on pain scores within 4 hours [mean difference (MD)=-1.48; 95% confidence interval (CI)=-3.54 to 0.58; P=0.16] and 8 hours (MD=-0.65; 95% CI=-1.43 to 0.12; P=0.10), but can significantly decrease pain intensity within 12 hours (MD=-1.16; 95% CI=-1.93 to -0.38; P=0.003) and 24 hours (MD=-1.10; 95% CI=-1.98 to -0.22; P=0.01), as well as postoperative analgesic consumption (standard MD=-1.21; 95% CI=-2.19 to -0.23; P=0.02), with no increase in nausea and vomiting (risk ratio=0.68; 95% CI=0.42-1.10; P=0.11), and headache (risk ratio=0.96; 95% CI=0.44-2.09; P=0.92).

CONCLUSIONS

Etoricoxib can substantially reduce pain intensity in patients with laparoscopic cholecystectomy.

A cost-consequence analysis of parecoxib and opioids vs opioids alone for postoperative pain: Chinese perspective

Purpose

The use of parecoxib plus opioids for postoperative analgesia in noncardiac surgical patients seems to be cost-saving in Europe due to a reduction in opioid use and opioid-related adverse events. Given the lack of information on postoperative analgesic use in Asia, this study assessed the economic consequences of the addition of parecoxib to opioids vs opioids alone to treat postsurgical pain in China.

Methods

A cost-consequence economic evaluation assessed direct medical costs related to opioid-related clinically meaningful events (CMEs) utilizing dosing information and reported frequency of events from a Phase III, randomized, double-blind, global clinical trial (PARA-0505-069) of parecoxib plus opioids vs opioids alone for 3 days following major orthopedic, abdominal, gynecologic, or noncardiac thoracic surgery requiring general or regional anesthesia. The cost of CMEs was calculated using information on resource utilization and unit costs provided by a panel of clinical experts in China. Sensitivity analyses were performed to test the robustness of the results.

Results

Patients treated with parecoxib plus opioids reported fewer CMEs (mean 0.62 vs 1.04 events per patient [P<0.0001]) compared with opioids alone for the 3-day postoperative period. This suggested a potential savings of 356 Chinese yuan (¥) per patient over the 3 days (total cost of ¥1,418 for parecoxib plus opioids vs ¥1,774 with opioid use alone).

Conclusion

Fewer CMEs with parecoxib plus opioids suggest a reduction in medical resource utilization and reduced costs compared to opioids alone when modeling analgesic use in non-cardiac surgery patients in China.

A review of dexketoprofen trometamol in acute pain

OBJECTIVE

Dexketoprofen trometamol is a modified non-selective COX inhibitor with a rapid onset of action that is available as both oral and parenteral formulations. The aim of this narrative review was to assess the efficacy and tolerability/safety of dexketoprofen trometamol in acute pain states using the best available published scientific evidence (randomized controlled clinical trials and systematic reviews/meta-analyses).

METHODS

Literature retrieval was performed via Medline, Embase and the Cochrane Library (from inception up to March 2017) using combinations of the terms "randomized controlled trials", "dexketoprofen", "celecoxib", "etoricoxib", "parecoxib" and "acute pain".

RESULTS

Single-dose dexketoprofen trometamol provides effective analgesia in the treatment of acute pain, such as postoperative pain (dental and non-dental surgery), renal colic, acute musculoskeletal disorders and dysmenorrhea, and reduces opioid consumption in the postoperative setting. It has a rapid onset of action (within 30 minutes) and is well tolerated during short-term treatment. Direct comparisons with COX-2 inhibitors are lacking; however, the efficacy and tolerability of single-dose dexketoprofen trometamol appears to be consistent with that seen with celecoxib, etoricoxib and parecoxib in the acute pain setting.

CONCLUSION

In conclusion, dexketoprofen trometamol appears to provide similar analgesic efficacy to COX-2 inhibitors when used to treat acute pain, has a rapid onset of action, is well tolerated, and has an opioid-sparing effect when used as part of a multimodal regimen in the acute pain setting.

Perioperative Duloxetine and Etoricoxibto improve postoperative pain after lumbar Laminectomy: a randomized, double-blind, controlled study

BACKGROUND

Duloxetine, Etoricoxib and opioid are of the commonly administered drugs in Lumbar laminectomy. The aim of this study is to assess the effect of perioperative use of Duloxetine in combination with Etoricoxib on postoperative pain and opioid requirements.

METHODS

One hundred twenty patients with ASA physical status were enrolled with age between 18 and 70 years. Patients were divided randomly into four groups of 30 patients: group P received placebo, group E received etoricoxib 120 mg, group D received duloxetine 60 mg and group D/E received duloxetine 60 mg capsules and etoricoxib 120 mg; 1 h before surgery and 24 h after.

RESULTS

Neither Duloxetine nor etoricoxib individually had effect on pain with movement, while their combination revealed a significant reduction in pain scores over the entire postoperative period at rest and on movement. Etoricoxib showed a significant decrease in pain at all times at rest when compared with group P, while it showed significant pain decrease only at 0, 2 and 4 h when compared with group D. On the other hand duloxetine alone showed significant decrease in pain at rest at 24 h and 48 h when compared with group P. ConcerningMorphine requirement after 24 h.; it wassignificantly lower in the D/E group in comparison with groups P, E and D. It should be noted also that there was a significant decrease morphine requirement in both groups E and D.

CONCLUSION

The perioperative administration of the combination of etoricoxib and duloxetine improved analgesia and reduced opioid consumption without significant side effects.

TRIAL REGISTRATION

ISRCTN48329522 . 17 June 2017.

Protective multimodal analgesia with etoricoxib and spinal anesthesia in inguinal hernia repair: a randomized controlled trial

BACKGROUND

Inguinal hernia repair is a common procedure, and can be performed under spinal anesthesia. Although adequate analgesia is crucial to postoperative recovery, the optimal protective analgesic regimen remains to be established.

PURPOSE

To investigate the effects of preoperative etoricoxib within a protective multimodal analgesic regimen with respect to pain control following open inguinal hernia repair.

METHODS

Sixty adult patients undergoing open inguinal hernia repair participated in a single-center, randomized, double-blinded, placebo-controlled trial in a general academic medical center. The intervention group (n = 30) received 120 mg of oral etoricoxib 1 h preoperatively, and 10-12 mg bupivacaine with 25 μg fentanyl as spinal anesthesia. The control group (n = 30) received oral placebo 1 h preoperatively, and spinal anesthesia as above. Postoperative Visual Analog Scale pain scores at rest and on active straight leg raise were recorded and analyzed.

RESULTS

Resting pain scores were significantly lower in the intervention than the control group at 16 h, 24 h, and on discharge (3.00 vs. 4.35; 1.57 vs. 4.00; 1.24 vs. 3.76, respectively; p < 0.05). Pain scores on active straight leg raise were significantly lower in the intervention than the control group at 16 h, 24 h, and on discharge (3.85 vs. 5.59, p < 0.01; 2.84 vs. 4.90, p < 0.05; 3.55 vs. 5.32, p < 0.05, respectively).

CONCLUSION

The addition of etoricoxib to spinal anesthesia as a multimodal protective regimen can improve pain control after inguinal hernia repair. The optimal dose and applicability to other operations remains to be established.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

Risk of perioperative bleeding related to highly selective cyclooxygenase-2 inhibitors: A systematic review and meta-analysis

BACKGROUND

Several literatures reported that highly selective cycloxygenase-2 inhibitors (COX-2 inhibitors) had no effect on platelet function. However, some experts suggested stopping all non-steroidal anti-inflammatory drugs (NSAIDs), including COX-2 inhibitors at least five elimination half-lives prior to surgery. We, therefore, systematically summarized the risk of clinical bleeding or platelet dysfunction in healthy or surgical subjects who received COX-2 inhibitors.

METHODS

Two electronic databases, MEDLINE and EMBASE, were searched for randomized, controlled studies published during 1980-December 2015. Additionally, manual search was performed to identify potential eligible studies. Intervention was perioperative use of any available COX-2 inhibitors in current practice (celecoxib, parecoxib, or etoricoxib), compared to non-selective NSAIDs, analgesics, or placebo. Two independent reviewers selected eligible studies, extracted the data, and assessed the quality of the included studies. The primary outcome was postoperative bleeding. All analyses were performed using RevMan-5.3.

RESULTS

Of 3900 abstracts reviewed, 35 studies met the inclusion criteria. The data from 16 out of 35 studies were used in this meta-analysis, and outcomes of other 19 remaining studies were descriptively summarized. COX-2 inhibitors did not significantly increase the risk of postoperative bleeding events (relative risk or RR = 0.92; 95% confidence interval or CI: 0.63-1.33; p = 0.65), intraoperative blood loss (mL) (weighted mean difference or WMD = -4.38; 95% CI: -14.69 to 5.92; p = 0.4), postoperative blood loss (mL) (WMD = -13.89; 95% CI: -30.24 to 2.47; p = 0.10), and 24-h postoperative hemoglobin loss (g/dL) (WMD = 0.47; 95% CI: -0.14 to 1.09; p = 0.13). Platelet function analyzer closure time (second) significantly decreased with the use of COX-2 inhibitors (WMD = -22.22; 95% CI: -44.03 to -0.41; p < 0.00001). In the 19 remaining studies, COX-2 inhibitors did not significantly increase risk of bleeding in both clinical and laboratory outcomes.

CONCLUSION

Highly selective COX-2 inhibitors did not significantly increase the risk of intraoperative, postoperative bleeding, or blood loss. They also had no significant effect on platelet function. Therefore, perioperative, single dose, or short course of COX-2 inhibitors can be safely used in individuals who are undergoing surgery.

Ambulatory laparoscopic cholecystectomy: A single center experience

AIM

To evaluate the demographic and clinical parameters affecting the outcomes of ambulatory laparoscopic cholecystectomy (ALC) in terms of pain, nausea, anxiety level, and satisfaction of patients in a tertiary health center.

MATERIALS AND METHODS

ALC was offered to 60 patients who met the inclusion criteria. Follow-up (questioning for postoperative pain or discomfort, nausea or vomiting, overall satisfaction) was done by telephone contact on the same day at 22:00 p.m. and the first day after surgery at 8: 00 a.m. and by clinical examination one week after operation. STAI I and II data were used for proceeding to the level of anxiety of patients before and/or after the operation.

RESULTS

Sixty consecutive patients, with a mean age of 40.6 ± 8.1 years underwent ALC. Fifty-five (92%) patients could be sent to their homes on the same day but five patients could not be sent due to anxiety, pain, or social indications. Nausea was reported in four (6.7%) cases and not associated with any demographic or clinical features of patients. On the other hand, pain has been reported in 28 (46.7%) cases, and obesity and shorter duration of gallbladder disease were associated with the increased pain perception (P = 0.009 and 0.004, respectively). Preopereative anxiety level was significantly higher among patients who could not complete the ALC procedure (P = 0.018).

CONCLUSION

Correct management of these possible adverse effects results in the increased satisfaction of patients and may encourage this more cost-effective and safe method of laparoscopic cholecystectomy.

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.

Loxoprofen sodium and celecoxib for postoperative pain in patients after spinal surgery: a randomized comparative study

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to treat inflammation, pain, and fever, but no criterion standard exists for the management of postoperative pain following spinal surgery. In the present study, we compared the analgesic efficacy of loxoprofen sodium (loxoprofen) and celecoxib for the management of postoperative pain following spinal surgery.

METHODS

One-hundred forty-one patients (mean age 62.2 years) were randomly assigned to two groups before spinal surgery: a loxoprofen group (n = 73, 180 mg/day) and a celecoxib group (n = 68, 200 mg/day). The drugs were administered from 1 day until 7 days after surgery. A numeric rating scale (NRS) was used to evaluate pain at nine predefined times every day and the findings were compared between the two groups. Laboratory data and adverse events were also recorded.

RESULTS

There was no significant difference in the maximum and mean NRS scores on each day between loxoprofen and celecoxib, suggesting a comparable analgesic effect for these two NSAIDs. Greater improvement in the NRS score between preadministration (baseline) and 30 min or 2 h after administration was obtained for loxoprofen. This tendency was shown for both slight (NRS score <5 at baseline) and severe pain (NRS score ≥ 5 at baseline). Loxoprofen was discontinued in one patient on day 4 because of renal dysfunction. Celecoxib was discontinued in one patient on day 2 at the patient's request.

CONCLUSIONS

Both loxoprofen sodium and celecoxib were well tolerated for the relief of acute postoperative pain after spinal surgery. A single administration of loxoprofen showed superior and rapid effectiveness compared with celecoxib for both slight and severe postoperative pain.

Evaluation of the Efficacy of Methylprednisolone, Etoricoxib and a Combination of the Two Substances to Attenuate Postoperative Pain and PONV in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Placebo-controlled Trial

Background

Establishment of laparoscopic cholecystectomy as an outpatient procedure has accentuated the clinical importance of reducing early postoperative pain, as well as postoperative nausea and vomiting (PONV). We therefore planned to evaluate the role of a multimodal approach in attenuating these problems.

Methods

One hundred and twenty adult patients of ASA physical status I and II and undergoing elective laparoscopic cholecystectomy were included in this prospective, randomized, placebo-controlled study. Patients were divided into four groups of 30 each to receive methylprednisolone 125 mg intravenously or etoricoxib 120 mg orally or a combination of methylprednisolone 125 mg intravenously and etoricoxib 120 mg orally or a placebo 1 hr prior to surgery. Patients were observed for postoperative pain, fentanyl consumption, PONV, fatigue and sedation, and respiratory depression. Results were analyzed by the ANOVA, a Chi square test, the Mann Whitney U test and by Fisher's exact test. P values of less than 0.05 were considered to be significant.

Results

Postoperative pain and fentanyl consumption were significantly reduced by methylprednisolone, etoricoxib and their combination when compared with placebo (P<0.05). The methylprednisolone + etoricoxib combination caused a significant reduction in postoperative pain and fentanyl consumption as compared to methylprednisolone or etoricoxib alone (P<0.05); however, there was no significant difference between the methylprednisolone and etoricoxib groups (P>0.05). The methylprednisolone and methylprednisolone + etoricoxib combination significantly reduced the incidence and severity of PONV and fatigue as well as the total number of patients requiring an antiemetic treatment compared to the placebo and etoricoxib (P<0.05).

Conclusions

A preoperative single-dose administration of a combination of methylprednisolone and etoricoxib reduces postoperative pain along with fentanyl consumption, PONV, antiemetic requirements and fatigue more effectively than methylprednisolone or etoricoxib alone or a placebo.

Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy

BACKGROUND

While laparoscopic cholecystectomy is generally considered less painful than open surgery, pain is one of the important reasons for delayed discharge after day-surgery and overnight stay following laparoscopic cholecystectomy. The safety and effectiveness of different pharmacological interventions such as non-steroidal anti-inflammatory drugs, opioids, and anticonvulsant analgesics in people undergoing laparoscopic cholecystectomy is unknown.

OBJECTIVES

To assess the benefits and harms of different analgesics in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal (WHO ICTRP) to March 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different pharmacological interventions with no intervention or inactive controls for outcomes related to benefit in this review. We considered comparative non-randomised studies with regards to treatment-related harms. We also considered trials that compared one class of drug with another class of drug for this review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using Review Manager 5 analysis. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 25 trials with 2505 participants randomised to the different pharmacological agents and inactive controls. All the trials were at unclear risk of bias. Most trials included only low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. Participants were allowed to take additional analgesics as required in 24 of the trials. The pharmacological interventions in all the included trials were aimed at preventing pain after laparoscopic cholecystectomy. There were considerable differences in the pharmacological agents used and the methods of administration. The estimated effects of the intervention on the proportion of participants who were discharged as day-surgery, the length of hospital stay, or the time taken to return to work were imprecise in all the comparisons in which these outcomes were reported (very low quality evidence). There was no mortality in any of the groups in the two trials that reported mortality (183 participants, very low quality evidence). Differences in serious morbidity outcomes between the groups were imprecise across all the comparisons (very low quality evidence). None of the trials reported patient quality of life or time taken to return to normal activity. The pain at 4 to 8 hours was generally reduced by about 1 to 2 cm on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence). The pain at 9 to 24 hours was generally reduced by about 0.5 cm (a modest reduction) on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of very low quality that different pharmacological agents including non-steroidal anti-inflammatory drugs, opioid analgesics, and anticonvulsant analgesics reduce pain scores in people at low anaesthetic risk undergoing elective laparoscopic cholecystectomy. However, the decision to use these drugs has to weigh the clinically small reduction in pain against uncertain evidence of serious adverse events associated with many of these agents. Further randomised clinical trials of low risk of systematic and random errors are necessary. Such trials should include important clinical outcomes such as quality of life and time to return to work in their assessment.

Randomized clinical trial of a simple pulmonary recruitment manoeuvre to reduce pain after laparoscopy

Background

Shoulder tip and abdominal pain following laparoscopic procedures are well recognized causes of postoperative morbidity. In this double-blind randomized clinical trial attempts were made to reduce postoperative pain in patients undergoing laparoscopic surgery by implementing a simple intraoperative technique.

Methods

Patients undergoing elective laparoscopic cholecystectomy or laparoscopic transabdominal preperitoneal inguinal hernia repair were randomized to receive either the current standard treatment (control group) or an intervention to remove residual carbon dioxide. In the intervention group, the pneumoperitoneum was removed at the end of the operation by placing the patient in the Trendelenburg position and utilizing a pulmonary recruitment manoeuvre consisting of two manual inflations to a maximum pressure of 60 cmH2O. In the control group, residual pneumoperitoneum was evacuated at the end of the procedure by passive decompression via the open operative ports.

Results

Seventy-six randomly assigned patients, 37 in the intervention group and 39 in the control group, were recruited. Overall postoperative pain scores were significantly lower in the intervention group (P = 0·001). Median (interquartile range) pain scores were significantly lower in the intervention group compared with the control group at both 12 h (3·5 versus 5; P &lt; 0·010) and 24 h (3 versus 4·5; P &lt; 0·010).

Conclusion

Active evacuation of residual pneumoperitoneum following laparoscopic procedures, by means of two pulmonary recruitment manoeuvres in the Trendelenburg position, reduces postoperative pain significantly. This simple and safe technique can be implemented routinely after abdominal laparoscopy. Registration number: NCT01720433 (http://www.clinicaltrials.gov).

Evaluation of a single preoperative dose of etoricoxib for postoperative pain relief in therapeutic knee arthroscopy: a randomized trial

BACKGROUND AND PURPOSE Analgesics can have undesirable effects. We assessed whether a single preoperative dose of 120 mg etoricoxib reduces the need for additional opioids after therapeutic arthroscopic knee surgery. METHODS A double-blind, placebo-controlled study was performed at a single center. 66 patients scheduled to undergo elective therapeutic knee arthroscopy were included. They were randomly selected to be given either 120 mg of etoricoxib (n = 33) or placebo (n = 33) 1 hour before induction of general anesthesia. A patient-controlled analgesia device was used postoperatively. We recorded total postoperative morphine consumption over 24 h, degree of pain as assessed with a visual analog scale, degree of satisfaction, and occurrence of adverse effects. RESULTS Mean total morphine consumption during the first 24 h was 24 (9-60) mg in the placebo group and 9 (0-34) mg in the etoricoxib group. In the etoricoxib group, pain intensity levels at rest were reduced and patient satisfaction with the analgesia provided was higher during the first postoperative day. There was no difference in the incidence of typical adverse effects of opioids in the 2 groups.

INTERPRETATION

Etoricoxib is a suitable premedication to use before therapeutic arthroscopic knee surgery, as it reduced patients' morphine requirements.

Preoperative administration of etoricoxib in patients undergoing hip replacement causes inhibition of inflammatory mediators and pain relief

OBJECTIVE

Administering cyclooxygenase-2 inhibitors preoperatively appears attractive since these drugs reduce post-operative pain, but do not increase the risk of post-operative bleeds, asthmatic attacks and stress-related gastrointestinal ulcers. In a former investigation, we could show that post-operative administration of etoricoxib reduces prostaglandin production in wound fluid, but the onset of action is variable due to delayed post-operative absorption.

METHODS

In this study, we investigated the preoperative administration of etoricoxib in patients undergoing hip replacement. They received 120 mg etoricoxib or placebo 2 h before surgery and 1 day after in a double-blinded, randomized, parallel group design.

RESULTS

A total of 11 patients were randomized (placebo n = 5; verum n = 6). We found high and constant levels of the drug in blood, central nervous system and wound fluid already at the end of surgery (t(max) < 2 h). This was accompanied by inhibition of prostaglandin production in the wound tissue (treatment p < 0.05), suppression of interleukin 6 increase in plasma (treatment p < 0.01), and - despite existing standard pain relief procedures - higher satisfaction with analgesics (time vs. treatment p < 0.05) and less demand for opioids (treatment p < 0.01) and intrathecal bupivacaine (treatment p = 0.05) administration.

CONCLUSION

Administration of etoricoxib 2 h before surgery allows for an effective drug concentration in critical tissues, a reduction of the production of pro-inflammatory mediators and for better pain relief.

A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy

OBJECTIVES

  We aimed to perform a systematic review of the literature to identify interventions that may facilitate ambulatory laparoscopic cholecystectomy (LC).

METHODS

The PubMed and CENTRAL databases were interrogated for key MeSH headings. To be eligible for systematic review, trials were required to include outcome measures of postoperative pain, nausea or vomiting and time to discharge following LC. Interventions were subsequently assessed for the level of evidence and grade of recommendation given.

RESULTS

A total of 331 trials were identified, 68 of which met the predefined study inclusion criteria. Interventions which met Level I, Grade A recommendation included the administration of 8 mg i.v. dexamethasone, preoperative administration of analgesia including the use of non-steroidal anti-inflammatory or COX II inhibitors, intraoperative use of an anti-emetic, pre-incisional use of bupivacaine, administration of intraperitoneal bupivacaine on establishment of pneumoperitoneum, and avoidance of drains.

CONCLUSIONS

  High-quality evidence describing interventions that minimize barriers to ambulatory LC exists. Further studies will be required to determine the optimal combination of these interventions.

Comparing etoricoxib and celecoxib for preemptive analgesia for acute postoperative pain in patients undergoing arthroscopic anterior cruciate ligament reconstruction: a randomized controlled trial

Background

The efficacy of selective cox-2 inhibitors in postoperative pain reduction were usually compared with conventional non-selective conventional NSAIDs or other types of medicine. Previous studies also used selective cox-2 inhibitors as single postoperative dose, in continued mode, or in combination with other modalities. The purpose of this study was to compare analgesic efficacy of single preoperative administration of etoricoxib versus celecoxib for post-operative pain relief after arthroscopic anterior cruciate ligament reconstruction.

Methods

One hundred and two patients diagnosed as anterior cruciate ligament injury were randomized into 3 groups using opaque envelope. Both patients and surgeon were blinded to the allocation. All of the patients were operated by one orthopaedic surgeon under regional anesthesia. Each group was given either etoricoxib 120 mg., celecoxib 400 mg., or placebo 1 hour prior to operative incision. Post-operative pain intensity, time to first dose of analgesic requirement and numbers of analgesic used for pain control and adverse events were recorded periodically to 48 hours after surgery. We analyzed the data according to intention to treat principle.

Results

Among 102 patients, 35 were in etoricoxib, 35 in celecoxib and 32 in placebo group. The mean age of the patients was 30 years and most of the injury came from sports injury. There were no significant differences in all demographic characteristics among groups. The etoricoxib group had significantly less pain intensity than the other two groups at recovery room and up to 8 hours period but no significance difference in all other evaluation point, while celecoxib showed no significantly difference from placebo at any time points. The time to first dose of analgesic medication, amount of analgesic used, patient's satisfaction with pain control and incidence of adverse events were also no significantly difference among three groups.

Conclusions

Etoricoxib is more effective than celecoxib and placebo for using as preemptive analgesia for acute postoperative pain control in patients underwent arthroscopic anterior cruciate ligament reconstruction.

Trial registration number

NCT01017380

Comparison of etoricoxib vs. ketorolac in postoperative pain relief

BACKGROUND

COX-2 inhibitors have been claimed to have equal analgesic efficacy as non-selective nonsteroidal anti-inflammatory drugs, but this has been disputed in animal experiments.

METHODS

One hundred thirty-three women scheduled for ambulatory, laparoscopic gynaecological surgery were included in this randomised, double-blind study. Group E received 120 mg etoricoxib orally as premedication. Group K received 30 mg ketorolac i.v. after induction of anaesthesia. General anaesthesia was induced and maintained with propofol and remifentanil. Fentanyl 0.5 microg/kg i.v. and local wound anaesthesia was administered at the end of surgery. Postoperatively, the patients received fentanyl 0.5 microg/kg i.v. if visual analogue scale (VAS) >or=30 mm. Before discharge, Group K received 30 mg ketorolac i.v. Twenty-four hours postoperatively, Group E received 120 mg etoricoxib.

RESULTS

The first 4 h postoperatively, Group K required 83+/-65 microg and Group E required 123+/-91 microg fentanyl [mean (SD), P=0.004]. After 30 min VAS in Group K was 31.3+/-19.7 mm and 43.8+/-16.9 mm in Group E [mean (SD), P<0.001]. Discharge readiness was significantly shorter in Group K (222+/-40 min) compared with Group E (244+/-47 min) [mean (SD), P=0.004]. There were no differences in pain scores or rescue pain medication at 24 or 48 h postoperatively. Less nausea was observed in the 4-24-h period in Group E.

CONCLUSIONS

Thirty milligram ketorolac i.v. after induction of anaesthesia resulted in significantly less immediate pain and opioid consumption during the first 4 h postoperatively compared with 120 mg etoricoxib preoperatively.

Etoricoxib for pain management during thyroid surgery–a prospective, placebo-controlled study

Objective

To assess the efficacy of etoricoxib in pain treatment during thyroid surgery.

Design

Double-blind, placebo-controlled, randomized trial.

Setting

A secondary-level central hospital in Finland.

Patients

Sixty-nine consecutive patients (59 women) aged 18 to 70 years who underwent thyroid surgery.

Interventions

Patients were randomized to receive etoricoxib 120 mg (n = 34) or placebo (n = 35) by mouth 60 minutes before surgery. After surgery oxycodone 2 mg administered intravenously was provided for rescue analgesia.

Main Outcome Measures

Oxycodone consumption during the first 6 (primary) and the 7 to 24 hours (secondary) after surgery.

Results

During the first 6 hours, all patients in the placebo group and 31 of 34 patients in the etoricoxib group were given oxycodone for rescue analgesia ( P = 0.072). In the 7 to 24 postsurgical hours, 25 of 35 patients in the placebo group versus 16 of 34 patients in the etoricoxib group needed rescue analgesics (mean difference 24%, 95% CI −1 to 47%, P = 0.039).

Conclusion

Etoricoxib 120 mg reduced pain in the 7 to 24 postsurgical time period but did not have opioid-sparing effect during the first 6 hours after surgery.

Etoricoxib pre-medication combined with intra-operative subacromial block for pain after arthroscopic acromioplasty

BACKGROUND

Arthroscopic shoulder surgery under general anaesthesia is often associated with severe post-operative pain which may delay discharge and the start of rehabilitation. Etoricoxib is a new cyclo-oxygenase-2 inhibitor with a long duration of action and a lack of a deteriorating effect on platelet function. Therefore, the effect of pre-operative etoricoxib combined with local anaesthesia on post-operative pain and the discharge profile was studied in day-surgery patients undergoing arthroscopic shoulder surgery under general anaesthesia.

METHODS

Thirty ASA I-II adult patients scheduled for arthroscopic shoulder surgery were enrolled in this randomized prospective study. Half of the patients received etoricoxib 120 mg orally (group E) and the other half received placebo tablet orally (group C) 1 h before surgery. All patients received 20 ml of bupivacaine 2.5 mg/ml solution with epinephrine at the start of surgery and 20 ml of bupivacaine 5.0 mg/ml solution with epinephrine at the end of surgery into the subacromial space. All patients received general anaesthesia with spontaneous breathing via a laryngeal mask. In the post-anaesthesia care unit, pain was assessed on a scale from 0 to 10 (visual analogue scale, VAS) and intravenous fentanyl 25 microg was administered as scheduled (VAS > or = 3). In the day-surgery unit and at home, the analgesic was a tablet containing paracetamol 500 mg + codeine 30 mg (VAS > or = 3), as needed.

RESULTS

Patients in group E reported lower post-operative pain scores at 30, 60, 120 (P < 0.01) and 180 min (P < 0.05) after surgery, and longer time to first analgesic use (P < 0.05). Patients in group E required less fentanyl (P < 0.05) and were discharged more quickly (P < 0.05) than patients in group C. Patients in group E had a lower cumulative consumption of paracetamol + codeine tablets (P < 0.05) and lower pain scores (P < 0.05) during 7 days at home than patients in group C. Adverse events were rare in both groups.

CONCLUSION

In patients having arthroscopic shoulder surgery under general anaesthesia combined with intra-operative subacromial regional analgesia, etoricoxib 120 mg reduced immediate and late post-operative pain, and facilitated early post-operative discharge.