NSAIDs and Tonsillectomy: Efficacy for Pain Relief

Transcription

1 NSAIDs and Tonsillectomy: Efficacy for Pain Relief Natasha Cohen, Sarah Lapner, Jayant Ramakrishna, Lehana Thabane, Doron Sommer, Gideon Koren McMaster OTL HNS Resident Research Day October 25 th 2013

2 CanMEDS Medical Expert: Management of post-tonsillectomy pain Role of NSAIDs for treatment of this pain Scholar: Overview of current literature Best evidence currently available addressing the analgesic efficacy of NSAIDs for post-tonsillectomy pain (1a)

3 NSAIDs Non-Steroidal Anti-Inflammatory Drugs BACKGROUND

4 Anti-platelet Pain Inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac Clin Ophthalmol. 2009;3:

5 Tonsillectomy Tonsillectomy most commonly performed surgery in NA Complications Pain: Can be intractable Can result in dehydration, re-admission Other: Fever Hemorrhage: 0.2-2%

6 NSAIDs Seldom used in OTL HNS Increase in bleeding risk Studies in other surgical fields (eg: orthopedics, neurosurgery, general surgery) have established the safety and efficacy of NSAID s post-op

7 No statistically significant difference in bleeding for NSAIDS

8 Analgesic dilemma Codeine Over the last decade Severe respiratory depression and death Feb 2013 FDA issued a black box warning against codeine post-operatively AAO-HNS & CSO HNS endorsed NSAIDs and Acetaminophen Efficacy of NSAIDs has been shown in RCT s but no SR s exist on this topic

9 Available limited evidence suggests that prophylactic NSAIDs are at least as effective as prophylactic administration of opioids

10 P: Patients of all ages undergoing tonsillectomy I: NSAIDs C: Other analgesic regimens O: Pain control T: Post-operative period (T=0 à 3 weeks)

11 Methods Systematic Review Medline, EMBASE systematic search through OVID Cochrane trial registry Grey literature searched using Web of Science Search conducted September 25 th independent reviewers

12 Outcomes Primary Analgesic efficacy All measures accepted Secondary: Vomiting Bleeding (clinically significant) Readmission to hospital

13 Inclusions RCT s only NSAIDs vs other English and French Report on pain (primary or secondary outcome)

14 Statistical Analysis RevMan version 5.2 (Cochrane Collaboration 2012) Pain: Standardized mean difference Vomiting: Odds ratio

15 ANSWER RESULTS

16 Search results

17 Search results Number of patients: 4782 Average number of subjects per study: 83.9 SD 52.3 min 25, max 340 Pediatric: 38 studies Adult: 19 studies 1 not specified Publication date: 1964 to 2013

18 Mean total dose rescue at 24h Morphine Tramadol Acetaminophen Lidocaine Acetaminophen Diclofenac PR Lornoxicam IV Flurbiprophen IV Diclofenac PR Rofecoxib PO Sensitivity analysis: pediatric vs. adult studies did not affect results

19 Pain Scores at 24h Oropivalone bacitracin Acetaminophen Papaveretum Rofecoxib po Flurbiprophen IV Ketorolac IV Rofecoxib po

20 Vomiting at 24h

21 Vomiting at <6h

22 Long Term Pain Study NSAID Comparator Follow up duration Results Angot 1987 Niflumic Acid po Oropivalone gel caps 8 days NSAID>comparator POD 1 and 2, NS POD 3,4 &7 Bean Lejewski 2007 Rofecoxib po Acetaminophen and hydrocodone po 3 day diary NSAID < comparator for active pain Courtney 2001 Diclofenac po Tramadol po 14 days Not statistically significantly better Harley 1998 Ibuprofen po Acetaminophen and codeine po POD 1, 3, 14 Comparator > NSAID POD 1 & 3, NS POD 5 Ozkiris 2013 Ibuprofen po Metamizole and Acetaminophen po 7 days Pain not reported Parker 1986 Ibuprofen po Placebo 6 days Long term results only graphical Roy 1968 Oxyphenbutazone po Placebo 8 days NSAID> placebo (stats not done) Stewart 2002 Piroxicam po Dexamethasone po 8 days NSAID< comparator (statistically significant)

23 Discussion NSAIDs =/> in pain control posttonsillectomy Varied measurement tools Homogeneity achieved with sensitivity analyses based on pre-existing hypotheses Placebo group?

24 Discussion Limitations: little long term data available beyond 24h, and could not be meta-analyzed Heterogeneous methods (analgesics) and reporting of pain (timing, scale) Small N for pain comparisons Advantage for vomiting Well recognized in previous studies Compared to both opioids, nonopioids and placebo

25 Conclusions NSAIDs are adequate options for post-operative pain control Little evidence available for long term pain outcome posttonsillectomy Randomized controlled trial needed to address the adequacy of pain control

26 What s next RCT Issues: Pediatric population Exclusion criteria? Which NSAID? Rescue and comparator Morphine? Pain measurement tool? Short vs. long term Follow up Minimize attrition Validity of recordings Timing, frequency vs.