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
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)
NSAIDs Non-Steroidal Anti-Inflammatory Drugs BACKGROUND
Anti-platelet Pain Inhibition of surgically induced miosis and prevention of postoperative macular edema with nepafenac Clin Ophthalmol. 2009;3:219-226.
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%
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
No statistically significant difference in bleeding for NSAIDS
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
Available limited evidence suggests that prophylactic NSAIDs are at least as effective as prophylactic administration of opioids
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)
Methods Systematic Review Medline, EMBASE systematic search through OVID Cochrane trial registry Grey literature searched using Web of Science Search conducted September 25 th 2013 2 independent reviewers
Outcomes Primary Analgesic efficacy All measures accepted Secondary: Vomiting Bleeding (clinically significant) Readmission to hospital
Inclusions RCT s only NSAIDs vs other English and French Report on pain (primary or secondary outcome)
Statistical Analysis RevMan version 5.2 (Cochrane Collaboration 2012) Pain: Standardized mean difference Vomiting: Odds ratio
ANSWER RESULTS
Search results
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
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
Pain Scores at 24h Oropivalone bacitracin Acetaminophen Papaveretum Rofecoxib po Flurbiprophen IV Ketorolac IV Rofecoxib po
Vomiting at 24h
Vomiting at <6h
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)
Discussion NSAIDs =/> in pain control posttonsillectomy Varied measurement tools Homogeneity achieved with sensitivity analyses based on pre-existing hypotheses Placebo group?
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
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
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.