Page 124 Acute Pain Management

Efficacy
Coxibs were as effective as nsNSAIDs in the management of postoperative pain (Romsing &
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Moiniche, 2004 Level I ). They were also as effective as nsNSAIDs for the treatment of low back
pain (although effect sizes were small) but the incidence of side effects was lower with coxibs
(Roelofs et al, 2008 Level I). NNTs are comparable with those for nsNSAIDs for the treatment of
moderate to severe acute pain. For a list of NNTs for each drug see Table 6.1.
Preoperative coxibs reduced postoperative pain and opioid consumption and increased
6
patient satisfaction (Straube et al, 2005 Level I ). When given in combination with opioids after
surgery, coxibs were opioid‐sparing (Hubbard et al, 2003 Level II; Malan et al, 2003 Level II; Ng et al,
2003 Level II; Reynolds et al, 2003 Level II; Gan et al, 2004 Level II; Celik et al, 2005 Level II; Nussmeier et
al, 2006 Level II; Snabes et al, 2007 Level II; White PF et al, 2007 Level II), but both a decrease in the
incidence of opioid‐related side effects (Malan et al, 2003 Level II; Gan et al, 2004 Level II) and no
difference (Hubbard et al, 2003 Level II; Ng et al, 2003 Level II; Celik et al, 2005 Level II; Snabes et al,
2007 Level II; White PF et al, 2007 Level II) has been reported. A meta‐analysis concluded that
there was no evidence for a decrease in adverse effects (Romsing et al, 2005 Level I) as did a
meta‐analysis that included trials of coxibs given to patients receiving PCA morphine; it
showed reduced opioid consumption but no significant reductions in pain scores or opioid‐
7
related adverse effects (Elia et al, 2005 Level I ).
CHAPTER 4 or postoperatively and continued for 3 days after surgery, showed opioid‐sparing and
Timing of administration may not be critical. A comparison of celecoxib, started preoperatively
improved patient satisfaction in both patient groups compared with placebo, but there was no
advantage for administration before surgery (Sun et al, 2008 Level II). Similarly, in patients
undergoing hip arthroplasty, preoperative administration of parecoxib offered no advantage
compared with postoperative use; opioid‐sparing was again seen in both groups compared
with placebo (Martinez et al, 2007 Level II). Pain relief was also no better when parecoxib was
given before incision compared with administration at the end of surgery in patients
undergoing colorectal surgery (Lee et al, 2008 Level II).
Adverse effects
Renal function
COX‐2 is constitutively expressed in the kidney and is highly regulated in response to
alterations in intravascular volume. COX‐2 has been implicated in maintenance of renal blood
flow, mediation of renin release and regulation of sodium excretion (Cheng & Harris, 2004
Level IV; Kramer et al, 2004 Level IV).
Coxibs and nsNSAIDs have similar adverse effects on renal function (Curtis et al, 2004 Level I). A
statistically significant increased risk of renal failure was reported following administration of

6
This systematic review includes a study or studies that have since been withdrawn from publication. Please refer to
the Introduction at the beginning of this document for comments regarding the management of retracted articles.
While reanalysis of the data would be required to confirm the conclusions, in this instance, expert advice suggested
that withdrawal of the retracted articles would not influence the results. Marret et al (Marret et al, Anesthesiology
2009; 111:1279–89) re‐examined the data included in this review. While unable to reach a unanimous agreement as
to whether exclusion of the retracted papers would have altered any of the conclusions, their disagreement did not
concern the statement above to which this reference is attached but referred to specific comments about rofecoxib.
7
This meta‐analysis includes a study or studies that have since been withdrawn from publication. Please refer to the
Introduction at the beginning of this document for comments regarding the management of retracted articles.
Expert advice suggested that withdrawal of the retracted articles would not influence the conclusions but that
reanalysis would be required for this to be confirmed. Marret et al (Marret et al, Anesthesiology 2009; 111:1279–89)
reanalysed the data included in this meta‐analysis after excluding that obtained from the retracted publications.
They concluded that removal of this information did not significantly alter the results.
76 Acute Pain Management: Scientific Evidence