Page 126 Acute Pain Management

Gastrointestinal
GI complications are less likely with use of coxibs compared with nsNSAIDs; the incidence was
lowest with celecoxib and valdecoxib (Moore et al, 2007 Level I).
Short‐term use of parecoxib as required to treat acute pain results in gastroscopic ulcer rates
similar to placebo, even in elderly patients at increased risk, in contrast to increased rates of
ulceration with nsNSAIDs in the same setting (Harris et al, 2001 Level II; Stoltz et al, 2002 Level II;
Goldstein et al, 2003 Level II).
The best gastroprotective strategy was the combination of a coxib and a PPI (Targownik et al,
2008 Level III‐2). In high‐risk populations, ulcer recurrence can be avoided even in long‐term
therapy by combining a coxib (celecoxib) with a PPI (Chan et al, 2007 Level II).
Aspirin‐exacerbated respiratory disease
Investigation of patients with AERD has provided encouraging evidence that coxibs,
administered at analgesic doses, do not produce bronchospasm in these patients (Martin‐Garcia
et al, 2003 Level II; West & Fernandez, 2003 Level I).
Bone healing
At present, data on the effect of coxibs on bone healing are mainly limited to animal models.
There is no good evidence of any clinically significant inhibitory effect of coxibs on bone
CHAPTER 4 healing (Gerstenfeld & Einhorn, 2004; Bandolier, 2004).

Key messages
1. Paracetamol is an effective analgesic for acute pain; the incidence of adverse effects
comparable to placebo (S) (Level I [Cochrane Review]).
2. Non‐selective NSAIDs are effective in the treatment of acute postoperative and low back
pain, renal colic and primary dysmenorrhoea (N) (Level I [Cochrane Review]).

3. Coxibs are effective in the treatment of acute postoperative pain (N) (Level I [Cochrane
Review]).
4. With careful patient selection and monitoring, the incidence of nsNSAID‐induced
perioperative renal impairment is low (U) (Level I [Cochrane Review]).

5 Non‐selective NSAIDs do not increase the risk of reoperation for bleeding after
tonsillectomy in paediatric patients (Q) (Level I [Cochrane Review]).
6. Coxibs do not appear to produce bronchospasm in individuals known to have aspirin‐
exacerbated respiratory disease (U) (Level I).
7. In general, aspirin increases bleeding after tonsillectomy (N) (Level I).
8. Non‐selective NSAIDs given in addition to paracetamol improve analgesia compared with
paracetamol alone (U) (Level I).
9. Paracetamol given in addition to PCA opioids reduces opioid consumption but does not
result in a decrease in opioid‐related side effects (N) (Level I).
10. Non‐selective NSAIDs given in addition to PCA opioids reduce opioid consumption and the
incidence of nausea, vomiting and sedation (N) (Level I).
11. Non‐selective NSAIDs and coxibs are effective analgesics of similar efficacy for acute pain
(U) (Level I).

12. Preoperative coxibs reduce postoperative pain and opioid consumption, and increase
patient satisfaction (N) (Level I).

78 Acute Pain Management: Scientific Evidence