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(Kardash et al, 2008 Level II). Similarly, after ambulatory breast surgery, dexamethasone
improved pain relief on movement between 24 and 72 hours postoperatively compared with
placebo, but the differences at other time periods were not significant; the power of this study
was possibly limited because of the low pain scores in both patient groups — all were also
given paracetamol and rofecoxib (Hval et al, 2007 Level II). Dexamethasone was no more
effective than placebo in reducing back pain after lumbar discectomy, but there was a
significant reduction in postoperative radicular leg pain and opioid consumption (Aminmansour
et al, 2006 Level II). Pain after tonsillectomy was reduced on postoperative day 1 in patients
given dexamethasone, although by a score of just 1 out of 10 (Afman et al, 2006 Level I); pain
relief was also better from day 1 to day 7 (McKean et al, 2006 Level II). Compared with lower
doses of dexamethasone and placebo, 15 mg IV dexamethasone significantly reduced 24‐hour
oxycodone requirements after laparoscopic hysterectomy, but there were no differences in
pain scores at rest or with movement between any of the study groups (Jokela et al, 2009
Level II). While preoperative dexamethasone reduced pain, fatigue, nausea and vomiting in
patients undergoing laparoscopic cholecystectomy compared with placebo (Bisgaard et al, 2003
Level II), no differences were found in these factors in patients given oral prednisone or
placebo (Bisgaard et al, 2008 Level II).
After orthopaedic surgery, there was no difference in analgesic effect between
methylprednisolone and ketorolac (both were better than placebo); methylprednisolone led
to greater opioid‐sparing but there was no difference in the incidence of adverse effects
(Romundstad et al, 2004 Level II). After mixed ambulatory surgery, ketorolac provided better pain
relief than either dexamethasone or betamethasone in the immediate postoperative period, CHAPTER 4
but there were no differences in pain relief or analgesic use in the 4 to 72 hour period after
surgery (Thagaard et al, 2007 Level II). Similarly, after breast augmentation, methylprednisolone
and parecoxib provided similar analgesia; however, PONV and fatigue scores were lower in the
patients given methylprednisolone (Romundstad et al, 2006).
A combination of gabapentin and dexamethasone provided better pain relief and led to less
PONV than either drug given alone after varicocoele surgery; both the combination and the
individual drugs were more effective than placebo (Koç et al, 2007 Level II). There was no
difference in pain scores or PCA morphine requirements during the first 24 hours
postoperatively in patients given pregabalin, pregabalin with dexamethasone, or placebo after
hysterectomy (Mathiesen et al, 2009 Level II).
Glucocorticoids have also been shown to have antihyperalgesic effects in animals and humans
(Romundstad & Stubhaug, 2007; Kehlet, 2007). Using experimental burn injury pain, both
methylprednisolone and ketorolac reduced secondary hyperalgesia and increased pain
pressure tolerance threshold compared with placebo, although the increase in pain pressure
tolerance threshold was greater with ketorolac (Stubhaug et al, 2007 Level II). In surgical
patients, preoperative administration of methylprednisolone resulted in significantly less
hyperesthesia compared with parecoxib and placebo, but there was no reduction in persistent
spontaneous or evoked pain (Romundstad et al, 2006 Level II).

Key message
1. Dexamethasone, compared with placebo, reduces postoperative pain, nausea and
vomiting, and fatigue (Level II).

Acute pain management: scientific evidence 95