We reviewed seventeen randomized clinical trials that represented the best available evidence including nine high quality and eight moderate quality studies to assess the effectiveness of selective COX-2 (includes selective [i.e. Celecoxib] and preferential [i.e. Meloxicam] COX-2 inhibitory agents) and non-selective (COX-1 and -2 inhibitory agents) oral NSAIDs to reduce pain and/or opioid consumption postoperatively following TJA. ADDIN EN.CITE.DATA [2-18] Among the included studies comparing either a selective and/or non-selective NSAID to placebo, ten studies investigated a selective NSAID and five studies investigated a non-selective NSAID.[2-5, 7-15, 17] Similar to other topics within the clinical practice guidelines, only a limited amount of meta-analyses was able to be performed due to inconsistency in the reporting of outcomes and timepoints for reporting the outcomes.
Oral NSAIDs demonstrated with limited heterogeneity in direct meta-analysis to reduce opioid consumption and sum of pain intensity differences (outcome is a four-point scale that summarizes the treatment benefit over a specific time period) compared to placebo. When direct meta-analysis was performed individually for primary total hip and knee arthroplasty, opioid consumption was lower when patients were administered preoperative and/or postoperative oral NSAIDs. Combined analysis of primary hip and knee arthroplasties demonstrated similar results favoring reduced opioid consumption and improved sum of pain intensity differences for oral NSAIDs compared to placebo.
Due to a lack of consistent outcomes, no direct or network meta-analysis could be performed comparing selective or non-selective NSAIDs. However, qualitative analysis of selective and non-selective oral NSAIDs consistently demonstrate an overwhelmingly significant response of a reduction in postoperative pain and opioid consumption for both types of NSAIDs. Three studies have directly compared selective and non-selective oral NSAIDs, which showed no significant difference in the outcomes of postoperative opioid consumption or pain scale.[13, 18] Similarly, no direct or network meta-analysis could be performed to investigate preoperative verses postoperative dosing of oral NSAIDs. Among the studies comparing a selective NSAID to placebo, three studies included preoperative dosing, four studies included postoperative dosing, and four studies included both preoperative and postoperative doses.[2, 3, 5, 7-9, 11-14] The studies comparing a non-selective NSAID to placebo included four studies utilizing postoperative dosing and one study utilizing both preoperative and postoperative doses.[4, 10, 13, 15, 17] However, one high quality study comparing preoperative and postoperative administration of a single dose of a selective NSAID showed a reduction in opioid consumption with the preoperative administration of the oral selective NSAID.
- Camu F, Beecher T, Recker DP, Verburg KM. Valdecoxib, a COX-2-specific inhibitor, is an efficacious, opioid-sparing analgesic in patients undergoing hip arthroplasty. Am J Ther 9(1): 43-51, 2002
- Chen J, Zhu W, Zhang Z, Zhu L, Zhang W, Du Y. Efficacy of celecoxib for acute pain management following total hip arthroplasty in elderly patients: A prospective, randomized, placebo-control trial. Exp Ther Med 10(2): 737-42, 2015 DOI: 10.3892/etm.2015.2512.
- Dahl V, Raeder JC, Drosdal S, Wathne O, Brynildsrud J. Prophylactic oral ibuprofen or ibuprofen-codeine versus placebo for postoperative pain after primary hip arthroplasty. Acta Anaesthesiol Scand 39(3): 323-6, 1995 DOI: 10.1111/j.1399-6576.1995.tb04070.x.
- De Miguel Rivero C AG, Sousa MM, Lopez de Rueda FS, Gonzalez FL, Marquez AP, de Anta Barrio J. Comparative efficacy of oral ibuprofen-arginine, intramuscular magnesic dipyrone and placebo in patients with postoperative pain following total hip replacement. Clinical Drug Investigation 14(4): 276-85, 1997.
- Florescu CS, Anastase, D.M., Munteanu, A.M., Porumbac, G., Mihailide, N. A. Randomized Parallel Controlled Study of the Efficacy and Safety of Lornoxicam Versus Etoricoxib after Total Knee Arthroplasty. Int J Anesth Res 4(12): 373-6, 2016.
- Gong L, Dong JY, Li ZR. Effects of combined application of muscle relaxants and celecoxib administration after total knee arthroplasty (TKA) on early recovery: a randomized, double-blind, controlled study. The Journal of arthroplasty 28(8): 1301-5, 2013 DOI: 10.1016/j.arth.2012.10.002.
- Huang YM, Wang CM, Wang CT, Lin WP, Horng LC, Jiang CC. Perioperative celecoxib administration for pain management after total knee arthroplasty - a randomized, controlled study. BMC musculoskeletal disorders 9: 77, 2008 DOI: 10.1186/1471-2474-9-77.
- Ittichaikulthol W, Prachanpanich N, Kositchaiwat C, Intapan T. The post-operative analgesic efficacy of celecoxib compared with placebo and parecoxib after total hip or knee arthroplasty. J Med Assoc Thai 93(8): 937-42, 2010.
- Jianda X, Yuxing Q, Yi G, Hong Z, Libo P, Jianning Z. Impact of Preemptive Analgesia on inflammatory responses and Rehabilitation after Primary Total Knee Arthroplasty: A Controlled Clinical Study. Sci Rep 6: 30354, 2016 DOI: 10.1038/srep30354.
- McQuay HJ, Moore RA, Berta A, Gainutdinovs O, Fulesdi B, Porvaneckas N, Petronis S, Mitkovic M, Bucsi L, Samson L, Zegunis V, Ankin ML, Bertolotti M, Piza-Vallespir B, Cuadripani S, Contini MP, Nizzardo A. Randomized clinical trial of dexketoprofen/tramadol 25 mg/75 mg in moderate-to-severe pain after total hip arthroplasty. British journal of anaesthesia 116(2): 269-76, 2016 DOI: 10.1093/bja/aev457.
- Meunier A, Lisander B, Good L. Effects of celecoxib on blood loss, pain, and recovery of function after total knee replacement: a randomized placebo-controlled trial. Acta Orthop 78(5): 661-7, 2007 DOI: 10.1080/17453670710014365.
- Munteanu AM, Cionac Florescu S, Anastase DM, Stoica CI. Is there any analgesic benefit from preoperative vs. postoperative administration of etoricoxib in total knee arthroplasty under spinal anaesthesia?: A randomised double-blind placebo-controlled trial. Eur J Anaesthesiol 33(11): 840-5, 2016 DOI: 10.1097/EJA.0000000000000521.
- Rawal N, Viscusi E, Peloso PM, Minkowitz HS, Chen L, Shah S, Mehta A, Chitkara DK, Curtis SP, Papanicolaou DA. Evaluation of etoricoxib in patients undergoing total knee replacement surgery in a double-blind, randomized controlled trial. BMC musculoskeletal disorders 14: 300, 2013 DOI: 10.1186/1471-2474-14-300.
- Reynolds LW, Hoo RK, Brill RJ, North J, Recker DP, Verburg KM. The COX-2 specific inhibitor, valdecoxib, is an effective, opioid-sparing analgesic in patients undergoing total knee arthroplasty. J Pain Symptom Manage 25(2): 133-41, 2003 DOI: 10.1016/s0885-3924(02)00637-1.
- Serpell MG, Thomson MF. Comparison of piroxicam with placebo in the management of pain after total hip replacement. British journal of anaesthesia 63(3): 354-6, 1989 DOI: 10.1093/bja/63.3.354.