Oral COX-2 NSAID and Postoperative Pain and/or Opioid Use
Administration of an oral selective clyclooxygenase-2 (COX-2) NSAID immediately preoperatively, compared to early postoperative administration, provides improved postoperative pain control and reduced opioid consumption following primary TJA.
Anesthesia and Analgesia in Total Joint Arthroplasty (2020)
Developed by: American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, The Hip Society, and The Knee Society


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.[12]


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