LIMITED RECOMMENDATION There is one moderate quality study (Oh 2018) that compared cox-2 inhibitors, ibuprofen and tramadol. There was no significant difference in terms of pain intensity, incidence of adverse effects or dosage of rescue medications at 3 days or 2 weeks.
Benefits/Harms of Implementation
Tramadol is a centrally acting, oral analgesic that contains an opioid and is therefore considered a controlled substance. Side effects such as nausea, vomiting and dizziness are associated with Tramadol, although unlike other opioids, respiratory depression is rare. Traditional NSAIDs inhibit cyclooxygenase COX-1 and may inhibit platelet function or lead to gastrointestinal or renal toxicity. They have minimal side effects in most patients and are safe if avoided in patients considered high risk. Selective COX-2 inhibitors are thought to have fewer side effects. There have been some recent evidence to suggest that COX-2 medications may impair muscle regeneration or weaken tendon-bone healing.
Outcome Importance
In patients without significant kidney disease or gastrointestinal diseases in the setting of equal outcomes ibuprofen would be an inexpensive, easily obtainable option for postoperative pain control compared to Tramadol or COX-2 inhibitors. Targeting multiple pain pathways with multimodal analgesics including a combination of Tramadol and NSAIDs will decrease parenteral opioid use and side effects. In addition, using Tramadol in conjunction with NSAIDs may decrease the dose of Tramadol required, subsequently decreasing side effects.
Cost Effectiveness/Resource Utilization
Ibuprofen is an over the counter medication which is inexpensive and easily available to all patients. COX-2 inhibitors require a prescription and often require approval for insurance coverage. Tramadol is a controlled substance and requires a prescription.
Acceptability
Tramadol and NSAIDs are all commonly used medications for postoperative orthopedic pain.
Feasibility
This recommendation does not significantly change clinical practice as all of these medications are widely used.
Future Research
Future research should focus on determining the most effective combination and dose of medications.