Cyclooxygenase-2–selective inhibitors in the management of acute and perioperative pain

ABSTRACT

Postsurgical pain is often undertreated. Opioids are frequently used in perioperative analgesia, but concern about side effects can result in administration of an inadequate dose for pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used increasingly for postoperative analgesia. The use of balanced analgesia—a combination of opioids, NSAIDs, and local anesthesia utilizing agents from other classes (eg, ketamine, clonidine)—improves the efficacy of pain relief and decreases risk of side effects. While lacking some of the troublesome side effects of opioids, nonselective NSAIDs may cause bleeding as a result of their inhibitory effects on COX-1. For this reason, COX-2–selective inhibitors (coxibs) are attractive opioid-sparing analgesic options in the perioperative setting. Factors in addition to side effects such as time to onset of action, duration of action, maximum pain relief, use of rescue medication, and other factors relevant to a given pain model are important in determining overall analgesic efficacy. Clinical studies show that COX-2–selective inhibitors are effective for the treatment of preoperative and postoperative pain and reduce postsurgical requirements for opioids. This evidence supports a role for COX-2–derived prostaglandins as key mediators of nociceptive pain and peripheral sensitization (hyperalgesia). Pain management in the perioperative setting and the role of COX-2–selective inhibitors in acute and postoperative pain are reviewed here.