Ortho postop anti-inflammatory/NSAID

[PA1122]

Curious what others use for postop anti-inflammatories ?

My practice typically sends ibuprofen 600mg TID. We’ve had some patients develop AKI so I have started moving towards meloxicam or Celebrex, especially in patients >50 or who have been on anti-inflammatory long term. 
 

looking to see what others use! 

[ohiovolffemtp]

EM, not ortho, but I recently had C3-C7 fused.  Was told no NSAIDs for 1 month prior and 6 months post surgery.

[SedRate]

I really like toradol immediately post-op if I'm not too worried about fx healing. Most of my patients are trauma/fracture pts so I don't routinely recommend scheduled NSAIDs due to healing and bleeding risks with their DVT prophylaxis. If pts need something, I'll recommend alternating low-dose Ibuprofen, like 200-400, with APAP QID. If still struggling, they can go up to 600-800 TID but I caution them. Also, I tell people to elevate around the clock and use their compression socks/ACE wraps to keep swelling in check which is often a culprit for pain. 

[Reality Check 2]

The use of NSAIDs in post op ortho is a difficult choice. Back in the day - dark ages - we used NO NSAIDs for fractures or post op due to bone healing. Now more acceptable as shown below in the articles. Still a complete NO NO for fusions.

The bigger issue I face is that my patients are mostly older with comorbid conditions and HTN, DM, Cardiac Issues and NSAIDs are a NO NO ALL THE TIME.

Ibuprofen is my least favorite NSAID under almost any circumstance. Celebrex crosses over to Sulfa allergies. Naproxen is a personal favorite, particularly OTC at 220 mg per pill - can customize it without having to rely on rx sizes of 375 mg and 500 mg. 

Oral Toradol is limited to 10 mg TID x 5 days max but can be quite useful if kidneys ok. It rocks with kidney stones if Crt and Crt clearance is good. 

The effect of NSAIDs on postfracture bone healing: a meta-analysis of randomized controlled trials - PMC (nih.gov)

Conclusions:

Six RCTs (609 patients) were included. The risk of nonunion was higher in the patients who were given NSAIDs after the fracture with an OR of 3.47. However, once the studies were categorized into the duration of treatment with NSAIDs, those who received NSAIDs for a short period (<2 weeks) did not show any significant risk of nonunion compared to those who received NSAIDs for a long period (>4 weeks). Indomethacin was associated with a significant higher nonunion rate and OR ranging from 1.66 to 9.03 compared with other NSAIDs that did not show a significant nonunion risk.

NSAIDs and COX-2 Inhibitors Do Not Affect Healing After Rotator Cuff Repair - A Systematic Review and Meta Analysis. - Arthroscopy (arthroscopyjournal.org)

Conclusion

This systematic review and meta-analysis indicates that NSAIDs do not affect healing rate after arthroscopic rotator cuff repair but they do significantly improve post-operative pain and functional outcomes. No significant difference was seen in pain or functional outcomes with the use of COX-2 inhibitors.

Nonsteroidal Anti-inflammatory Drugs in the Acute Post-opera... : Spine (lww.com)

Conclusions. 

Both NSAID and COX-2 inhibitor use in the early post-surgical period may be associated with increased rates of pseudarthrosis, hardware failure, and revision surgery in patients undergoing posterior spinal instrumentation and fusion.

[SedRate]

1 hour ago, Reality Check 2 said:

The bigger issue I face is that my patients are mostly older with comorbid conditions and HTN, DM, Cardiac Issues and NSAIDs are a NO NO ALL THE TIME.

I worked with a cardiac surgeon who routinely prescribed Toradol immediately post-CABG. kinda crazy. 

[CAAdmission]

1 hour ago, SedRate said:

I worked with a cardiac surgeon who routinely prescribed Toradol immediately post-CABG. kinda crazy. 

How many bad outcomes as a result?

[SedRate]

2 hours ago, CAAdmission said:

How many bad outcomes as a result?

Don't know, didn't stick around long enough to find out. Their explanation was that the pt was inflammatory and thus the anti inflammatory. 

[SedRate]

6 hours ago, Reality Check 2 said:

those who received NSAIDs for a short period (<2 weeks) did not show any significant risk of nonunion compared to those who received NSAIDs for a long period (>4 weeks)

Yep, for the general population, I caution its use after the acute phase of fx healing to avoid becoming one of the nonunions that get referred to my practice. And like I said, for pts I'm worried about fx healing aka high risk for nonunion, e.g., open fx, DM smokers, nonunion repairs, etc, I try to avoid NSAIDs whenever possible or stick to low doses. But, we do what we can, and when pain becomes an issue and difficult to manage, just gotta counsel folks and let them make an informed decision about their care. 

[CornellSPA]

In the surgical world an infusion of IV Acetaminophen generally works well (of course avoid in liver disease including fatty liver).  Although not EBM, using oral tylenol 325 3-4 tabs a day and oral and or topical Arnica can be effective, very safe, and wildly popular with many patients! 

Arnica references: 

1. acute sports injury:

https://www.contemporarypediatrics.com/view/healing-the-young-athlete-with-otc-medications (topical use)

2. Post extraction  dental pain

"There was no difference between Arnica and Ibuprofen in the postextraction pain management in 8–12-year-old children." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9357536/

3. The anti-inflammatory bundle 

https://journals.sagepub.com/doi/abs/10.1177/17504589211031069

[ventana]

an N of 1

I have taken a lot of NSAID for back pain

read and article a few years back stating it was no help

stopped

pain worse for a few weeks

Then better then when on NSAIDs

 

NSAIDs are not chronic meds (never were intended to be)

 

Post op - acute phase - narc's

post acute low dose narcs

after 4-8 weeks nothing oral - topicals, massage, PT/OT

 

I would rather taper someone slowly from opiates then deal with a GI bleed or AKI... (I use a very minimal amount of opi)

 

We have unrealistic expectations around pain.  PAin can be good - just have to accept it and work with it

 

Nonhealing for both muscle and bone is an issue.....  AKI is an issue..... GI bleed is an issue...

 

 

[SedRate]

11 hours ago, ventana said:

We have unrealistic expectations around pain.  PAin can be good - just have to accept it and work with it

Definitely. Some extra counseling and shared decision-making go a long way.