Patients undergoing robotic hysterectomy were found to report comparable pain scores when receiving celecoxib perioperatively or ketorolac postoperatively — both as part of a multimodal pain management plan — in a study published in Gynecologic Oncology. In addition, treatment that included celecoxib was associated with lower postoperative opioid use.
Celecoxib, a COX-2 inhibitor with anti-inflammatory properties, is not associated with gastric ulceration, acute renal damage, or postsurgical bleeding, unlike COX-1 inhibitors. However, the optimal perioperative analgesic regimen for celecoxib remains unclear. The current study aimed to examine celecoxib vs ketorolac as an adjunctive component of a multimodal postsurgical pain regimen.
A randomized clinical trial (clinicaltrials.gov identifier NCT03331315) including women undergoing open or robotic hysterectomy between September 2013 and June 2016 (n=170) was conducted. Study participants were assigned to receive intravenous ketorolac 30 mg intraoperatively and every 6 hours after surgery until discharge or oral celecoxib 400 mg preoperatively followed by celecoxib 200 mg twice a day for 7 days after discharge. Women who had undergone an open hysterectomy (n=32) were excluded because of poor accruement, leaving 138 patients for analysis in the robotic cohort (ketorolac: n=70, mean age, 56.3; celecoxib: n=68, mean age, 55.1).
All participants were prescribed a common multimodal regimen comprising acetaminophen, gabapentin, and opioids as needed. The primary outcome was inpatient pain intensity assessed with a visual analog scale (VAS), and secondary outcomes included inpatient narcotic and antiemetic use, length of hospital stay, occurrence of complications, amount of hemorrhage, outpatient narcotic use, and time until return to activities of daily living. A postoperative questionnaire was used to assess all outpatient metrics and was returned by 96% of study participants 2 weeks after surgery.
Mean inpatient VAS scores and hospital length of stay were comparable in patients who had received ketorolac and celecoxib (VAS, 2.7±1.9 vs 2.4±1.6, respectively; P =.21; length of stay, 11.6±8.1 hours vs 11.9±7.6 hours, respectively; P =.41). Fewer outpatient opioids were used in patients receiving celecoxib vs ketorolac (6.0±3.6 pills vs 8.1±4.0 pills, respectively; P =.001), and these outpatient opioids were discontinued sooner in participants taking celecoxib vs ketorolac (3.8±2.6 days vs 5.7±2.8 days, respectively; P <.001). Inpatient narcotic or antiemetic use, perioperative complications, and time until return to activities of daily living were comparable in the 2 groups (ketorolac, 2.4±0.8 days vs celecoxib, 2.2±0.9 days; P =.14).
Study strengths include patient homogeneity and randomization to different multimodal pain protocols instead of standard narcotic administration for pain control. Study limitations include reliance on patient-reported opioid usage, inability to account for alternative or home remedies, use of intravenous vs oral ketorolac, and short lengths of hospital stay.
“Celecoxib provides an effective alternative for surgeons reluctant to incorporate ketorolac as part of a postoperative multimodal pain control regimen,” concluded the study authors, who recommended that future trials examine oral celecoxib use after open procedures as well as scheduled non-prescription nonsteroidal anti-inflammatory drug use postoperatively to reduce opioid use.
Ulm MA, Elnaggar AC, Tillmanns TD. Celecoxib versus ketorolac following robotic hysterectomy for the management of postoperative pain: An open-label randomized control trial. Gynecol Oncol. 2018;151(1):124-128. doi:10.1016/j.ygyno.2018.08.015