Benefits of NSAIDs as Part of Multimodal Analgesia Regimen in Children
Investigators searched for randomized controlled trials that evaluated the use of NSAIDs as part of a multimodal analgesia regimen for the management of pain in children.
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LAS VEGAS — Perioperative and emergency department use of non-steroidal anti-inflammatory drugs (NSAIDs) as part of a multimodal analgesia regimen may improve pain control in pediatric populations and avoid opioid-related adverse events, according to a study presented during the 2018 PAINWeek conference, held September 4–8.
Using the PubMed database, investigators searched for randomized controlled trials that evaluated the use of NSAIDs as part of a multimodal analgesia regimen for the management of pain in children in a perioperative or emergency department setting and for conditions of special interest (tonsillectomy, sickle cell, musculoskeletal, and fracture). Outcome measures included the effect of multimodal analgesics on pain scores, morbidity, opioid dose consumption, and adverse events.
The literature review included 18 articles on NSAID studies that investigated the effects of ibuprofen (n=9), ketoprofen (n=4), diclofenac (n=2), ketorolac (n=2), and lornoxicam (n=1) in pediatric populations. Eight studies examined NSAID use for musculoskeletal injury and orthopedic surgery, 5 studies involved NSAID use for tonsillectomy or adenoidectomy, 3 studies involved “other” surgeries, and 2 involved dental surgery. Two studies compared different administration routes and formulations of ketoprofen (intravenous vs intramuscular, and intravenous vs per rectum).
Ibuprofen provided equivalent analgesia compared with opioid medications (6 studies), and significantly reduced pain scores compared with acetaminophen alone or in combination with codeine. Ibuprofen was shown to reduce meperdine need (1 study). Ketoprofen offered a significant reduction in morphine equivalents and pain scores compared with tramadol and placebo. Diclofenac was found to reduce pain scores compared with placebo and acetaminophen, and offered longer-lasting analgesia when combined with bupivacaine infiltration vs bupivacaine caudal block. Ketorolac showed a significant reduction in morphine need (1 study) and reduced pain scores to levels comparable with those obtained with tramadol (1 study). Lornoxicam was beneficial in reducing pain at rest but was not assessed for change in morphine equivalent consumption. In all of the studies, NSAIDs were well tolerated by pediatric patients. Adverse events associated with NSAIDs were less than with opioids and similar to placebo; only 1 study involving ketoprofen reported significant operative blood loss.
”In pediatric studies where NSAIDs are evaluated as part of a multimodal regimen, pain relief is consistent with their use, often in an equivalent fashion to pain relief from opioid analgesics such as morphine or oxycodone. Additionally, NSAIDS are better tolerated than opioids and do not appear to be associated with increased operative blood loss over placebo, with the possible exception of ketoprofen,” concluded the study authors.
Angoulvant F, Barbosa S. Multimodal pain management in children: NSAID use in the perioperative and emergency department setting. Presented at: 2018 PAINWeek; September 4–8, 2018; Las Vegas, NV. Poster 26.
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