As the Popularity of NSAIDs Grows, New Uses and Research Potential Emerge
In an overview article, the authors explore the increased use of nonsteroidal anti-inflammatory drugs (NSAIDs) in pain management and provide a concise explanation of the pros and cons and future avenues for research.
As over-the-counter options with rapid onset and typically fewer central nervous system problems than some analgesics, these agents are a common choice among patients. Given the ongoing opioid crisis and the prioritization of enhanced recovery, interest has been further renewed for both long-term and short-term use. Moreover, NSAIDs come in multiple formulations (ie, liquid, topical gel, and patch), and thus can be tailored to fit individual cases.
However, there are potential side effects. Main concerns include excessive bleeding, hepatic and renal insufficiency, and an increased risk of gastric bleeding and gastric ulcers.
Having a complete history for the patient is essential. Celecoxib, a COX-2-selective NSAID, has a decreased risk of gastrointestinal (GI) disturbance, but a potentially increased risk for cardiovascular events. In patients who have a history of cardiovascular disease, risks are increased with long-term use. Meloxicam may be preferable in those cases.
Pain has an inflammatory component, making NSAIDs effective options both in acute and chronic situations. Additionally, swelling and pain caused by a muscle strain or sprain can be reduced by NSAIDs. Also, migraine or temporomandibular disorders respond to NSAIDs. However, NSAIDs do not seem to have any effect on diabetic neuropathy.
Several studies have looked at potential complications of adding NSAIDs to an enhanced recovery protocol. For example, NSAID use did not increase postoperative GI bleeding after joint surgery.
Further areas of research will explore the type of pain NSAIDs can help. Historically, pain has been considered as nociceptive or neuropathic, each with different characteristics and treatment options. But with the realization that nerve-related pain can sometimes have an inflammatory component and that the immune system may modulate how people experience this type of pain, NSAIDs may have a place in treatment. As the population continues to develop interest in dietary and nutritional supplements, especially as they relate to pain management, combination of NSAIDs with herbal products indicates another area of research. (See Nalley C. NSAIDs in pain management: new clinical avenues to explore. ASA Monitor. 2020;84:1-6.)
Spinal Anesthesia Found Effective for Pain Management After Uterine Artery Embolization
Uterine artery embolization (UAE) has been shown to be effective in the management of uterine fibroids, which are benign myometrial neoplasms. Management is usually under conscious sedation. However, postprocedural pain is considerable due to pain modulation from inflammatory mediators. Thus, adoption of this technique has been limited.
In a collaborative study among radiology, gynecology, and anesthesiology departments, Trister and colleagues in a New York City hospital identified 47 patients scheduled to undergo UAE.
Of these 47 patients, 21 received only conscious sedation (CS) and 26 patients were first given spinal analgesia (SA) consisting of bupivacaine 0.75%, followed by conscious sedation. Pain scores were analyzed on arrival to the postanesthesia care unit (PACU) (ie, <30 minutes after embolization), and at 4, 8, 12 and 24 hours after the completion of the procedure. Other data collected included hospital length of stay, and requirements for additional analgesics.
The researchers found a progressive decline in pain in both groups. Mean scores on PACU admission were 5.8% for the CS group and 3.8% for the CS/SA group. Of the patients who received CS, 43% reported moderate to severe pain at 24 hours, compared with 4% of patients who received additional SA (mean score 2.5 for CS and 0.5 score for CS/SA, P = 0.003).
Length of stay and use of more analgesics did not differ between the groups.
Conclusions drawn were that the addition of SA would make the procedure more amenable to expanded use, as postoperative pain could be better controlled. Use of SA alone has not been studied and may prove to be superior by significantly reducing postoperative nausea and vomiting, while also providing transmission modulation and decreased pain perception. (See Trister G, Sathyanarayana SK, Arampulikan J, et al. Use of spinal anesthesia for postoperative analgesia after uterine artery embolization. Anesthesiology News. September 1, 2020.)