Single dose oral etoricoxib for acute postoperative pain in adults Stable (no update expected for reasons given in 'What's new')

Abstract

Abstract Background

This is an updated version of the original Cochrane review first published in Issue 2, 2009, and updated in Issue 4, 2012.

Etoricoxib is a selective cyclo‐oxygenase‐2 (COX‐2) inhibitor licensed for the relief of chronic pain in osteoarthritis and rheumatoid arthritis, and acute pain in some jurisdictions. This class of drugs is believed to be associated with fewer upper gastrointestinal adverse effects than conventional non‐steroidal anti‐inflammatory drugs (NSAIDs).

Objectives

To assess the efficacy and adverse effects of single dose etoricoxib for acute postoperative pain using methods that permit accurate comparison with other analgesics evaluated in the same way, using criteria of efficacy recommended by in‐depth studies at the individual patient level.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Database, www.clinicaltrials.gov, and reference lists of articles. The date of the most recent search was 31 January 2014.

Selection criteria

Randomised, double‐blind, placebo‐controlled clinical trials of single dose, oral etoricoxib for acute postoperative pain in adults.

Data collection and analysis

Two review authors independently considered studies for inclusion in the review, assessed quality, and extracted data. We used the area under the pain relief versus time curve to derive the proportion of participants prescribed etoricoxib or placebo with at least 50% pain relief over six hours, using validated equations. We calculated relative risk (RR) and number needed to treat to benefit (NNT). We used information on use of rescue medication to calculate the proportion of participants requiring rescue medication and the weighted mean of the median time to use. We also collected information on adverse events.

Main results

We identified no new studies for this updated review, which includes six studies with 1214 participants in comparisons of etoricoxib with placebo. All six studies reported on the 120 mg dose (798 participants in a comparison with placebo). Sixty‐six per cent of participants with etoricoxib 120 mg and 12% with placebo reported at least 50% pain relief (NNT 1.8 (1.7 to 2.0); high‐quality evidence). For dental studies only, the NNT was 1.6 (1.5 to 1.8). A single dose of 90 mg produced similar results in one large trial. Other doses (60, 180, and 240 mg) were each studied in only one treatment arm.

Significantly fewer participants used rescue medication over 24 hours when taking etoricoxib 120 mg than placebo (NNT to prevent remedication 2.2 (1.9 to 2.8)), and the median time to use of rescue medication was 20 hours for etoricoxib and two hours for placebo. Adverse events were reported at a similar rate to placebo (moderate‐quality evidence), with no serious events.

Authors' conclusions

Single‐dose oral etoricoxib produces high levels of good quality pain relief after surgery, and adverse events did not differ from placebo in these studies. The 120 mg dose is as effective as, or better than, other commonly used analgesics.

Author(s)

Rachel Clarke, Sheena Derry, R Andrew Moore

Abstract

Plain language summary

Single dose oral etoricoxib for acute postoperative pain in adults

Acute pain is often felt soon after injury. Most people who have surgery have moderate or severe pain afterwards. People with pain are used to test painkillers. They have often had wisdom teeth removed. The pain is often treated with pain killers taken by mouth. Results can be applied to other forms of acute pain.

A series of reviews looks at how good painkillers are. This review looks at a drug called etoricoxib. This is one of a type of pain killer called an NSAID (non‐steroidal anti‐inflammatory drug). The amount of pain relief experienced depends on the dose taken.

We found six clinical trials with 1214 people. A single 120 mg dose of etoricoxib produced useful pain relief in 7 in 10 (66%) people with moderate or severe pain, compared with just over 1 in 10 (12%) with placebo. A single 90 mg dose produced similar results in one large trial. Pain relief lasted for 20 hours in half of people treated.

Adverse events occurred at similar rates with etoricoxib and placebo in these single‐dose studies. No serious adverse events or withdrawals due to adverse events occurred with etoricoxib.

Author(s)

Rachel Clarke, Sheena Derry, R Andrew Moore

Reviewer's Conclusions

Authors' conclusions

Implications for practice

A single dose of etoricoxib 120 mg (and probably 90 mg) is an effective analgesic, providing at least 50% pain relief to about two‐thirds of treated patients with acute, moderate to severe, postoperative pain (high‐quality evidence). The number needed to treat to benefit (NNT) of 1.8 for at least 50% pain relief and median time to use of rescue medication of more than 20 hours are both better than other analgesics commonly used for postoperative pain. In a single dose it is associated with a low rate of mainly mild adverse events, similar to that with placebo.

Implications for research

We identified no new studies for this update. It is unlikely that further studies will be carried out for this dose and in this setting, and if they were, that they would change the result here. Studies at lower doses might help to determine whether lower doses can provide adequate analgesia without loss of duration of action. Multiple‐dose studies over a longer duration may help to evaluate the risk of adverse events, particularly rare adverse events (serious, death), and more adequately reflect clinical practice. However, such information is more likely to be taken from studies in chronic pain, such as arthritis.

It is more important to recognise the gulf between results in single‐dose clinical trials and in treatment of acute pain in clinical practice. Single‐dose trials can show that certain drugs at certain doses produce excellent analgesia in the majority of patients. Surveys consistently show that acute pain is badly treated, even in hospital, and that a large percentage of patients suffer moderate or severe pain over long periods. The clinical practice research agenda is how best to use the excellent analgesics we have to improve day‐to‐day results in treatment of acute pain in hospital and primary care.

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