Assessment of pain management in anaesthesia

Abstract

Pharmacotherapy within anaesthesia includes pain relief with an aim to ensure patient comfort through adequate analgesia and sedation. To control acute pain within intraoperative and post-operative scenarios, paracetamol, opiates, and NSAIDS are used. Selective COX-2 inhibitors celecoxib, parecoxib and the selective α2-AR agonist dexmedetomidine are currently not available on the local hospital formulary for use within the Anaesthesia department. This study aimed to gather evidence regarding indications and advantages of celecoxib, parecoxib and dexmedetomidine, to assess the value of these drugs for inclusion in the local formulary for use in pain management, and to identify local clinicians’ perspective regarding these drugs. Scientific evidence was gathered from Summary of Product Characteristics (SPCs) and through a literature review. Feedback from pain specialists and anaesthetists (N=18) within the Department of Anaesthesia, Mater Dei Hospital, was sought via an online questionnaire. Both celecoxib and parecoxib carry a marketing authorisation for the relief of acute postoperative pain. They have similar pharmacological properties but exhibit lower GI side effects relative to other NSAIDs. Celecoxib is highly COX-2 specific but has reduced aqueous solubility, limiting its dosage options. Parecoxib, the water-soluble prodrug of valdecoxib, is the only injectable COX-2. No evidence indicates superior degrees of pain relief between the two, but parecoxib offers advantages in the immediate post-operative scenario, when oral administration is not possible. Dexmedetomidine serves as a sedative and analgesic agent, it is indicated in ITU patients and poses less risk of causing respiratory depression, delirium and agitation compared to other opioids. Local anaesthetists feel limited in prescribing with the absence of these drugs. They tallied with evidence from literature that these are valuable agents to be included within the local formulary because of their advantageous dosage forms and safety profiles. From the three agents, dexmedetomidine was given highest priority for introduction.