Effect of Over the Counter Ibuprofen Dosing after Sinus Surgery for Chronic Rhinosinusitis: A Prospective Cohort Pilot Study

Abstract

Introduction: Management of pain following endoscopic sinus surgery (ESS) often involves intermittent use of opioid medications. Given the current opioid crisis, many surgeons aim to minimize opioid prescriptions. However, surgeons often avoid the use of NSAIDs following ESS out of concern for increased bleeding risk. We sought to evaluate the effectiveness and safety of over the counter dosing of ibuprofen on pain and bleeding rates following ESS. Methods: Prospective cohort pilot study of patients undergoing ESS. Patients self-selected either control arm (acetaminophen and PRN oxycodone) or intervention arm (alternating ibuprofen with acetaminophen, and PRN oxycodone). Outcome measures included pain (10-point visual analog scale [VAS]), bleeding rate (10-point VAS), and number of opiate pills consumed. Results: Thirty-nine patients completed the study (15 control and 24 intervention). Overall, patients in the intervention arm reported decreased pain levels at days 1 (−0.9 [95%CI: −2.2, 0.5], 3 (−0.9 [95%CI: −2.3, 0.5]), and 7 (−0.6 [95%CI: −1.8, 0.6]), as well as decreased postoperative bleeding at those same days −0.9 [95%CI: −2.1, 0.4], −0.9 [95%CI: −2.1, 0.4], and −0.7 [95% CI: −1.2, −0.7], compared to controls. Opiate consumption was similar between groups with patients consuming on average four opiate pills (oxycodone 5 mg). Conclusions: Over the counter dosing of ibuprofen along with acetaminophen may yield better pain control after sinus surgery compared to acetaminophen alone. Additionally, there was no significant difference in epistaxis in the ibuprofen cohort compared to the cohort who did not take ibuprofen. Furthermore, this study showed very few opioid pills were consumed after routine ESS regardless of pain regimen prescribed. A larger trial is needed to make definitive statements on safety and efficacy. Level of Evidence: 2b

American Rhinologic Society expert practice statement: Postoperative pain management and opioid use after sinonasal surgery

“…47 Both groups took a similar amount of breakthrough opioids and the NSAID cohort reported reduced pain scores. 47 Wu et al performed a multicenter cohort study comparing mean pain VAS scores and opioid usage after ESS in patients who were given a prescription of hydrocodoneacetaminophen and recommended preferentially to take 325 mg acetaminophen vs those who were given a prescription of hydrocodone-acetaminophen and preferentially told to take 325 mg acetaminophen and 200 mg ibuprofen. The cohort that used NSAIDs were found to have decreased overall pain scores and took significantly fewer opioid pills (mean, 3.77) than the non-NSAID group (mean, 6.94; p = 0.018).…”

“…44.45 Moreover, the combination of acetaminophen and NSAIDs is effective for providing primary pain control and reducing opioid use in certain head and neck procedures. 43,44,47 The role of NSAIDs and acetaminophen in primary pain control and reducing opioid use in the immediate postoperative period has been examined in several studies (Table 3). Nguyen et al performed an RCT of pain control in postoperative head and neck surgery patients.…”

“…38 Two prospective cohort studies addressed the use of NSAIDs and acetaminophen as primary pain control on opioid consumption after ESS. 39,47 Miller et al performed a prospective cohort study of patients who used opioid for breakthrough pain and either alternated NSAID and acetaminophen for pain control or used only acetaminophen for primary pain control. 47 Both groups took a similar amount of breakthrough opioids and the NSAID cohort reported reduced pain scores.…”

“…39,47 Miller et al performed a prospective cohort study of patients who used opioid for breakthrough pain and either alternated NSAID and acetaminophen for pain control or used only acetaminophen for primary pain control. 47 Both groups took a similar amount of breakthrough opioids and the NSAID cohort reported reduced pain scores. 47 Wu et al performed a multicenter cohort study comparing mean pain VAS scores and opioid usage after ESS in patients who were given a prescription of hydrocodoneacetaminophen and recommended preferentially to take 325 mg acetaminophen vs those who were given a prescription of hydrocodone-acetaminophen and preferentially told to take 325 mg acetaminophen and 200 mg ibuprofen.…”

Multicenter study on the effect of nonsteroidal anti‐inflammatory drugs on postoperative pain after endoscopic sinus and nasal surgery

“…Specifically, NSAIDs have been avoided after FESS because of the risk of epistaxis. However, NSAIDs have been shown to be safe and effective in perioperative pain management after FESS and nasal surgeries in several recent studies . There is growing evidence that NSAIDs may decrease the requirement for rescue analgesics, including opioids .…”