Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study

Abstract

Background and objectivesThe significance of intravenous over oral acetaminophen (APAP) as part of multimodal analgesic protocols is contested, particularly when considering its relatively high price and use in a surgical cohort such as total hip or knee arthroplasty (THA/TKA), which generally tolerates oral medications. This study aims to elucidate APAP’s effectiveness in a large, population-based patient sample.Methods1 039 647 THA/TKA procedures were sampled from the Premier Healthcare claims database 2011–2016. APAP use was categorized by intravenous/oral and use on the day of surgery, postoperative day 1 and thereafter. Outcomes were opioid utilization (in oral morphine equivalents), length and cost of hospitalization, and opioid-related adverse effects (respiratory, gastrointestinal, and naloxone use as a proxy). Mixed-effects models measured the associations between intravenous/oral APAP use and outcomes. Percent (%) change and 95% CIs are reported.ResultsOverall, 23.6% (n=245 454) of patients received intravenous APAP; of these, 56.3% (n=138 180) received just one dose on the day of surgery. After adjustment for relevant covariates, particularly use of >1 dose of intravenous APAP (compared with no use) on postoperative day 1 was associated with −6.0% (CI −7.2% to −4.7%) reduced opioid utilization; this was −10.7% (CI −11.4% to -9.9%) for use of > 1 dose oral APAP on postoperative day 1. Further comparisons regarding other outcomes also favored oral (over intravenous) APAP.ConclusionsThese results do not support the routine use of intravenous APAP in patients undergoing lower joint arthroplasty, especially since oral APAP shows more beneficial outcome patterns.

A systematic review and trial sequential analysis of intravenous vs. oral peri‐operative paracetamol

“…The conclusions of both reviews were limited by the poor methodological or reporting quality of the included trials. This is consistent with large observational studies [35]. Important differences between administration routes could not be excluded.…”

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…Around-the-clock oral acetaminophen should be the backbone of postoperative pain regimens because of its safety and low cost, in the absence of acute decompensated liver disease [178,385]. Compared with the oral route, intravenous acetaminophen administration may offer faster onset and better analgesia thirty minutes after administration, but overall drug exposure after repeated doses and general clinical benefits are not significantly different [176,[386][387][388]. Additionally, the intravenous formulation may impose financial toxicity without additional benefit in patients with functional gastrointestinal tracts as discussed previously [389][390][391].…”

Inpatient Perioperative Formulary Restriction of Intravenous Acetaminophen at Vizient Partner Hospitals: A National Survey of Pharmacists

“…APAP has been associated with small, statistically significant reductions in length of stay in some, but not all comparisons completed against oral APAP. 18-23 While available evidence does not present a compelling case for the incremental value of i.v. over oral APAP, the possibility exists that commonly assessed outcomes are not sensitive enough to capture differences in the short- and long-term benefits of different formulations.…”