Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults

Abstract

Background Oxycodone is a strong opioid agonist used to treat severe pain. It is commonly combined with milder analgesics such as paracetamol. This review updates a previous review that concluded, based on limited data, that all doses of oxycodone exceeding 5 mg, with or without paracetamol, provided analgesia in postoperative pain, but with increased incidence of adverse events compared with placebo. Additional new studies provide more reliable estimates of efficacy and harm. Objectives To assess efficacy, duration of action, and associated adverse events of single dose oral oxycodone, with or without paracetamol, in acute postoperative pain in adults. Search methods Cochrane CENTRAL, MEDLINE, EMBASE and Oxford Pain Relief Database, searched in May 2009. Selection criteria Randomised, double blind, placebo-controlled trials of single dose orally administered oxycodone, with or without paracetamol, in adults with moderate to severe acute postoperative pain. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number-needed-to-treat-to-benefit (NNT) were calculated. Numbers of participants remedicating over specified time periods, and time-to-use of rescue medication, were sought as additional measures of efficacy. Adverse events and withdrawals information was collected. Main results This updated review includes 20 studies, with 2641 participants. For oxycodone 15 mg alone compared with placebo, the NNT for at least 50% pain relief was 4.6 (95% Confidence Interval 2.9 to 11). For oxycodone 10 mg plus paracetamol 650 mg, the NNT was 2.7 (2.4 to 3.1). A dose response was demonstrated for this outcome with combination therapy. Duration of effect was 10 hours with oxycodone 10 mg plus paracetamol 650 mg, and 4 hours with half that dose. Fewer participants needed rescue medication over 6 hours at the higher dose. Adverse events occurred more frequently with combination therapy than placebo, but were generally described as mild to moderate in severity and rarely led to withdrawal. Authors’ conclusions Single dose oxycodone is an effective analgesic in acute postoperative pain at doses over 5 mg; oxycodone is two to three times stronger than codeine. Efficacy increases when combined with paracetamol. Oxycodone 10 mg plus paracetamol 650 mg provides good analgesia to half of those treated, comparable to commonly used non-steroidal anti-inflammatory drugs, with the benefit of longer duration of action.

Analgesia in the Emergency Department: A GRADE-based Evaluation of Research Evidence and Recommendations for Practice

“…Th ree articles compared fentanyl and morphine (PICO #1); fi ve articles assessed hydromorphone (PICO #2), two of which analyzed the 1 + 1 hydromorphone protocol (PICO #3); three articles compared oral hydromorphone and oxycodone (PICO #4); eight articles compared non-specifi c NSAIDs and co deine-acetaminophen (PICO #5); two articles compared specifi c NSAIDs and co deine-acetaminophen (PICO #6); and fi ve articles compared oxycodone and codeine (PICO #7). Th e same reviewer assessed the full text articles and determined that 14 of the 26 off ered quantitative results that could be analyzed using the GRADE-pro software [28][29][30][31][32][33][34][35][36][37][38][39][40][41]. Th e remaining 12 articles were excluded because they did not compare both drugs assessed in a PICO question [42][43][44][45][46][47], compared analgesics not addressed in the seven P ICO qu estions (such as acetaminophen alone) [48,49], used unconventional medication dosing [50,51], used non-validated pain me asurement scales [52,53], and/or unusual study designs [50].…”

“…However, although the number of studies used to make our recommendations may seem low, our re commendations take into consideration the quality of evidence of the studies. Pragmatic derivations of the seven PICO questions, their recommendations, and the rationale for these recommendations are listed in Table 4 [28][29][30][31][32][33][34][35][36][37][38][39][40][41]. Furthermore, we also developed a fl owchart as a suggested approach to analges ia in the ED (Fig.…”

“…We recommend oxycodone-acetaminophen as marginally superior to codeineacetaminophen (weak recommendation, low quality evidence) Rationale [39][40][41] • This recommendation is based on two Cochrane reviews that compared each of these drugs with placebo • There are few studies that directly compare these two drugs, especially in an adult emergency department setting • However, the Cochrane reviews and single studies consistently show that oxycodone with acetaminophen is slightly better at relieving pain than acetaminophen-codeine…”

A Comparison of Intravenous Oxycodone and Parecoxib in the Treatment of Visceral Pain after Laparoscopic Cholecystectomy

“…Moreover, further study can focus on optimal dose with least side effects for the treatment of the visceral pain after LC (28).…”

Recent Advances in Postoperative Pain Therapy for Thoracic Surgery

“…The application and dosage of NSAIDs must strictly follow the recommendations, because the analgesic effect is limited, and higher doses may induce cardiac, renal, hemostatic, and gastrointestinal side effects [23]. The perioperative use of acetaminophen during major surgery is able to reduce the opioid demand, even if thoracotomy-specific evidence is still lacking [24][25][26][27][28][29][30][31]. Perioperative analgesic therapy with sNSAIDs remains controversial [32,33].…”