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Meta-Analysis
. 2015 Sep 28;2015(9):CD008659.
doi: 10.1002/14651858.CD008659.pub3.

Single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews

R Andrew Moore  1 , Sheena Derry, Dominic Aldington, Philip J Wiffen
Affiliations
Meta-Analysis

Single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews

R Andrew Moore et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an updated version of the original Cochrane overview published in Issue 9, 2011. That overview considered both efficacy and adverse events, but adverse events are now dealt with in a separate overview.Thirty-nine Cochrane reviews of randomised trials have examined the analgesic efficacy of individual drug interventions in acute postoperative pain. This overview brings together the results of those individual reviews and assesses the reliability of available data.

Objectives: To summarise the efficacy of pharmaceutical interventions for acute pain in adults with at least moderate pain following surgery who have been given a single dose of oral analgesic.

Methods: We identified systematic reviews in the Cochrane Database of Systematic Reviews in The Cochrane Library through a simple search strategy. All reviews were overseen by a single review group, had a standard title, and had as their primary outcome the number of participants with at least 50% pain relief over four to six hours compared with placebo. For individual reviews, we extracted the number needed to treat for an additional beneficial outcome (NNT) for this outcome for each drug/dose combination, and also the percentage of participants achieving at least 50% maximum pain relief, the mean of mean or median time to remedication, and the percentage of participants remedicating by six, eight, 12, or 24 hours. Where there was adequate information for pairs of drug and dose (at least 200 participants, in at least two studies), we defined the addition of four comparisons of typical size (400 participants in total) with zero effect as making the result potentially subject to publication bias and therefore unreliable.

Main results: The overview included 39 separate Cochrane Reviews with 41 analyses of single dose oral analgesics tested in acute postoperative pain models, with results from about 50,000 participants in approximately 460 individual studies. The individual reviews included only high-quality trials of standardised design, methods, and efficacy outcome reporting. No statistical comparison was undertaken.Reliable results (high quality information) were obtained for 53 pairs of drug and dose in painful postsurgical conditions; these included various fixed dose combinations, and fast acting formulations of some analgesics. NNTs varied from about 1.5 to 20 for at least 50% maximum pain relief over four to six hours compared with placebo. The proportion of participants achieving this level of benefit varied from about 30% to over 70%, and the time to remedication varied from two hours (placebo) to over 20 hours. Good (low) NNTs were obtained with ibuprofen 200 mg plus paracetamol (acetaminophen) 500 mg (NNT compared with placebo 1.6; 95% confidence interval 1.5 to 1.8), ibuprofen fast acting 200 mg (2.1; 1.9 to 2.3); ibuprofen 200 mg plus caffeine 100 mg (2.1; 1.9 to 3.1), diclofenac potassium 50 mg (2.1; 1.9 to 2.5), and etoricoxib 120 mg (1.8; 1.7 to 2.0). For comparison, ibuprofen acid 400 mg had an NNT of 2.5 (2.4 to 2.6). Not all participants had good pain relief and, for many pairs of drug and dose, 50% or more did not achieve at least 50% maximum pain relief over four to six hours.Long duration of action (eight hours or greater) was found for etoricoxib 120 mg, diflunisal 500 mg, paracetamol 650 mg plus oxycodone 10 mg, naproxen 500/550 mg, celecoxib 400 mg, and ibuprofen 400 mg plus paracetamol 1000 mg.There was no evidence of analgesic effect for aceclofenac 150 mg, aspirin 500 mg, and oxycodone 5 mg (low quality evidence). No trial data were available in reviews of acemetacin, meloxicam, nabumetone, nefopam, sulindac, tenoxicam, and tiaprofenic acid. Inadequate amounts of data were available for nine drugs and doses, and data potentially susceptible to publication bias for 13 drugs and doses (very low quality evidence).

Authors' conclusions: There is a wealth of reliable evidence on the analgesic efficacy of single dose oral analgesics. Fast acting formulations and fixed dose combinations of analgesics can produce good and often long-lasting analgesia at relatively low doses. There is also important information on drugs for which there are no data, inadequate data, or where results are unreliable due to susceptibility to publication bias. This should inform choices by professionals and consumers.

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Conflict of interest statement

RAM has no conflicts relating to this review or any similar product.

SD has no conflicts relating to this review or any similar product.

DA has no conflicts relating to this review or any similar product.

PJW has no conflicts relating to this review or any similar product.

We are funded by the NIHR for work on a series of reviews informing the unmet need of chronic pain and providing the evidence for treatments of pain but this review is not supported by that funding.

This review was identified in a 2019 audit as not meeting the current definition of the Cochrane Commercial Sponsorship policy. At the time of its publication it was compliant with the interpretation of the existing policy. As with all reviews, new and updated, at update this review will be revised according to 2020 policy update.

Figures

1
1
Single dose oral analgesics in moderate or severe pain: NNT for at least 50% maximum pain relief over four to six hours.
2
2
Mean or median time to remedication.
3
3
Relationship between NNT over four to six hours and time to remedication in individual drugs.
4
4
Percentage remedicating within eight hours with active and placebo. Lines connect review results for active drugs and placebo.
5
5
Percentage remedicating within six hours with active and placebo. Lines connect review results for active drugs and placebo.
See this image and copyright information in PMC

Update of

Comment in

References

References to included reviews

Aceclofenac 2009
    1. Moore RA, Derry S, McQuay HJ. Single dose oral aceclofenac for postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007588.pub2] - DOI - PMC - PubMed
Acemetacin 2009
    1. Moore RA, Derry S, McQuay HJ. Single dose oral acemetacin for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007589.pub2] - DOI - PMC - PubMed
Aspirin 2012
    1. Derry S, Moore RA. Single dose oral aspirin for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2012, Issue 4. [DOI: 10.1002/14651858.CD002067.pub2] - DOI - PMC - PubMed
Celecoxib 2013
    1. Derry S, Moore RA. Single dose oral celecoxib for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2013, Issue 10. [DOI: 10.1002/14651858.CD004233.pub4] - DOI - PMC - PubMed
Codeine 2010
    1. Derry S, Moore RA, McQuay HJ. Single dose oral codeine, as a single agent, for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2010, Issue 4. [DOI: 10.1002/14651858.CD008099.pub2] - DOI - PMC - PubMed
Dexibuprofen 2009
    1. Moore RA, Derry S, McQuay HJ. Single dose oral dexibuprofen [S(+)‐ibuprofen] for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007550.pub2] - DOI - PMC - PubMed
Diclofenac 2015
    1. Moore RA, Derry S, Wiffen PJ. Single dose oral diclofenac for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 7. [DOI: 10.1002/14651858.CD004768.pub3] - DOI - PMC - PubMed
Diflunisal 2010
    1. Wasey JO, Derry S, Moore RA, McQuay HJ. Single dose oral diflunisal for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2010, Issue 4. [DOI: 10.1002/14651858.CD007440.pub2] - DOI - PMC - PubMed
Dihydrocodeine 2000
    1. Moore RA, Rees J, Derry S, McQuay HJ. Single dose oral dihydrocodeine for acute postoperative pain. Cochrane Database of Systematic Reviews 2000, Issue 2. [DOI: 10.1002/14651858.CD002760] - DOI - PMC - PubMed
Dipyrone 2010
    1. Edwards J, Meseguer F, Faura C, Moore RA, McQuay HJ, Derry S. Single dose dipyrone for acute postoperative pain. Cochrane Database of Systematic Reviews 2010, Issue 9. [DOI: 10.1002/14651858.CD003227.pub2] - DOI - PMC - PubMed
Etodolac 2009
    1. Tirunagari SK, Derry S, Moore RA, McQuay HJ. Single dose oral etodolac for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007357.pub2] - DOI - PMC - PubMed
Etoricoxib 2014
    1. Clarke R, Derry S, Moore RA. Single dose oral etoricoxib for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2014, Issue 5. [DOI: 10.1002/14651858.CD004309.pub4] - DOI - PMC - PubMed
Fenbufen 2009
    1. Moore RA, Derry S, McQuay HJ. Single dose oral fenbufen for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007547.pub2] - DOI - PMC - PubMed
Fenoprofen 2011
    1. Traa MX, Derry S, Moore RA. Single dose oral fenoprofen for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 2. [DOI: 10.1002/14651858.CD007556.pub2] - DOI - PMC - PubMed
Flurbiprofen 2009
    1. Sultan A, McQuay HJ, Moore RA, Derry S. Single dose oral flurbiprofen for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007358.pub2] - DOI - PMC - PubMed
Gabapentin 2010
    1. Straube S, Derry S, Moore RA, Wiffen PJ, McQuay HJ. Single dose oral gabapentin for established acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2010, Issue 5. [DOI: 10.1002/14651858.CD008183.pub2] - DOI - PMC - PubMed
Ibuprofen + caffeine 2015
    1. Derry S, Wiffen PJ, Moore RA. Single dose oral ibuprofen plus caffeine for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 7. [DOI: 10.1002/14651858.CD011509.pub2] - DOI - PMC - PubMed
Ibuprofen + codeine 2015
    1. Derry S, Karlin S, Moore RA. Single dose oral ibuprofen plus codeine for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 2. [DOI: 10.1002/14651858.CD010107.pub3] - DOI - PMC - PubMed
Ibuprofen + oxycodone 2013
    1. Derry S, Derry CJ, Moore RA. Single dose oral ibuprofen plus oxycodone for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD010289.pub2] - DOI - PMC - PubMed
Ibuprofen + paracetamol 2013
    1. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD010210.pub2] - DOI - PMC - PubMed
Ibuprofen 2009
    1. Derry C, Derry S, Moore RA, McQuay HJ. Single dose oral ibuprofen for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD001548.pub2] - DOI - PMC - PubMed
Indometacin 2004
    1. Moore RA, Derry S, Mason L, McQuay HJ, Rees J. Single dose oral indometacin for the treatment of acute postoperative pain. Cochrane Database of Systematic Reviews 2004, Issue 4. [DOI: 10.1002/14651858.CD004308.pub2] - DOI - PMC - PubMed
Ketoprofen and dexketoprofen 2009
    1. Barden J, Derry S, McQuay HJ, Moore RA. Single dose oral ketoprofen and dexketoprofen for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007355.pub2] - DOI - PMC - PubMed
Lornoxicam 2009
    1. Hall PE, Derry S, Moore RA, McQuay HJ. Single dose oral lornoxicam for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007441.pub2] - DOI - PMC - PubMed
Lumiracoxib 2010
    1. Roy YM, Derry S, Moore RA. Single dose oral lumiracoxib for postoperative pain in adults. Cochrane Database of Systematic Reviews 2010, Issue 7. [DOI: 10.1002/14651858.CD006865.pub2] - DOI - PMC - PubMed
Mefenamic acid 2011
    1. Moll R, Derry S, Moore RA, McQuay HJ. Single dose oral mefenamic acid for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 3. [DOI: 10.1002/14651858.CD007553.pub2] - DOI - PMC - PubMed
Meloxicam 2009
    1. Moore RA, Derry S, McQuay HJ. Single dose oral meloxicam for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007552.pub2] - DOI - PMC - PubMed
Nabumetone 2009
    1. Moore RA, Derry S, Moore M, McQuay HJ. Single dose oral nabumetone for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007548.pub2] - DOI - PMC - PubMed
Naproxen 2009
    1. Derry C, Derry S, Moore RA, McQuay HJ. Single dose oral naproxen and naproxen sodium for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD004234.pub3] - DOI - PMC - PubMed
Nefopam 2009
    1. Kakkar M, Derry S, Moore RA, McQuay HJ. Single dose oral nefopam for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007442.pub2] - DOI - PMC - PubMed
Paracetamol + codeine 2009
    1. Toms L, Derry S, Moore RA, McQuay HJ. Single dose oral paracetamol (acetaminophen) with codeine for postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD001547.pub2] - DOI - PMC - PubMed
Paracetamol 2008
    1. Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD004602.pub2] - DOI - PMC - PubMed
Paracetamol ± dextropropoxyphene 1999
    1. Moore RA, Collins S, Rees J, Derry S, McQuay HJ. Single dose oral dextropropoxyphene, alone and with paracetamol (acetaminophen), for postoperative pain. Cochrane Database of Systematic Reviews 1999, Issue 1. [DOI: 10.1002/14651858.CD001440] - DOI - PMC - PubMed
Paracetamol ± oxycodone 2009
    1. Gaskell H, Derry S, Moore RA, McQuay HJ. Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD002763.pub2] - DOI - PMC - PubMed
Piroxicam 2000
    1. Moore RA, Rees J, Loke Y, Derry S, McQuay HJ. Single dose oral piroxicam for acute postoperative pain. Cochrane Database of Systematic Reviews 2000, Issue 2. [DOI: 10.1002/14651858.CD002762] - DOI - PMC - PubMed
Rofecoxib 2009
    1. Bulley S, Derry S, Moore RA, McQuay HJ. Single dose oral rofecoxib for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD004604.pub3] - DOI - PMC - PubMed
Sulindac 2009
    1. Moore RA, Derry S, McQuay HJ. Single dose oral sulindac for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007540.pub2] - DOI - PMC - PubMed
Tenoxicam 2009
    1. Moore OA, McIntyre M, Moore RA, Derry S, McQuay HJ. Single dose oral tenoxicam for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007591.pub2] - DOI - PMC - PubMed
Tiaprofenic acid 2009
    1. Moore RA, Derry S, Moore M, McQuay HJ. Single dose oral tiaprofenic acid for acute postoperative pain in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. [DOI: 10.1002/14651858.CD007542.pub2] - DOI - PMC - PubMed

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