Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis

Abstract

Background: Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery.

Methods: CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis.

Results: We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs.

Conclusions: Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.

Keywords: Analgesia; Cesarean section; Non-steroidal anti-inflammatory agents; Obstetrical anesthesia; Postoperative pain; Systematic review..

Fig. 1.

PRISMA flow diagram summarizing the retrieved, included, and excluded randomized controlled trials. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Fig. 2.

Risk of bias assessment of included trials using the revised Cochrane tool.

Fig. 3.

Network plot in regard to the need for cumulative intravenous morphine equivalent consumption at 24 h. Each intervention is depicted by a circle that is proportional in size to the number of patients who were randomized to that intervention. Connecting lines between the circles indicate the direct comparisons of interventions, their width proportional to the number of trials evaluating the comparison, and their color representing the average risk of bias. Green: low risk, yellow: some concerns, red: high risk.