ORIGINAL RESEARCH

Parecoxib Provides Analgesic and Opioid-SparingEffects Following Major Orthopedic Surgery: A SubsetAnalysis of a Randomized, Placebo-Controlled ClinicalTrial

Efrain Diaz-Borjon . Armando Torres-Gomez . Margaret Noyes Essex .

Patricia Salomon . Chunming Li . Raymond Cheung . Bruce Parsons

Received: December 19, 2016 / Published online: March 2, 2017� The Author(s) 2017. This article is published with open access at Springerlink.com

ABSTRACT

Introduction: Orthopedic surgeries are amongthe most common and most painful surgeriesperformed. A multimodal analgesic approachis recommended to reduce opioid consump-tion, provide effective pain relief, and improveoutcomes following surgery. This studyexamined the efficacy and opioid-sparingeffects of parecoxib following major orthope-dic surgery.

Methods: This subset analysis of a large, mul-ticenter, randomized, double-blind,placebo-controlled study of parecoxib exam-ined treatment effects on postoperative painseverity, pain interference with function, opioidconsumption, occurrence of opioid-relatedsymptoms, safety, and patient satisfaction fol-lowing major orthopedic surgery.Results: Pain scores were significantly lower inthe parecoxib group (n = 142) compared withplacebo (n = 139) on day 2 (-22%; p\0.001)and day 3 (-17%; p = 0.004). Pain interferencewith function scores were also significantlylower in the parecoxib group on day 2 (-32%;p\0.001) and day 3 (-27%; p = 0.003) relativeto placebo. Additionally, significantly less sup-plemental morphine was required in the pare-coxib group relative to placebo through 24 h(-28%; p = 0.008) and 48 h (-33%; p\0.001).Patients in the parecoxib group had a reducedrisk of experiencing opioid-related symptomsincluding fatigue, drowsiness, inability to con-centrate, confusion, nausea, constipation, andconfusion on day 2 and/or day 3. Finally, morepatients receiving parecoxib (42%) rated treat-ment as ‘‘excellent’’ compared to those receiv-ing placebo (21%).Conclusions: These findings support the use ofparecoxib for the management of pain follow-ing major orthopedic surgery.

Keywords: Opioid-sparing; Orthopedicsurgery; Parecoxib; Postoperative pain

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E. Diaz-BorjonOrthopedics and Traumatology, Hospital AngelesLomas, Huixquilucan, Mexico

A. Torres-GomezOrthopaedics, ABC Medical Center, Mexico City,Mexico

M. N. Essex (&) � R. Cheung � B. ParsonsGlobal Medical Affairs, Pfizer Inc, New York, NY,USAe-mail: Margaret.essex@pfizer.com

P. SalomonPain Division for Latin America, Pfizer Inc, MexicoCity, Mexico

C. LiStatistics, Pfizer Inc, Madison, NJ, USA

Pain Ther (2017) 6:61–72

DOI 10.1007/s40122-017-0066-5

INTRODUCTION

Orthopedic surgeries are among the most com-mon major surgeries and their incidence hasgrown over the past 15 years [1–3]. In 2011there were approximately 645,062 total kneereplacements, 465,070 spinal fusions, and306,600 total hip replacements in the USAalone [2]. These types of surgeries, particularlyknee and hip replacements, are expected todramatically increase over the next 15 years [3].Orthopedic surgeries, however, are also amongthe most painful surgeries, and moder-ate-to-severe postoperative pain is not uncom-mon [4–6]. Pain management is of utmostimportance in the early stages after total kneeand hip arthroplasty, because prompt andextensive physical rehabilitation and activityare encouraged, but may be restrained by pain.Indeed, though surgeries such as total jointreplacement have a high success rate, they areunderutilized, in part, because of fear of pain[7, 8]. Furthermore, there is a high rate ofpatient dissatisfaction following total kneearthroplasty, and pain is the most significantpredictor of dissatisfaction [9]. Thus, the selec-tion and use of effective analgesics are impor-tant considerations following major orthopedicprocedures to ensure that the patient can rest atnight and tolerate therapy during the day.

Appropriate pain control after orthopedicsurgeries can enhance early functional recovery[10, 11]. Managing acute pain begins in thepreoperative period and continues throughoutthe postoperative phase. Multimodal analgesiacan provide superior control of postsurgicalpain compared with a traditional opioid anal-gesic regimen [10, 12]. Although opioids areeffective against moderate-to-severe pain, theyare frequently associated with a variety ofunwanted side effects including drowsiness,confusion, nausea, itching, and constipation[13–15]. These side effects add stress to thepatient and may require them to undergo sup-plementary treatments for the management ofthese effects, further delaying mobilization andincreasing recovery/hospitalization times[16, 17]. In addition, though they are effectivefor pain at rest, opioids are less effective formovement-related pain which may be

problematic during physical rehabilitation andearly mobilization strategies [18, 19]. As a result,to reduce overall opioid consumption and theoccurrence of opioid-associated side effects,current treatment guidelines recommend amultimodal treatment strategy that incorpo-rates non-steroidal anti-inflammatory drugs(NSAIDs), cyclooxygenase-2 inhibitors (COX-IBs), and/or acetaminophen to supplementopioid use [20]. Multimodal analgesia has pro-ven to be provide adequate pain control, assistin early recovery, and even allow for same-daydischarge after total knee and hip replacementsurgery [11].

Parecoxib, an injectable COXIB withlong-acting duration, has been approved in over80 countries as analgesia to reduce postopera-tive pain. Since parecoxib is selective forcyclooxygenase-2 inhibition, it poses less riskfor bleeding and gastrointestinal-related adverseevents as compared to nonselective NSAIDs[21–24]. It also does not pose a risk for many ofthe central nervous system-related side effectsthat are associated with opioids. However, thereare few studies in the literature that examinethe analgesic efficacy and opioid-sparing effectsof postoperative parecoxib administration inpatients undergoing major orthopedic surgery.The current analysis, therefore, examines theefficacy and opioid-sparing effects of parecoxibfollowing major orthopedic surgery [25].

METHODS

Data Source

Data were derived from a multicenter, ran-domized, double-blind, placebo-controlledclinical trial that examined the safety and effi-cacy of parecoxib followed by valdecoxib forpostoperative pain resulting from a variety ofnon-cardiac surgeries [25]. The study was con-ducted at 113 site in 14 countries including theUSA, Canada, Chile, Argentina, Australia, NewZealand, Bulgaria, Czech Republic, Poland,Romania, Ukraine, Finland, Israel, and SouthAfrica. Here, we examine a large subset ofpatients from this clinical trial that includes allpatients who underwent major orthopedic

62 Pain Ther (2017) 6:61–72

surgery. The study was approved by an institu-tional review board or independent ethicscommittee at each investigational center, andpatients provided written informed consentbefore participation. The study was conductedin compliance with the Declaration of Helsinkiof 1964, as revised in 2013, and all InternationalConference on Harmonization Good ClinicalPractice Guidelines. Detailed methods of thetrial can be found in the original publicationbut a brief summary is given below [25].

Following surgery, patients were admitted tothe recovery room. Here, upon recovery fromanesthesia, patients who met all pre-, intra-, andpostoperative inclusion criteria were random-ized in a double-blind manner to receive pare-coxib/valdecoxib or matching placebo. On day1 (the day of surgery and recovery from anes-thesia) all patients randomized to the pare-coxib/valdecoxib group received an initial40-mg IV dose of parecoxib. These patients thenreceived parecoxib 20 mg (IV or IM) every 12 hthrough at least day 3. Once the patient couldtolerate oral medication, but no earlier than day4, they received 20-mg doses of oral valdecoxibthrough day 10, and patients assigned to receiveplacebo did so on a matching schedule. Itshould be noted that all assessments in thisanalysis were done when patients were receiv-ing parecoxib (prior to switching to valdecoxib)(Table 1). As such the parecoxib/valdecoxibgroup will simply be referred to as the parecoxibgroup from here on. Patients with inadequatepain relief were allowed supplemental analgesiathat consisted of IV administration of morphine

sulfate through patient-controlled analgesia(PCA) or in IV/IM bolus as needed. No othersupplemental analgesia was permitted.

Efficacy Assessments Included in CurrentAnalysis

Patient demographics and baseline characteris-tics were summarized descriptively in all ran-domized patients.

Summed pain intensity over 24 h (SPI-24)was calculated on day 2 (the day after surgery)and day 3 for each treatment group as describedpreviously and was derived from dailypatient-reported pain assessments that rangedin score from 0 = none to 3 = severe pain [25].An analysis of variance (ANOVA) model withtreatment and country as factors and a lastobservation carried forward (LOCF) approach tomissing data were used to compare SPI scoresbetween the placebo and parecoxib treatmentgroups.

Composite pain interference with functionscores were derived from five items of the paininterference with function question of themodified Brief Pain Inventory-short form(mBPI-sf) [26]. The five items included paininterference with general activity, mood, walk-ing ability, relations with others, and sleep.Scores on day 2 (the day after surgery) and day 3were compared between parecoxib and placebotreatment groups using a general linear model,with treatment and country as factors. A LOCFapproach was used to account for missing data.

Table 1 Administration of parecoxib

Treatment Schedule

40 mg IV parecoxib One dose on day 1 (the day of surgery following recovery from anesthesia)

20 mg IV or IM parecoxib At 8:00 P.M. or midnight on day 1 and then every 12 h through at least day 3a

Patients assigned to placebo received a matching placebo administered in the same manner as parecoxiba Patients who received their first dose of 40 mg IV parecoxib on day 1 between 8:00 A.M. and 12:00 P.M. received theirfirst dose of 20 mg IV/IM parecoxib at 8:00 P.M. on day 1. Patients who received their first dose of 40 mg IV parecoxib onday 1 between 12:01 P.M. and 6:00 P.M. received their first dose of 20 mg IV/IM parecoxib at midnight on day 1. Patientswho received their first dose of 40 mg IV parecoxib after 6:01 P.M. on day 1 did not receive a 20 mg IV/IM dose ofparecoxib on day 1. All patients received a 20 mg IV/IM dose of parecoxib at 8:00 A.M. on Day 2 and then every 12 haccording to the schedule in Table 1

Pain Ther (2017) 6:61–72 63

On day 2 (24 h post initial dose of studytreatment) and day 3 (48 h post initial dose ofstudy treatment), the cumulative amount ofsupplemental morphine consumed was deter-mined and compared between the parecoxiband placebo groups. This comparison employedan ANOVA model with treatment and countryas factors.

The occurrence of opioid-related symptoms(drowsiness, retching/vomiting, confusion,dizziness, itching, difficulty with urination,constipation, inability to concentrate, nausea,and fatigue) was determined on day 2 (the dayafter surgery) and day 3 using the Opioid-Re-lated Symptom Distress Scale (ORSDS) [14]. Therelative risk (RR; parecoxib versus placebo) wascalculated for each particular symptom on thebasis of the percentage of patients experiencingthat symptom in each treatment group. Statis-tical significance was assessed using a Fisher’sexact test. An RR (parecoxib versus placebo) ofexperiencing C1, C2, and C3 opioid-relatedsymptoms was also determined for day 2.

Physicians and patients evaluated the studymedication at the time of transition from IV/IMto oral dosing using a scale from 1 = poor to4 = excellent. These scores were comparedbetween parecoxib and placebo treatmentgroups using a Cochran–Mantel–Haenszel test,controlling for country.

Safety was assessed by examining the occur-rence of treatment-related adverse events (AEs).AEs were monitored for 7 days after receivinglast dose, so both acute and non-acute eventswere recorded. The frequency of the mostcommon AEs (those occurring in C2% ofpatients in either treatment group) was calcu-lated for the placebo and parecoxib groups andsummarized descriptively. NSAIDs and COXIBshave been associated with specific adverseevents such as gastrointestinal events, cardio-vascular events, and bleeding. Therefore, wealso examined the frequency of these specificevents by searching all treatment-emergent AEsusing the Standardized Medical Dictionary forRegulatory Activities (version 19.0) Queries ofembolic and thrombotic events; gastrointestinalperforation, ulceration, hemorrhage orobstruction; hemorrhage terms (excluding lab-oratory terms).

All statistical analyses were performed usingthe modified intent-to-treat population, whichconsisted of all randomized patients whoreceived at least one dose of study medication.Analyses were performed using Statistical Anal-ysis System software (SAS Institute, Cary, NC,USA). It should be noted that all assessments inthis analysis were done at a time when patientsin the parecoxib group were receiving IV or IMparecoxib and had not yet switched to oralvaldecoxib.

RESULTS

The number of patients in the orthopedic subsetwho were randomized to treatment was 139 forthe placebo group and 142 for the parecoxibgroup (Fig. 1). Basic patient demographics weresimilar between the placebo and parecoxibtreatment groups (Table 2). The patient popu-lation was predominantly white and had amedian age of approximately 61 years. Themost common surgeries in both treatmentgroups were procedures involving the knee(placebo = 52.5%; parecoxib = 46.5%), fol-lowed by procedures involving the hip(placebo = 21.6%; parecoxib = 31.0%) or theneck/spine (placebo = 15.8%; pare-coxib = 12.7%). Over 85% of all knee proce-dures were total knee replacements and over95% of the hip procedures were total hipreplacements. The number of patients receivingat least one dose of study medication was 138 in

Fig. 1 Flow of patients through the trials

64 Pain Ther (2017) 6:61–72

the placebo group and 138 in the parecoxibgroup.

Parecoxib demonstrated a significant anal-gesic effect on day 2 (the day after surgery), withmean SPI-24 scores 22% (p\0.001) lower in theparecoxib group relative to placebo (Fig. 2). Thiscorresponds to an absolute difference of 7.7points, on a scale from 0 to 72, between thetreatment groups. Likewise, SPI-24 scores werealso significantly lower in the parecoxib group,compared with placebo, on day 3 (Fig. 2). The

absolute difference between the groups was 4.9points, which corresponds to a 17% (p = 0.004)reduction in the parecoxib group relative toplacebo.

In addition to lower pain intensity scores,parecoxib treatment also provided significantimprovements in patient function comparedwith placebo (Fig. 3). Composite pain interfer-ence with function scores were reduced by 32%(p\0.001) on day 2 (the day after surgery) and27% (p = 0.003) on day 3 relative to placebo.These percentages correspond to an absolutedifference of 1.6 and 0.9 points (on a scale from0 to 10) on day 2 and day 3, respectively.

On day 2 (24 h post initial dose of studymedication) and day 3 (48 h post initial dose ofstudy medication), treatment with parecoxibwas associated with a significant opioid-sparingeffect (Fig. 4). Patients in the parecoxib groupconsumed 28% less morphine at 24 h(p = 0.008) and 33% less morphine at 48 h(p\0.001) relative to placebo. This correspondsto absolute reductions of 9.9 and 22.8 morphineequivalents at 24 and 48 h, respectively.

Patients receiving parecoxib also had areduced risk of experiencing opioid-relatedsymptoms on day 2 (the day after surgery) andday 3 compared to patients receiving placebo(Table 3). Specifically, the risk of experiencingfatigue, drowsiness, inability to concentrate,and confusion was significantly reduced onboth day 2 (the day after surgery) and day 3 inthe parecoxib group compared with placebo. Inaddition, the risk of experiencing nausea, con-stipation, and retching/vomiting was signifi-cantly reduced on day 3 but not day 2 in theparecoxib group relative to placebo. The risks ofdizziness, itching, and difficulty with urinationwere not significantly different between treat-ment groups on either day 2 or day 3. Theoverall relative risk (RR) of experiencing C1(RR = 0.71; p\0.010), C2 (RR = 0.55;p\0.001), and C3 (RR = 0.33; p\0.001) opi-oid-related symptoms was significantly lowerwith parecoxib compared with placebo on day3.

Both patient (Fig. 5a) and physician (Fig. 5b)evaluations of study medication scores weresignificantly different between the parecoxiband placebo groups at the time of transition

Table 2 Demographics of patients included in the analysis

Parecoxib(n5 142)

Placebo(n5 139)

p value

Age, year 0.461

Mean (SD) 58.4 (13.9) 59.0 (14.4)

Median 60.5 60.8

Range 22–81 19–81

Gender, n (%) 0.475

Male 65 (45.8) 70 (50.4)

Female 77 (54.2) 69 (49.6)

Race, n (%) 0.924

White 131 (92.3) 130 (93.5)

Black 9 (6.3) 7 (5.0)

Not listed 2 (1.4) 2 (1.4)

BMI, kg/m2 0.591

Mean (SD) 29.8 (5.0) 30.2 (4.7)

Median 29.7 29.7

Surgery type, n (%) 0.262

Knee 66 (46.5) 73 (52.5)

Hip 44 (31.0) 30 (21.6)

Neck/spine 18 (12.7) 22 (15.8)

Ankle/foot/bunion 9 (6.3) 6 (4.3)

Arm/shoulder/hand 4 (2.8) 8 (5.8)

Other 1 (0.7) 0 (0.0)

Percentages in the table may not add up to 100 because ofroundingSD standard deviation, BMI body mass index

Pain Ther (2017) 6:61–72 65

from IV/IM to oral dosing (both p\0.001). Agreater percentage of patients (42%) andphysicians (46%) in the parecoxib group ratedtheir treatment as ‘‘excellent’’ compared withpatients (21%) and physicians (19%) in theplacebo group. Likewise, fewer patients (13%)and physicians (8%) in the parecoxib grouprated their treatment as ‘‘poor’’ or ‘‘fair’’

compared with patients (32%) and physicians(35%) in the placebo group.

Treatment-emergent AEs during the IV/IMphase occurred with a similar frequency in theplacebo (55.8%) and parecoxib (58.7%) groups.The most common treatment-emergent AEs foreach group are shown in Table 4. Of these AEs,nausea (parecoxib = 17.4%; placebo = 15.9%),vomiting (parecoxib = 9.4%; placebo = 5.8%),pruritus (parecoxib = 7.2%; placebo = 4.3%),insomnia (parecoxib = 6.5%; placebo = 2.9%),dizziness (parecoxib = 2.9%; placebo = 0.7%),headache (parecoxib = 2.9%; placebo = 2.2%),fatigue (parecoxib = 2.2%; placebo = 0.0%),and sleep disorder (parecoxib = 2.2%;placebo = 0.0%) occurred more frequently inthe parecoxib group relative to placebo.

NSAIDs and COXIBs have been associatedwith a variety of specific adverse eventsincluding cardiovascular embolic and throm-botic events; gastrointestinal ulceration, bleed-ing, perforation, or hemorrhage; and bleeding.No instances of these types of events werereported among parecoxib-treated patients,with the following exception. There was oneinstance of myocardial infarction in a 74--year-old man reported in the parecoxib groupthat resulted in death of the subject; this eventwas deemed unrelated to the study drug or theuse of opioids by the site investigator. Thepatient had been permanently withdrawn from

Fig. 2 Mean SPI-24 scores following surgery. **p\0.001;*p\0.010 versus placebo. Day 2 is the day after surgery.SD standard deviation, SPI-24 summed pain intensity over24 h

Fig. 3 Mean mBPI-sf composite pain interference withfunction scores following surgery. **p\0.001 versusplacebo; *p\0.010 versus placebo. Day 2 is the day aftersurgery. SD standard deviation, mBPI-sf modified briefpain inventory-short form

Fig. 4 Cumulative morphine consumption following ini-tial dose of study medication. **p\0.001 versus placebo;*p\0.010 versus placebo. SD standard deviation

66 Pain Ther (2017) 6:61–72

the study because of elevated creatinine andurea nitrogen in the blood after 2 days oftreatment (the day after surgery). The myocar-dial infarction occurred 3 days after discontin-uation of treatment.

DISCUSSION

Pain control is directly related to fast recovery,early rehabilitation, and patient satisfactionafter orthopedic surgeries such as total jointreplacement [10–12]. In this subset analysis ofpatients undergoing major orthopedic surgery,postoperative administration of parecoxibresulted in significantly lower pain scores rela-tive to placebo on day 2 (the day after surgery)and day 3 following surgery. Pain interferencewith function scores, which are a compositescore that examines how pain affects generalactivity, mood, walking ability, relations withothers, and sleep, were also significantly better

with parecoxib compared with placebo. Thesedata demonstrate that parecoxib provides clin-ically meaningful improvement in pain andpatient function following orthopedic surgery.Indeed, a large percentage of both patients(42%) and physicians (46%) rated parecoxibtreatment as ‘‘excellent’’ during the study.

Opioids can elicit a variety of adverse eventsthat slow patient recovery and rehabilitation,and current treatment guidelines recommend amultimodal treatment approach that incorpo-rates other agents to provide supplementalanalgesia and reduce overall opioid consump-tion [13, 15–17, 20, 27]. In the current study,parecoxib significantly reduced overall postop-erative opioid consumption, compared to pla-cebo, and decreased the occurrence of multipleopioid-related adverse events.

Pain and pain control following orthopedicsurgery vary according to procedure and thetype of anesthesia utilized [28]. Pain controlafter hip replacement, for example, is

Table 3 Frequency of opioid-related symptoms following surgery

Symptom Day 2 Day 3

Parecoxib(%)

Placebo(%)

RRa (95% CI) p valuea Parecoxib(%)

Placebo(%)

RRa (95% CI) p valuea

Fatigue 27 48 0.58 (0.41, 0.80) \0.001 23 42 0.54 (0.37, 0.79) \0.010

Drowsiness 39 58 0.67 (0.51, 0.87) \0.010 22 44 0.51 (0.35, 0.74) \0.001

Inability to

concentrate

16 32 0.50 (0.32, 0.80) \0.010 8 22 0.35 (0.18, 0.69) \0.010

Nausea 22 30 0.76 (0.50, 1.15) NS 4 14 0.28 (0.11, 0.72) \0.010

Dizziness 12 17 0.72 (0.39, 1.30) NS 9 12 0.69 (0.33, 1.42) NS

Constipation 22 13 1.63 (0.94, 2.83) NS 18 34 0.53 (0.34, 0.83) \0.010

Itching 21 20 1.09 (0.68, 1.77) NS 13 13 0.99 (0.53, 1.86) NS

Difficulty with

urination

4 8 0.49 (0.17, 1.40) NS 2 3 0.73 (0.17, 3.21) NS

Confusion 2 8 0.20 (0.04, 0.87) \0.050 2 9 0.27 (0.08, 0.93) \0.050

Retching/

vomiting

13 18 0.71 (0.40, 1.28) NS 0b 6 – –

NS non-significant, RR relative riska Parecoxib compared to placebob It was not possible to calculate the RR since no patients in the parecoxib group experienced retching/vomiting

Pain Ther (2017) 6:61–72 67

considered easier than after knee replacement[29, 30]. In addition, pain and recovery follow-ing total joint replacement can be significantlyworse using general anesthesia compared withspinal or epidural approaches [31, 32]. Ourstudy is the first, to our knowledge, to combineseveral types of orthopedic procedures andanalyze them as a single heterogeneous group.However, our findings are in broad agreementwith previous placebo-controlled studies ofparecoxib in specific orthopedic surgery models.For example, significant improvements inpostoperative pain have been associated withmultiple dose parecoxib in patients undergoingtotal hip arthroplasty [33, 34], total kneearthroplasty [35, 36], and a variety of spinalprocedures including spinal fusion [37]. Innearly all these trials, parecoxib also reducedtotal postoperative opioid consumption com-pared to placebo [33, 35–37].

In our clinical trial setting, it is recognizedthat AEs can result from the use of study treat-ment, rescue opioids (which were available toboth placebo and parecoxib treatment groups),or the surgical procedure itself. In our analysis,the overall frequency of AEs was similar in theparecoxib and placebo groups and, with theexception of nausea, no specific AE was reportedin more than 10% of patients in either treat-ment group. Certain AEs, however, occurredmore frequently in the parecoxib group

including nausea, vomiting, pruritus, insomnia,dizziness, headache, fatigue, and sleep disorder.

Our study is also limited in that it was asubset analysis of patients from a clinical trialthat was not powered specifically to look at theoutcomes assessed here [25]. However, thenumber of patients included in our analysis islarge and on par with previous trials of pare-coxib for postoperative pain. Our analysis is alsolimited in that the original clinical trial did notspecifically assess movement-related pain,which is particularly important in patients fol-lowing orthopedic surgery. Parecoxib has beenshown to relieve movement-related pain fol-lowing gynecological surgery [38, 39] and totalhip arthroplasty (in press). Additionally, a pre-vious placebo-controlled study has shown thatparecoxib results in improved range of motion,relative to placebo, following total kneereplacement [35].

The patients included in our analysisreceived parecoxib postoperatively, thoughstudies have shown that traditional NSAIDs andsome COXIBs may provide preemptive analge-sia and demonstrate greater pain relief whenadministered 30–45 min prior to surgery[40, 41]. Traditional NSAIDs, however, inhibitplatelet function and may increase bleedingtime. Parecoxib does not affect platelet func-tion, making it a potentially attractive preop-erative analgesic option [21, 22]. Though

Fig. 5 Patient (a) and physician (b) global evaluation of study medication scores at the time of transition from IV/IM tooral dosing

68 Pain Ther (2017) 6:61–72

parecoxib provides an analgesic benefit whenadministered preoperatively or postoperatively,few studies have compared timing of parecoxibadministration, and the results are mixed. Pre-operative administration of parecoxib providedgreater pain relief compared to postoperativeadministration in trials of general surgery andtotal hip replacement [42, 43]. In another studyof total hip replacement, however, there was nosignificant difference in pain severity or totalopioid consumption between pre- and postop-erative administration of parecoxib [44]. Addi-tionally, there was no difference in analgesiaand opioid-related adverse events between pre-and postoperative administration of parecoxibin patients following colorectal surgery [45].Further studies are required to determine

whether preoperative administration of pare-coxib offers any advantages over postoperativeadministration in patients undergoing ortho-pedic procedures. Currently, Procedure SpecificPostoperative Pain Management (PROSPECT)guidelines recommend COXIBs, such as pare-coxib, as postoperative analgesia following totalknee or hip arthroplasty [28].

CONCLUSION

Overall, postoperative administration of pare-coxib provided significant analgesic and opi-oid-sparing effects in our analysis. Thus, thedata suggest that parecoxib is a good option forpatients following orthopedic surgeries, whichoften depend on early mobilization and physi-cal rehabilitation for successful outcomes.

ACKNOWLEDGEMENTS

Sponsorship and article processing charges forthis study were funded by Pfizer Inc. Allauthors had full access to all of the data in thisstudy and take complete responsibility for theintegrity of the data and accuracy of the dataanalysis. All named authors meet the Interna-tional Committee of Medical Journal Editors(ICMJE) criteria for authorship for this manu-script, take responsibility for the integrity ofthe work as a whole, and have given finalapproval for the version to be published.Medical writing support was provided by MattSoulsby PhD, CMPP of Engage Scientific Solu-tions and was funded by Pfizer Inc. Portions ofthis analysis were presented at the AmericanSociety of Anesthesiologists (ASA) anesthesiol-ogy annual meeting, Oct 24–28, 2015, SanDiego, CA, USA.

Disclosures. Margaret Noyes Essex is afull-time employee of, and owns stock in, Pfizer.Patricia Salomon is a full-time employee of, andowns stock in, Pfizer. Bruce Parsons is a full-timeemployee of, and owns stock in, Pfizer. Chun-ming Li is a full-time employee of, and ownsstock in, Pfizer. Raymond Cheung is a full-time

Table 4 Frequency of most common treatment-emergentAEs

AE, n (%) Parecoxib Placebo

Any AE 81 (58.7) 77 (55.8)

Nausea 24 (17.4) 22 (15.9)

Vomiting 13 (9.4) 8 (5.8)

Constipation 13 (9.4) 13 (9.4)

Pruritus 10 (7.2) 6 (4.3)

Insomnia 9 (6.5) 4 (2.9)

Anemia 5 (3.6) 5 (3.6)

Dizziness 4 (2.9) 1 (0.7)

Headache 4 (2.9) 3 (2.2)

Procedural nausea 4 (2.9) 4 (2.9)

Fatigue 3 (2.2) 0 (0.0)

Sleep disorder 3 (2.2) 0 (0.0)

Anemia postoperative 3 (2.2) 3 (2.2)

Dyspepsia 3 (2.2) 4 (2.9)

Pyrexia 2 (1.4) 12 (8.7)

Musculoskeletal stiffness 1 (0.7) 3 (2.2)

Body temperature increased 1 (0.7) 17 (12.3)

Muscle spasms 0 (0.0) 4 (2.9)

Occurring in C2% of patients in either treatment groupduring the IV/IM treatment phase

Pain Ther (2017) 6:61–72 69

employee of, and owns stock in, Pfizer. EfrainDiaz-Borjon serves as a consultant to Zim-mer-Biomet. Armando Torres-Gomez has servedas a speaker for Pfizer Inc.

Compliance with Ethics Guidelines. Thestudy was approved by an institutional reviewboard or independent ethics committee at eachinvestigational center and patients providedwritten informed consent before participation.The study was conducted in compliance withthe Declaration of Helsinki of 1964, as revised in2013, and all International Conference onHarmonization Good Clinical PracticeGuidelines.

Data Availability. Pfizer provides access todetailed clinical data in response to legitimaterequests from researchers and regulators. http://www.pfizer.com/research/clinical_trials/trial_data_and_results.

Open Access. This article is distributedunder the terms of the Creative CommonsAttribution-NonCommercial 4.0 InternationalLicense (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommer-cial use, distribution, and reproduction in anymedium, provided you give appropriate creditto the original author(s) and the source, providea link to the Creative Commons license, andindicate if changes were made.

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