LOCAL OPERATING PROCEDURE – CLINICAL
Approved Safety & Quality Committee May 2021
Review May 2026
NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) AND COX-2
INHIBITORS IN THE ACUTE POST OPERATIVE PAIN SETTING
Role:
• Managing moderate pain
• Opioid sparing effect
Action:
• Decreasing levels of inflammatory mediators generated at the site of tissue injury. Inhibition of
prostaglandin synthesis
• May have other mechanisms of action independent of any effect on prostaglandins including
effects on basic cellular and neuronal processes.
• Anti-pyretic
Pharmacology:
• Cyclo-oxygenase (COX) is present in 2 forms, COX-1 and COX-2. Inhibition of COX-1 is
associated with impaired gastric cytoprotection and antiplatelet effects. Inhibition of COX-2 is
associated with anti-inflammatory and analgesic action. Reduction in glomerular filtration rate
and renal blood flow is associated with both COX-1 and COX-2 inhibition. Nonselective
NSAIDs bind both COX-1 and COX-2 isoforms. COX-2 inhibitors selectively bind the COX-2
isoform. COX-2 may be associated with less risk of thrombosis.
• If the oral route is unavailable NSAIDs may be given rectally (diclofenac), by intramuscular
injection (ketorolac) or by intravenous injection (parecoxib)
Indications:
• Day surgery- simple post-operative pain relief in combination with paracetamol
• Obstetrics (e.g. perineal pain or after pains) - simple post-delivery pain relief in combination
with paracetamol
• Obstetric surgery - may be used following caesarean section up to a maximum of one week
• Gynaecology surgery - may be used peri-operatively or post-operatively with caution.
• Gynaecology/Oncology surgery- may be used peri-operatively or post operatively with
caution.
• May be used pre-operatively with caution and approval of surgical team.
Contraindications:
• Known sensitivity especially asthma sufferers (NSAIDs are not contraindicated in all asthma
sufferers)
• Renal impairment
• Active bleeding or increased risk of bleeding, thrombocytopenia
• Gastric ulceration or history of gastric ulceration
• Patients with an epidural catheter insitu who are also on heparin are at increased risk of
epidural or spinal haematoma formation, hence should not be prescribed NSAIDs.
• Cardiac failure
• NSAIDS (e.g. Ibuprofen) – Cat C in pregnancy - There is insufficient experience about the
safety of use of NSAIDs in humans during pregnancy. NSAID should, therefore, not be used
during the first 6 months of pregnancy unless the potential benefits to the patient outweigh the
possible risk to the foetus.
…./2
2.
LOCAL OPERATING PROCEDURE – CLINICAL
Approved Safety & Quality Committee May 2021
Review May 2026
NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) AND COX-2
INHIBITORS IN THE ACUTE POST OPERATIVE PAIN SETTING cont’d
• Cox 2 inhibitors (Celebrex) - There is no information on the use of celecoxib in pregnant
women. Celebrex use is not recommended in pregnancy unless it is considered clinically
essential (see information on animal studies). No studies have been done to evaluate the
effect of celecoxib on the closure of the ductus arteriosus in humans. In animal studies, both
COX-1 and COX-2 (e.g. Celebrex) - have been shown to be present in the ductus arteriosus
of fetal lambs and to contribute to maintenance of patency. Therefore, use of Celebrex during
the third trimester of pregnancy should be avoided, and Celebrex should not be used during
the first and second trimesters of pregnancy unless the potential benefit to the mother justifies
the potential risk to the fetus.
Precautions: (Please seek advice from medical/surgical/O&G team)
• Patients with poor urine output particularly pre-eclamptic women with impaired renal function
i.e. serum creatinine >70umol/l. It is reasonable for RN/RM to withhold NSAIDs if a patient has
poor urine output.
• Patients with poorly controlled hypertension particularly post-natal women with pre-eclampsia.
• Patients may be trialled on NSAIDs if they are asthmatic but have received aspirin or other
NSAID previously without exacerbation to their asthma.
• Concomitant use of anti-platelet agents e.g. aspirin >600mg/day, clopidogrel, dipyridamole
• Age >65 years: the risk and severity of NSAID associated side effects is increased in elderly
people.
• NSAIDs should only be given in pregnancy if the maternal benefits outweigh the potential
fetal risks, at the lowest effective dose and for the shortest duration possible. Please seek
advice from O&G medical team prior to prescribing NSAIDs for a pregnant woman.
Drug Interactions:
• Important pharmacokinetic interactions occur between NSAIDs and warfarin, lithium, oral
hypoglycaemic, phenytoin, methotrexate, digoxin, aminoglycosides, cyclosporine, and
probenicid.
Dosage and Administration:
• Diclofenac: (COX-1) PR maximum daily dose 200mg (i.e. 100mg twice daily) for no more
than 2 days followed by 150mg orally for maximum of 3 days (i.e. 50mg three times daily). The
patient should be reviewed if ongoing diclofenac is thought necessary.
• Naproxen: (COX-1) 250mg qid for 5 days max then review.
• Ibuprofen: (COX-1) 400mg tds for 5 days max then review.
• Parecoxib: (COX-2) IV for a single dose intra-operatively for day stay and moderate surgery
cases. Parecoxib should be utilised as per the guidelines of one dose only. Any subsequent
dose of NSAID or COX-2 may be given 12 hours after this one-off dose of parecoxib.
• Oral NSAIDs and COX-2 inhibitors should be prescribed for administration after meals.
• Low body weight: < 55kg may require a reduction in the daily dose.
Avoid double dosing of more than one NSAID
…./3
3.
LOCAL OPERATING PROCEDURE – CLINICAL
Approved Safety & Quality Committee May 2021
Review May 2026
NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) AND COX-2
INHIBITORS IN THE ACUTE POST OPERATIVE PAIN SETTING cont’d
Adverse Effects
• Renal impairment: increased in the presence of factors such as pre-existing renal impairment,
hypovolemia, hypotension, use of other nephrotoxic agents
• Bleeding: GIT or surgical. Studies have demonstrated that short term use of COX-2 inhibitors
produce less clinically significant peptic ulceration than NSAIDS
• Bronchospasm
• Cardiac failure, fluid retention
• COX-2 inhibitors have been found to have a high adverse drug event profile when used
chronically for arthritis and chronic pain sufferers.
• There is no similar evidence when COX-2 inhibitors are used for short periods in the acute
post-operative setting
RISK RATING
Low
NATIONAL STANDARD
Standard 4 - Medications
REVISION & APPROVAL HISTORY
Reviewed and endorsed Therapeutic & Drug Utilisation Committee 28/4/21
Approved Quality & Patient Safety Committee 18/12/14
Reviewed and Endorsed Therapeutic & Drug Utilisation Committee 9/12/14
Approved Quality & Patient Safety Committee 15/7/10
Reviewed and Endorsed Therapeutic & Drug Utilisation Committee 20/4/10
Approved Quality Council 20/2/06
FOR REVIEW: MAY 2026
