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Round and round and back to diclofenac: an evaluation of non-steroidal anti-inflammatory drugs for analgesia following elective caesarean section

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Round and round and back to Diclofenac: An evaluation of NSAIDs for analgesia after elective caesarean section. Dr L French, Dr R Scale, Dr J Quinton, Dr S Churchill, Dr B Thomas, Dr S Bell. University Hospital of Wales, Cardiff

Introduction

•Recommended oral non-steroidal anti-inflammatory drug (NSAID) for analgesia following elective caesarean section (ELLSCS) is variable across the UK.1
•Choosing the most effective short-term NSAID following ELLSCS remains a dilemma because of evidence of cardiovascular risk associated with NSAID use.2 This led to temporary withdrawal of diclofenac as a take home medication by our pharmacy.
•As part of a locally registered quality improvement project introducing enhanced recovery for ELLSCS, we evaluated 3 NSAIDs to optimize post-operative analgesia.
 

Methods

•All ELLSCS patients received intrathecal Morphine 100mcg, Diclofenac 100mg BD for 48 hours, Paracetamol 1g QDS, Tramadol 50-100mg QDS (if required for breakthrough pain) and a variable NSAID regimen (Table 1).
•On discharge, patients received Paracetamol and the NSAID regimen, with 8 x 50mg tablets of Tramadol if required.
•Patients were not prescribed NSAIDs if they had cardiovascular risk factors or contra-indications.
•Patients were contacted by telephone 5 days following delivery to assess length of stay, pain scores, analgesia use and satisfaction using a structured questionnaire.
 

Results

•Results are summarized in Table 1 and 2, and Figure 1.
•In the Diclofenac group 14% were discharged with rescue Tramadol, compared with 80% in the Naproxen group.
•Pain scores did not correlate with satisfaction or parity.
 

Limitations

•The day 1 discharge rate increased whilst the evaluations were performed, which may have affected reported pain scores.
•Prescription and use of Tramadol was only recorded in the Naproxen and Diclofenac groups.
•The maximum dose of Ibuprofen was not evaluated due to concerns regarding gastrointestinal side effects.
 

Discussion

•The percentage of patients discharged the day after their ELLSCS has increased substantially (14% in 2014 to 49% in February 2018).
•The Diclofenac regimen is associated with lower median pain scores and fewer women requiring Tramadol for discharge. We will continue to use this regimen in our department.
•We did not identify any post-operative cardiovascular complications in the patients surveyed. Further studies to evaluate the long-term effects of a short-course of NSAID for acute post-operative pain are indicated.


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