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Anesthesiology:
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Postsurgical Safety of Opioid-sparing Cyclooxygenase-2 Inhibitors

Marret, Emmanuel M.D.*; Bonnet, Francis M.D.

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In Reply:—

We thank Drs. Babul, Sloan, and Lipman for their interest in our meta-analysis,1 which was primarily performed to study the effects of cyclooxygenase-selective and -nonselective inhibitors on morphine side effects. We agree with them (as we discussed in the article) that some concerns remain about the safety of short-term perioperative prescription of coxibs and that coxibs cannot be administrated to all surgical patients, especially patients with coronary artery disease or at risk of cerebral infarction. Two studies have indeed clearly demonstrated that the use of parecoxib and valdecoxib was associated with an increased risk of arterial thrombotic adverse events in patients scheduled to undergo coronary artery bypass surgery.2,3 However, some evidence also suggests that short-term perioperative use of coxibs may offer benefits in comparison with nonsteroidal antiinflammatory drugs. For example, tonsillectomy is one of the most frequently performed ambulatory surgical procedures in children, and nonselective inhibition of cyclooxygenase by nonsteroidal antiinflammatory drugs increases significantly the rate of reoperation4,5 but also decreases nausea and vomiting.5 In that setting, celecoxib, has been demonstrated to relieve posttonsillectomy pain and to decrease bleeding risk in comparison with nonsteroidal antiinflammatory drugs.6 Moreover, the risk of adverse cardiovascular events is extremely low in this population of young patients, as it is in patients devoid of arterial thrombotic pathology scheduled to undergo noncardiac surgery. Therefore, short-term perioperative use of coxibs could have a favorable risk–benefit ratio compared with nonsteroidal antiinflammatory drugs in patients without risk factors for arterial thrombotic events submitted to hemorrhagic surgical procedures.
Emmanuel Marret, M.D.,*
Francis Bonnet, M.D.
*Tenon University Hospital, Paris, France. emmanuel.marret@tnn.aphp.fr
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References

1. Marret E, Kurdi O, Zufferey P, Bonnet F: Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: Meta-analysis of randomized controlled trials. Anesthesiology 2005; 102:1249–60

2. Nussmeier NA, Whelton AA, Brown MT, Langford RM, Hoeft A, Parlow JL, Boyce SW, Verburg KM: Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. N Engl J Med 2005; 352:1081–91

3. Ott E, Nussmeier NA, Duke PC, Feneck RO, Alston RP, Snabes MC, Hubbard RC, Hsu PH, Saidman LJ, Mangano DT: Efficacy and safety of the cyclooxygenase 2 inhibitors parecoxib and valdecoxib in patients undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg 2003; 125:1481–92

4. Marret E, Flahault A, Samama CM, Bonnet F,: Effects of postoperative, nonsteroidal, antiinflammatory drugs on bleeding risk after tonsillectomy: Meta-analysis of randomized, controlled trials. Anesthesiology 2003; 98:1497–502

5. Moiniche S, Romsing J, Dahl JB, Tramer MR: Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: A quantitative systematic review. Anesth Analg 2003; 96:68–77

6. Nikanne E, Kokki H, Salo J, Linna TJ: Celecoxib and ketoprofen for pain management during tonsillectomy: A placebo-controlled clinical trial. Otolaryngol Head Neck Surg 2005; 132:287–94

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