Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis.

Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.

Adjunctive Intravenous Diclofenac Decreases Opioid Consumption and Increases Satisfaction in the Primary Total Hip Arthroplasty Population.

Despite the success of total hip arthroplasty (THA), postoperative pain management remains a concern. Although the nonsteroidal anti-inflammatory drug (NSAID) intravenous (IV) diclofenac is a promising addition, its impact on THA outcomes has not been investigated. This study evaluates the effects of adjunctive IV diclofenac on: 1) postoperative pain intensity; 2) opioid consumption; 3) discharge destination; 4) length of stay; and 5) patient satisfaction in primary THA patients. A retrospective study was performed for patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients of the study group (n=25) were treated postoperatively with IV diclofenac and the standard pain control regimen while the control group (n=88) did not receive diclofenac. Patients receiving adjunctive IV diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02; p=0.049). Patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the IV diclofenac group. Patients who received IV diclofenac had lower opioid consumption on postoperative days one and two (-67.2 and -129.0mg, respectively; p=0.001 for both). The growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. This study demonstrates that THA patients receiving adjunctive IV diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. To further investigate the optimal regimen, future studies comprising a larger cohort and comparing IV diclofenac to other NSAIDs are warranted.

The Addition of Diclofenac to a Multimodal Pain Control Regimen Decreases Postoperative Pain and Opioid Consumption.

INTRODUCTION: Total knee arthroplasty (TKA) is a commonly-performed orthopaedic procedure in the United States. However, inadequate postoperative pain management following TKA has been associated with a number of negative consequences, including chronic postoperative pain requiring long-term opioid use. Multimodal pain control is a recently-popularized means of maximizing analgesia and postoperative outcomes. We aimed to evaluate the outcomes of a multimodal pain regimen incorporating diclofenac, including: 1) length of stay (LOS); 2) pain intensity; and 3) opioid consumption in primary TKA patients. MATERIALS AND METHODS: A prospective cohort study was performed. All patients scheduled for primary TKA by a single surgeon between March 1, 2017 and August 31, 2017 were screened for study involvement, yielding 46 consecutive patients (52 TKAs). This study group was treated with a postoperative regimen of intravenous (IV) diclofenac, in addition to a perioperative pain control regimen including adductor canal blockade (ACB) and periarticular multimodal drug injection (PMDI). Postoperative outcomes in this group were compared to those of a matched cohort of 78 patients (88 primary TKAs) who had previously been treated with the same perioperative pain control regimen. RESULTS: Patients prescribed a postoperative diclofenac regimen had lower mean LOS (2.10 vs. 2.33 days; p=0.053) and lower 24-hour postoperative pain intensity (76 vs. 104; p=0.056) as compared to the untreated group. The diclofenac-treated group had a significantly lower opioid consumption in the first 24 hours postoperatively than did their untreated counterparts (39.8 vs. 53.1 morphine milligram equivalents [MME]; p=0.041). In addition, 17 patients (18 TKAs, 35%) in the diclofenac group had zero opioid requirements during the first 12 hours postoperatively, and 12 of these patients (13 TKAs, 25%) continued to not require any opioids through the first 24 hours postoperatively. DISCUSSION: In the midst of the rapidly-increasing rates of TKA in the US, multimodal pain control has emerged as an extremely effective means of maximizing postoperative patient outcomes. To our knowledge, this is the first study to evaluate the postoperative outcomes of TKA patients treated with a regimen of IV diclofenac. We demonstrate shorter LOS, decreased 24-hour pain intensity, and significantly decreased 24-hour opioid consumption in patients treated with adjunctive IV diclofenac compared to patients managed with our institution's standard perioperative regimen.

A comprehensive review of everolimus clinical reports: a new mammalian target of rapamycin inhibitor.

As new immunosuppressive agents are introduced to the market, clinicians are faced with the daunting task of sifting through the published literature to decide the value that the agent will add to their own practice. We often must extrapolate information provided through study in other solid-organ transplantation populations than our specific area of interest as we interpret the results and outcomes. With these challenges in mind, this compilation of published work for the newest mammalian target of rapamycin inhibitor everolimus (Certican; Novartis Pharmaceuticals, Hanover, NJ) (Zortress; Novartis Pharmaceuticals, Basel, Switzerland) is intended to provide a concise but thorough presentation of available literature so that the reader who may be unfamiliar with the agent can make their own judgment. Both Ovid and PubMed search engines were queried with a particular focus on high-impact articles noted in the Web of Science or Citation Index. Work described solely in abstract or case report form was excluded, as well as meta-analyses or those that were editorial or commentary in nature. Included were publications presented using the English language that described adult human subjects who received a heart, lung, kidney, or liver allograft. The goal of this strategy was to allow for the inclusion of pertinent literature in an unbiased fashion. Tables are provided that outline trial specific information, leaving a discussion of major outcomes to the text of the review.

The impact of reduced immunosuppression on graft outcomes in elderly renal transplant recipients.

Optimal immunosuppression (IS) for elderly kidney transplant recipients is unknown. We conducted a retrospective cohort study of recipients aged 60 yr or older to examine the impact of reduced IS on graft outcomes. Group 1 patients (n = 101) were initiated on mycophenolate mofetil 2 g/d and tacrolimus, target level 10-12 ng/mL; Group 2 patients (n = 88) with 1 g/d and 8-10 ng/mL, respectively. Dose adjustments were made as required. The groups were comparable except for diabetes, end-stage renal disease duration, and induction. Mycophenolate mofetil dose was reduced in 62% and 38% of the patients, respectively (p < 0.01). Patients were followed for 23.8 +/- 14.2 and 21.3 +/- 11.8 months post-transplant (p = 0.2). Twenty-seven cases in Group 1 (26.7%) and eight in Group 2 (9.1%) lost their grafts (p = 0.01); 19 (18.8%) and 7 (8.0%) cases in each group because of death, respectively (p = 0.09). Sixteen patients in Group 1 (15.8%) and 18 in Group 2 (20.5%) experienced acute rejection (p = 0.36). Patients in Group 2 had a lower risk of graft loss compared with those in Group 1 [adjusted hazard ratio (HR): 0.27, p = 0.006, 95% CI: 0.11-0.69]. There were no significant differences between the groups regarding graft function, BK virus nephropathy, and CMV infection. Our results suggest that reduction in overall IS in this group was associated with improved graft and patient survival.

Thymoglobulin dose optimization for induction therapy in high risk kidney transplant recipients.

BACKGROUND: Thymoglobulin (rATG) has become the agent of choice for induction therapy in high immunological risk kidney transplant recipients. However, its optimal dosing in this subgroup has not been studied. METHODS: To evaluate the effect of total rATG dosing on graft outcomes in such patients, we conducted a retrospective cohort study of 96 adult patients who received repeat transplants (85%) or had panel reactive antibody more than 40% (19%) and were maintained on tacrolimus, mycophenolate mofetil, and steroid. Group 1 (n=33) received less than or equal to 7.5 and group 2 (n=63) received more than 7.5 mg/kg rATG. Graft and patient survival, incidence of acute rejection (AR), and 12-month serum creatinine (SCr) were examined. RESULTS: The groups were comparable regarding demographics, donor source, retransplantation, panel reactive antibody, and human leukocyte antigen mismatch. Group 2 had more African Americans (44.4% vs. 21.2%, P=0.03). During the 25.4+/-18.0 months follow-up graft survival was 82.5% and 79.4%, respectively (P=0.54). Three in group 1 and four in group 2 died (P=0.65). The incidence of biopsy proven AR during the first 12-months did not differ between the groups (9.5% vs. 8.8%, respectively, P=0.9). SCr at 12 months was 1.6+/-0.7 in group 1 and 1.8+/-1.0 in group 2 (P=0.3). There was no independent association between rATG dose and graft survival (hazard ratio: 0.85, P=0.79, 95% CI: 0.26-2.7 for group 2 vs. 1) or 1-year SCr (regression coefficient=0.02 for ln(SCr), P=0.3; 95%CI: -0.01 to 0.6). CONCLUSION: Our results suggest that in high risk kidney transplant recipients total rATG doses less than or equal to 7.5 mg/kg are safe and effective in achieving a low rate of AR and graft outcomes comparable to higher doses.