From the Guidelines
For discharge analgesia after arthroplasty, a multimodal approach is recommended, prioritizing acetaminophen and NSAIDs, with opioids reserved for breakthrough pain, as supported by the most recent guidelines 1. The recommended regimen includes acetaminophen 1000mg every 6 hours regularly, combined with an NSAID such as celecoxib 200mg twice daily or ibuprofen 400-600mg three times daily for 2-3 weeks if not contraindicated. For moderate pain, tramadol 50-100mg every 6 hours as needed can be added, while for severe pain, short-term oxycodone 5-10mg every 4-6 hours as needed may be prescribed, typically limited to 1-2 weeks with a clear tapering plan, as emphasized by recent consensus statements 1. Key considerations include:
- Prioritizing scheduled acetaminophen and NSAIDs, using opioids only for breakthrough pain
- Implementing ice therapy for 20 minutes several times daily and elevation of the affected limb as important adjuncts
- Emphasizing early mobilization and physical therapy compliance to improve outcomes and reduce analgesic requirements
- Ensuring patient education on safe storage and disposal of unused opioids and avoiding opioid diversion, as highlighted in recent guidelines 1. This approach is supported by the latest evidence, which emphasizes the importance of a multimodal strategy to minimize opioid use and optimize pain management after arthroplasty 1.
From the Research
Discharge Analgesia Post Arthroplasty
- The use of strong opioids like morphine as postoperative analgesics can improve patient satisfaction and manage postoperative pain in patients undergoing large joint lower-limb arthroplasty 2.
- A study found that 40% of patients in the total hip replacement group and 50% in the total knee replacement group were discharged on adequate analgesia, which included a combination of NSAIDs, weak opioids, and strong opioids, and all reported manageable postoperative pain 2.
- Multimodal pain regimens (MPRs) that use different agents and modes of delivery to address pain at multiple levels of the pain pathway have been shown to be effective in managing pain in total joint arthroplasty patients 3.
- MPRs can include a combination of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, opioids, spinal/epidural analgesia, regional nerve blocks, and local anesthetics 3.
- The use of gabapentinoids, alone or in combination with other analgesics, has been associated with higher postoperative pulmonary complications (PPCs) in total hip or knee arthroplasty patients, while the combination of acetaminophen and NSAIDs has been associated with decreased odds of PPCs and lower opioid consumption 4.
- A randomized controlled trial found that oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen alone in patients with acute musculoskeletal pain refractory to ibuprofen, but was associated with more medication-related adverse events 5.
- Preemptive analgesia with oxycodone has been associated with more pain following total joint arthroplasty, and patients who received opioids preoperatively reported significantly greater visual analog scale pain scores and consumed more postoperative opioids than those who did not receive preemptive opioids 6.