Oncological Breast Surgery 2019

Breast Surgery-Specific Evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after breast surgery

Arguments for…

• One study compared paracetamol, metamizole and placebo. 42% of patients receiving paracetamol did not require rescue analgesia compared with 4% in the placebo group and 4% in the metamizole group (n=79) (Ohnesorge 2009; LoE 1).
• Another study documented that paracetamol 1g administered at the end of surgery improved pain control during recovery compared with placebo (n=65) (De Oliveira 2018; LoE 1).
• Pain control with paracetamol was documented to be equivalent to metamizole in another study (n=40) (Kampe 2006; LoE 1). However, there were insufficient numbers in this study to draw conclusions.
• Incidence of nausea and constipation was reduced in ambulatory patients receiving paracetamol and ibruprofen vs a combination of paracetamol, codeine and caffeine whilst the pain reduction was comparable (n=141) (Mitchell 2012; LoE 1).

Arguments against…

• Only one study in the search period specifically examined postoperative pain control with NSAIDs. The addition of systemic COX-2 inhibitors (parecoxib and celecoxib) to PVB decreased the intensity of pain on movement at day five but had no effect on the incidence of postoperative hyperalgesia (n=94) (Van Helmond 2016; LoE 1).

PROSPECT Recommendations

• Paracetamol (Grade B) and NSAID (Grade A) or COX-2-specific inhibitor (Grade B) are recommended for minor and major breast surgery, administered pre-operatively or intra-operatively and continued postoperatively, unless there are contra-indications.
• The use of NSAIDs (Grade A) is supported by studies performed before 2006 in breast surgery (Chan 1996, Priya 2002), although there are no recent data.
• The analgesic benefits and opioid-sparing effects of these simple analgesics are well described (Martinez 2017, Ong 2010).