| Drug | Usual analgesic dose (intravenous) | Maximum dose per day (mg) | Selected characteristics and role in therapy |
| Para-aminophenol derivative |
Acetaminophen
(paracetamol, APAP) | Weight ≥50 kg: 650 mg IV every 4 hours or 1000 mg IV every 6 hours Weight <50 kg: 12.5 mg/kg IV every 4 hours or 15 mg/kg IV every 6 hours | Weight ≥50 kg: 4000 mg IV Weight <50 kg: 75 mg/kg per day up to 3750 mg IV | - Short-term treatment of mild to moderate acute pain and febrile conditions when oral administration is not available and as part of a multimodal analgesic regimen for treatment of moderate to severe acute pain when a rapid onset is needed (eg, postoperatively).
- Also an option for use prior to or during surgery (ie, preemptive analgesia strategy) when oral route is not an option.
- Onset 5 to 10 minutes.
- Minimal alteration of platelet functioning.
- Less risk of GI bleeding, renal, and cardiovascular toxicity than nonselective NSAIDs.
- Lacks antiinflammatory activity.
- Patients should be well hydrated.
- Recommended infusion regimen requires 15 minutes and administration in 100 mL volume per 1000 mg dose.
- Avoid or use a lower total daily dose (maximum 2000 mg per day) in older adults, patients at risk for hepatotoxicity (eg, regular alcohol use, malnourished) or with significant renal or hepatic impairment.
|
| Nonselective NSAIDs* |
| Ketorolac | Age <65 years and weight ≥50 kg: 15 to 30 mg IV every 6 hours Age ≥65 years or weight <50 kg: 15 mg IV every 6 hours | Age <65 years and weight ≥50 kg: 120 mg IV per day for up to five days Age ≥65 years or weight <50 kg: 60 mg per day IV for up to five days | - A frequently used option for short-term treatment of acute pain when oral NSAID administration is not available, and as part of a multimodal analgesic regimen for the treatment of moderate to severe pain when rapid onset is required (eg, postoperatively).
- Onset ~30 minutes.
- Duration of platelet dysfunction ~24 hours.
- Administered as IV bolus over 15 seconds in minimal fluid volume.
- Risk of gastropathy and renal failure is related to dose and duration of use.
- Patients should be well hydrated and without significant kidney disease (CrCl >60 mL/minute).
- Avoid use in patients with a history of ischemic heart disease, stroke, or heart failure.
- According to the US label, NSAID use is contraindicated for the treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
|
| Ibuprofen | 400 to 800 mg IV every 6 hours | 3200 mg IV | - Short-term treatment of mild to moderate acute pain when oral administration is not available and as part of a multimodal analgesic regimen for treatment of moderate to severe postoperative pain.
- Onset ~30 minutes.
- Duration of platelet dysfunction ~8 hours.
- Patients should be well hydrated and without significant kidney disease (CrCl >60 mL/minute).
- Recommended infusion regimen requires 30 minutes and administration in 100 mL volume per 400 mg dose or 200 mL per 800 mg dose.
- Avoid use in patients with a history of ischemic heart disease, stroke, or heart failure.
- According to the US label, NSAID use is contraindicated for the treatment of perioperative pain in the setting of CABG surgery.
|
| Selective COX-2 inhibitor |
Parecoxib
(not available in United States) | 20 to 40 mg IV every 6 to 12 hours | Age <65 years: 80 mg IV Age ≥65 years and body weight <50 kg: 40 mg IV | - For short-term or single-dose treatment of postoperative pain.
- Also a potential option for use prior to or during surgery (ie, preemptive analgesia strategy).
- Onset <15 minutes.
- Minimal or no alteration of platelet functioning.
- Administered as rapid IV bolus in minimal fluid volume.
- Patients should be well hydrated and without significant kidney disease (CrCl >60 mL/minute).
- Increased risks of adverse cardiovascular thromboembolic events and surgical wound complications have been observed in CABG postoperative safety studies.
- Parecoxib is a prodrug of valdecoxib; chronic use of valdecoxib has been associated with an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke relative to some nonselective NSAIDs.
- Use is contraindicated in patients who are at increased risk for cardiovascular thrombotic events, during the perioperative period of coronary artery bypass graft (CABG) surgery, and/or with a history of sulfonamide hypersensitivity.
- Dose reduction needed for older adults and weight <50 kg.
|
| Semi selective COX-2 inhibitor |
| Meloxicam | 30 mg IV once every 24 hours | | - Once daily parenteral NSAID alternative.
- Administer by IV bolus injection over 15 seconds.
- Onset of analgesia in 6 to 8 minutes, maximal effect in 2 to 3 hours.
- Meloxicam preferentially inhibits COX-2 at low doses, but loses COX-2 selectivity at doses recommended for acute pain. When used clinically, meloxicam has effects, drug interactions, and toxicities similar to other nonselective NSAIDs described above.
- Undergoes hepatic metabolism by CYP2C9; with repeated dosing (eg, >2 to 3) may accumulate when given with CYP2C9 inhibitor drugs (eg fluconazole, voriconazole) and/or in patients with slow CYP2C9 function (poor metabolizers; <5% population).
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