Back to the future: postoperative pain management beyond COX-2 inhibitors

In the aftermath of the heated dispute on COX-2 selective nonsteroidal anti-inflammatory drugs (NSAID) that led to the national and international withdrawal of several of the recently introduced coxibs, a balanced discussion of pros and cons for their short term use is warranted. Further debate and research has highlighted risks with both classical NSAIDs and coxibs when administered to patients with cardiovascular disease. For several decades discussion about indications, risks and contraindications for the perioperative use of classical NSAIDs has been ongoing. The COX debate has further added some uncertainty amongst practitioners. With a vast amount of research available on this topic, it should however be feasible to reach some consensus for the perioperative use of NSAIDs as well as for coxibs. This would ensure that the right patients take advantage of our present knowledge of NSAIDs as part of a multimodal and balanced perioperative analgesic regimen and at the same time that the patients at risk are not prescribed such drugs. Rational use of NSAIDs in the perioperative period would benefit a major group of patients who at present are deprived of such therapy due to unfounded fears of side effects and lack of knowledge among prescribers. This review highlights some of the aspects of short term (i.e. less than 5 days) perioperative use of NSAIDs.