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Preoperative Evaluation/Patient Issues/When should COX-2 inhibitors be stopped before surgery?

QUESTION:

Cox-2 inhibitors , such as Celebrex (celecoxib), and Bextra (valdecoxib) are now very popular. They are touted for their safety profile, with reduced, if not absent, anti-platelet, renal and GI side effects.

Nevertheless, some of our surgeons are nervous about patients continuing to take these agents preoperatively. Have we reached the stage where we can safely instruct our patients to take their Cox-2 inhibitors on the day of surgery before coming to the ambulatory surgery facility? Or should we continue the traditional practice that was prevalent with standard NSAIDs, of advising that patients discontinue their Cox-2 drugs for some period before surgery?

-- From Gary Kantor, M.D., Cleveland, OH

REPLY:

The selective COX-2 inhibitors (celecoxib and valdecoxib), a new group of anti-inflammatory and analgesic drugs, were developed to avoid some of the side effects associated with traditional nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs). The selective COX-2 inhibitors appear have similar analgesic efficacy as the nonspecific NSAIDs; however, they do not affect platelet function and reduce the risk of gastrointestinal ulceration. Of note, the cardiovascular and renal effects of selective COX-2 inhibitors remain controversial. It is suggested the cardio-renal effects of selective COX-2 inhibitors are similar to that of nonspecific NSAIDs. Rofecoxib was recently withdrawn from the market because it has a higher incidence of cardiovascular adverse effects.

Because the selective COX-2 inhibitors do not affect platelet aggregation and thus do not affect perioperative bleeding, they can be safely administered preoperatively. However, one of the major concerns with the perioperative use of selective COX-2 inhibitors is the associated risk of delayed bone and ligament healing. This is one of the reasons many orthopedic surgeons are reluctant to use selective COX-2 inhibitors for surgical procedures in which delayed bone healing is a concern. However, the effects of selective COX-2 inhibitors on bone and ligament healing remain controversial as there is no good clinical study available.

In summary, selective COX-2 inhibitors need not be discontinued prior to surgery (unless if there is concern of delayed bone and ligament healing). In fact, the doses may have to be increased preoperatively to achieve superior postoperative pain relief (e.g., if the patient is on celecoxib 200 mg per day it needs to be increased to 400 mg preop). In addition, they need to be administered on a regular "round-the-clock" basis with, opioids used as "rescue" analgesics on an "as needed" basis. Furthermore, combination of selective COX-2 inhibitors with local anesthetic techniques provides superior pain relief. Based on numerous publications, the doses for celecoxib are 400 mg preoperatively followed by 200 mg twice daily, and valdecoxib 40 mg preoperatively followed by 20 mg twice daily. Because both nonspecific NSAIDs and selective COX-2 inhibitors act by inhibiting the COX-2 isoenzyme, it is imperative that the two groups of drugs are not administered simultaneously. For example, if the patient has received a selective COX-2 inhibitor preoperatively, it is not necessary to administer ketorolac intraoperatively.

-- From Girish Joshi, M.D., Dallas, TX

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