Role of COX-2 inhibitors in the evolution of acute pain management.

Management of acute postoperative pain remains suboptimal: nearly 80% of patients report moderate to extreme pain following surgery. New pain management paradigms incorporate multimodal analgesia, using a combination of analgesics throughout the perioperative period to control nociceptive and centrally-stimulated pain. Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) have a role in postoperative pain management, but concerns about increased bleeding and inhibited wound healing and bone fusion have limited their use. Cyclooxygenase (COX)-2-selective inhibitors (coxibs) offer the peripheral pain-relieving benefits of nonselective NSAIDs but with fewer adverse GI effects; they also may have a role in central sensitization. Clinical trials have demonstrated the efficacy and safety of celecoxib and rofecoxib for postoperative pain and for preemptive analgesia, and newer agents such as valdecoxib and etoricoxib also have demonstrated efficacy in these settings. In addition to their selectivity for the COX-2 isozyme overall, unique differences among the coxibs, such as in plasma half-life, may impart certain clinical advantages.