TRAUMA AND GENERAL ORTHOPAEDICS

 

Development of an NSAID decision tool for perioperative pain management in adult orthopaedic patients: a modified Delphi study

 

 

Ulla Plenge^I, ; Maritz Laubscher^II; Marc Β Nortje^II; Sithombo Maqungo^{II, III}; Thomas Hilton^II; Robert Dunn^{II, IV}; Stephen JL Roche^II; Marcin B Nejthardt^{I, V}; Alma de Vaal^I; Sibylle Eickhoff^{VI, VII}; Ettienne Coetzee^{I, VIII}; Owen S Porrill^{I, VI, VII}; Luis FM Pelaez^{I, IX}; Vernon J Louw^{X, XI}; Bridget Hodkinson^{X, XII}; Mashiko Setshedi^{X, XIII}; Peter J Raubenheimer^{X, XIV}; Nicola Wearne^{X, XV}; Ashley Chin^{X, XVI}; Romy Parker^{I, XVII}; Bruce M Biccard^{I, XVIII}

^IDepartment of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
^IIOrthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
^IIIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group:; Head of Clinical Unit: Orthopaedic Trauma
^IVGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head: Division of Orthopaedic Surgery
^VGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head of Clinical Unit
^VIPrivate practice anaesthetist, Life Vincent Pallotti Hospital, Cape Town, South Africa
^VIIPrivate practice anaesthetist, Life Kingsbury Hospital, Cape Town, South Africa
^VIIISpecialist anaesthetist, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
^XDepartment of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
^IXGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head of Clinical Unit: Cardiothoracic Anaesthesia
^XIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Chair and Head: Division of Clinical Haematology
^XIIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Chair and Head of Division: Rheumatology
^XIIIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Chair and Head of Medicine
^XIVGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head of Division: General Internal Medicine
^XVGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head of Division: Nephrology and Hypertension
^XVIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head of Division: Pacing and Electrophysiology, Cardiac Clinic
^XVIIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Head: Pain Management
^XVIIIGroóte Schuur Hospital Adult Reconstructive Orthopaedic Surgery Research Group: Second Chair

 

 

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ABSTRACT

BACKGROUND: Orthopaedic surgery is rated among the most painful of surgeries, leaving patients at risk of experiencing moderate to severe postoperative pain. A multimodal analgesic approach helps reduce opioid requirements, with nonsteroidal anti-inflammatory drugs (NSAIDs) playing a key role in this strategy, provided they are not contraindicated. However, only limited guidance exists for safe perioperative NSAID use in orthopaedic patients with comorbidities. The objective of the study was to achieve consensus on safe, short course (< 1 week) administration of NSAIDs in adult orthopaedic patients with comorbidities, and to convert the results into a decision tool to aid clinicians in safe perioperative NSAID administration
METHODS: A Delphi panel of 18 experienced orthopaedic surgeons, physicians and anaesthetists participated in a three-round Delphi process. The panel assessed 42 patient characteristics using a nine-point Likert scale in the first two rounds. After the second round, consensus was defined as > 75% either 'disagreeing' (Likert scale 1-3) or 'agreeing' (Likert scale 7-9) that NSAIDs ± proton pump inhibitors (PPIs) could or could not be administered safely. Characteristics without consensus by round 2 moved to round 3, where subspecialty experts conducted a rapid review of the literature. Consensus in this round required > 75% support for expert recommendations
RESULTS: All panel members participated in the first and third rounds, with 16 in the second. After the second round, consensus was achieved for 24 of 42 patient characteristics. However, in preparation for the third round, three characteristics which had achieved consensus after round 2 were added to the pool of characteristics to be considered by subspeciality experts, resulting in 21 proceeding to the third round. In round 3, consensus for all remaining subspeciality expert recommendations was achieved and an NSAID decision tool with guidance in safe perioperative NSAIDs use ± PPIs was subsequently developed for the 42 patient characteristics
CONCLUSION: This study establishes a consensus on short-term NSAID administration in adult orthopaedic patients with comorbidities, offering a decision tool to guide clinicians in safely incorporating NSAIDs into perioperative pain management strategies
Level of evidence: 5

Keywords: NSAIDs, decision tool, perioperative pain management, orthopaedic surgery, multimodal analgesia, Delphi consensus

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Introduction

Orthopaedic surgery is rated among the most painful of surgeries, leaving patients at risk of experiencing moderate to severe postoperative pain.¹ Inadequate postoperative pain control is associated with delayed recovery, increased length of hospital stay and risk of persistent postoperative pain.^2-4 A multimodal analgesic strategy, which combines two or more analgesic methods with different mechanisms of action, is widely regarded as a cornerstone of opioid-sparing postoperative pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs), when not contraindicated, are a vital component of this approach, enhancing its effectiveness.^5-9 Two categories of NSAIDs exist: non-selective NSAIDs, which inhibit both cyclooxygenase (COX) 1 and 2, and selective COX-2 inhibitors, which predominantly inhibit COX-2.¹⁰ Both provide analgesic and anti-inflammatory effects by inhibiting the COX-2 isoform.¹¹

Nevertheless, NSAIDs are often underutilised in the perioperative period.^12-14 Reasons might include drug misconceptions, e.g. the effect of NSAIDs on bone healing,¹⁵ a culture favouring the use of opioids for perioperative pain management,¹⁴ and erring on the side of caution in patients with comorbidities.¹⁶ This final reason reflects a cautionary conservative approach, as the evidence of serious adverse events following perioperative use of NSAIDs in the orthopaedic and surgical population is limited.^17-20 In fact, the literature documenting adverse events originates mainly from non-surgical patient cohorts dominated by patients with chronic pain conditions receiving NSAIDs for an extended period of time.²¹ Extrapolating this evidence to short-course treatment with NSAIDs in a surgical population can result in inadvertent under-prescription and inferior pain management.^16,22

The aim of our study was to identify which orthopaedic patients can safely receive NSAIDs as part of a multimodal approach to relieve postoperative pain. The objectives of our study were two-fold. The first was to conduct a modified Delphi survey to gather expert consensus on safe, short course (< 1 week) administration of NSAIDs in adult orthopaedic patients with a variety of comorbidities. A Delphi method is used in medical research to achieve consensus and produce guidelines among experts on specific clinical issues, especially when high-quality evidence is lacking.^23,24 It is characterised by anonymity, iteration, controlled feedback of the panellists' judgements, and statistical aggregation of group members' responses, allowing experts to refine their opinions and move towards agreement.²⁵ The modified Delphi is based on the principles of the Delphi process but allows for adaptation of the traditional framework. Our second objective was to translate the results of the Delphi study into a decision tool to aid clinicians in safe perioperative NSAID administration.

While the study was at first intended as a tool to support safe administration of NSAIDs as part of a multimodal pain management plan at Groote Schuur Hospital (GSH), the end result could be valuable to orthopaedic departments and settings throughout South Africa.

 

Methods

The study was prospectively registered with the Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (ref no. 715/2022), and is reported using the ACcurate COnsensus Reporting Document (ACCORD).²⁶

Panel selection

UP and BMB, both experienced in directing multidisciplinary Delphi consensus studies,^27,28 established a Delphi panel including specialists in perioperative patient management (anaesthetists and orthopaedic surgeons) and experts in medical adverse events (physicians). Clinical heads from the Departments of Orthopaedic Surgery (ten) and Medicine (nine) at GSH were invited to participate. Six orthopaedic surgeons representing spine, upper limb, lower limb and pelvic surgery (involving oncology, trauma and elective surgery) and six physicians from the divisions of Nephrology, Rheumatology, Medical Gastroenterology, Clinical Haematology, General Internal Medicine and Cardiology were recruited. We aimed for an equal inter-speciality representation; thus, six anaesthetists with a special interest in orthopaedic anaesthesia were invited (four from GSH and two full-time private practitioners). All 18 panel members consented to participate. Due to the highly technical and scientifically nuanced nature of the topic, members of the public and patients were not considered eligible for study inclusion.

Preparatory work

Scientific literature addressing the risk of adverse events following a short course of NSAIDs (< 7 days) in surgical patients with pre-existing comorbidities was limited at the time of study initiation.^22,29,30 Thus, the Delphi members' clinical experience and individual appraisals of the existing NSAID literature were sought over a pre-emptive group-based literature review. A list of 39 general patient comorbidities considered relevant for a perioperative NSAID tool was drafted for evaluation and modification by the Delphi participants. The result was 42 patient characteristics, categorised by adverse event risk: a. renal (six), b. cardiovascular (11), c. gastrointestinal (ten) and d. miscellaneous (15) (Table I).

The Delphi processes

Two electronically conducted Delphi rounds using Excel spreadsheets and a third and final virtual round to discuss patient characteristics that had not reached consensus, were planned 'a priori'.

First and second Delphi rounds

In the first two rounds, the Delphi panel members documented their level of agreement with three statements concerning perioperative pain management in adult orthopaedic patients, taking each of the 42 patient characteristics into account. Statement 1: A short course of non-selective NSAIDs can be administered with acceptable risk. Statement 2: A short course of selective COX-2 inhibitors is superior to a short course of non-selective NSAIDs AND can be administered with acceptable risk. Statement 3: Adding proton pump inhibitors (PPIs) to a short course of non-selective NSAIDs improves safety of non-selective NSAID administration AND can be administered with acceptable risk. A nine-point Likert scale was used to assess the level of agreement with each statement, where a Likert score of 1 represented the least level of agreement and a score of 9 represented the highest level of agreement (Appendix 1* - available online only). Scores 1-3 were categorised as 'disagree', 4-6 as 'undecided' and 7-9 as 'agree' with the statement.

After each round, participants anonymously received their individual, total group and inter-specialist group scores for each patient characteristic presented as median and interquartile range (IQR). They re-evaluated the previous round's scoring, taking into consideration the group scores. If their score differed greatly from that of the group, they were asked to provide comments or references supporting their decision, which were also shared anonymously.

After the second round, the Delphi panel's responses were assessed for agreement. Consensus was achieved if at least 75% of participants 'disagreed' (1-3) or 'agreed' (7-9) with a statement.³¹ For a given patient characteristic, consensus reached in support (Likert scores 7-9) of either COX-2 selective inhibitors (statement 2) or non-selective NSAIDs combined with PPIs (statement 3) would trump a treatment regimen with non-selective NSAIDs only (statement 1). Conversely, if the votes did not reach consensus in statements 2 or 3, consensus reached for statement 1 would prevail. Patient characteristics that achieved consensus were excluded from round 3 unless comments indicated that the overall group score was not supported by expert opinion or relevant literature. In such cases, the disputed characteristics were included in round 3 for further consideration.

Third Delphi round

We had originally planned to run the final third round as a virtual, non-anonymous meeting to discuss patient characteristics that did not reach consensus after the second Delphi round. However, due to a high number of 'undecided' Likert scores and panel members' appeal for subspecialty information and guidance to improve the quality of their voting, we decided to provide additional evidence and expert recommendation. Thus, UP consulted seven internal and ten external experts in fields such as haematology, psychiatry, clinical pharmacology, nephrology, neurology, allergology & immunology, gastroenterology, hepatology and anaesthesia to obtain specialised knowledge on NSAID safety for each remaining patient characteristic. This resulted in a rapid literature review, adjustments in wording (e.g. changing 'aspirin/ NSAID-induced asthma or allergic reactions' to 'aspirin/NSAID-exacerbated respiratory disease'), and simplification of the format to involve only one statement per remaining characteristic. Thus, in round 3, the Delphi panel received subspeciality expert recommendations linked with relevant articles for the remaining patient characteristics (Appendix 2.1-2.4*) along with round 2 scores (median and IQR) and panel members' comments, which were distributed electronically in an anonymous questionnaire. Consensus was achieved if at least 75% of participants agreed with the recommendation.

Recognising that NSAID adverse events are linked to the type and dose, we specified tablet ibuprofen < 1 200 mg/day as the preferred non-selective NSAID, as it offers an effective analgesic dose range within the lower end of cardiovascular (CVS) thrombotic risk estimates.^32,33 When combined with a PPI, this regimen provides a level of gastrointestinal protection in patients with moderate risk of gastrointestinal toxicity (one to two risk factors) comparable to that of selective COX-2 inhibitors.^34,35 Moreover, ibuprofen is included in South Africa's Essential Medicines List and is available in state hospitals. For patients unable to take oral medications, for example during surgery, suppository indomethacin or intravenous parecoxib were considered.

Panel members who failed to return their answers on time were offered one email as a reminder. UP and BMB were neutral in the scoring process throughout the study.

A fourth virtual round was not needed as consensus was achieved for all 42 patient characteristics by the end of the third round.

Our work classifies as a modified rather than a classic Delphi study, as we started with a predetermined set of patient characteristics and statements rather than an open-ended first round. This preparatory work provided a comprehensive and clinically relevant starting point for the Delphi group. Furthermore, the direct interaction with subject experts within and external to the Delphi group in preparation for round 3, and development of expert recommendations, nullifies the principle of complete anonymity and thus categorises the study as a modified Delphi. Figure 1 illustrates the Delphi process.

 

 

Results

The Delphi study

Participants and response rate

All 18 panel members participated in the first and third Delphi rounds, while one anaesthetist and one physician did not partake in the second round.

Delphi rounds 1 and 2

The first Delphi round questionnaire was sent to the panel on 11 November 2022, and responses were returned nine days later. The second Delphi round was distributed on 24 November and completed by 4 December. In the first round, consensus was reached for 12 patient characteristics, with nine in favour and three against the use of NSAIDs ± PPIs. As per protocol, all moved on to the second Delphi round, which saw 24 patient comorbidities reaching consensus (20 in favour and four against the use of NSAIDs ± PPIs) (Table I and Appendices 3-6*).

In the renal category, the Delphi panel did not support using selective COX-2 inhibitors or non-selective NSAIDs combined with PPIs over non-selective NSAIDs in either of the first two Delphi rounds. Three patient characteristics reached consensus with respect to safe administration of non-selective NSAIDs after round 2. This result was unchanged from round 1.

In the cardiovascular category, the panel did not support using selective COX-2 inhibitors or non-selective NSAIDs plus PPIs to lower the risk for CVS adverse events during perioperative treatment with NSAIDs. Rather, consensus regarding a short course of non-selective NSAIDs was achieved for four patient characteristics in round 2, which was a change from round 1, where only one achieved consensus.

Nine out of ten patient characteristics reached consensus in the second round in the gastrointestinal category, which was a marked increase from three in round 1. The Delphi group favoured a gastro-protective profile with selective COX-2 inhibitors or non-selective NSAIDs with PPIs in eight characteristics, while one patient group, patients on concomitant treatment with selective serotonin reuptake inhibitors (SSRIs), reached consensus in support of non-selective NSAIDs only.

The miscellaneous category included patient characteristics with various comorbidities. For patients with aspirin/NSAID-induced asthma or allergic reactions, the Delphi group reached consensus against the use of non-selective NSAIDs in both rounds, with undecided views on selective COX-2 inhibitors. For the other 14 characteristics, the panel generally voted against both selective COX-2 inhibitors and non-selective NSAIDs + PPIs, favouring non-selective NSAIDs. In total, consensus was achieved in Ave characteristics in round 1 and eight in round 2.

Thus, 24/42 patient comorbidities reached consensus after the second round. In preparation for the third round, UP, in discussion with appointed Delphi panel members, suggested three patient characteristics with consensus after round 2 be further evaluated by subspeciality experts due to concerns raised by participants. Thus, patients with a history of a. gastrointestinal bleeding/ perforation, b. concomitant use of SSRIs, and c. aspirin/NSAID-induced asthma or allergic reactions were reconsidered, leaving 21 patient characteristics to proceed to the third Delphi round. Table II depicts round 2 results. Finally, patients older than 75 years were reclassified to the gastrointestinal adverse events' category, as epidemiological studies suggest that ageing is an independent risk factor for NSAID-related gastrointestinal toxicity.³⁶

Third Delphi round

The third round, conducted in May/June 2023, achieved consensus on all remaining characteristics (see Table III). Expert recommendations received unanimous support (100%) for 15 characteristics and 94% support for six.

Development of the NSAID decision tool

The study outcomes were synthesised into a practical NSAID decision tool (Figure 2) and approved as Standard Operating Procedure at GSH and orthopaedic departments in the Western Cape, October 2023 (Appendix 7*). The tool organises recommendations into Ave sections: renal, cardiovascular and central nervous system (CVS and CNS, respectively), gastrointestinal, miscellaneous, and respiratory, highlighting areas where NSAID use poses risk.

To improve compliance with NSAID administration, a specific ibuprofen dosing schedule was recommended, aligning with dosing of other around-the-clock analgesics. Adjustments made to the decision tool included clarifying kidney hypoperfusion risks across all perioperative stages, moving diabetes to the CVS/CNS category, and advising staggered ibuprofen dosing in patients on low-dose aspirin for CVS prevention, as ibuprofen may reduce the irreversible antiplatelet effect of aspirin by interfering with aspirin acetylation of the COX-1 binding site on platelets.³⁷ For patients experiencing prolonged fasting periods, NSAIDs were recommended alongside a daily PPI dose to help minimise gastrointestinal risks. As a result, this group of patients was categorised under gastrointestinal adverse events.

 

Discussion

This study reports a consensus on short-term NSAID administration in adult orthopaedic patients with various comorbidities, and aims to guide clinicians in the safe use of NSAIDs as part of a perioperative pain management regimen through the development of our NSAID decision-tool.

NSAIDs are key to multimodal, opioid-sparing perioperative pain management; however, their association with severe adverse events (SAEs) remains uncertain.¹⁹ As highlighted in a recent systematic review of patients undergoing gastrointestinal procedures, 'high-quality randomised clinical trials with low risk of bias, adequate power to assess safety, and long-term follow-up' are essential to fully understand the impact of short-term NSAIDs on SAEs in this population.¹⁸ A similar study is underway in orthopaedic surgery.¹⁷ This evidence gap explains the lack of unified guidelines for perioperative NSAID administration across specialties such as nephrology, cardiology, neurology, gastroenterology, and their surgical counterparts - a gap that our study seeks to address.

Assessing the safe administration of NSAIDs is particularly challenging in patients with multiple comorbidities. Our NSAID decision tool did not account for clusters of comorbidities; instead, consensus was reached based on individual patient characteristics. This highlights the need for careful clinical judgement when managing such patients. Additionally, ibuprofen was the preferred NSAID in our decision tool due to its balance of analgesic efficacy, safety profile, and affordability within our resource-limited setting. It is important to note, however, that the risk profiles of non-selective NSAIDs may differ, and healthcare providers should remain cognisant of these variations when making treatment decisions.

Encouragingly, a recently published guidance on safe use of NSAIDs in the postoperative period in patients with various comorbidities, broadly aligns with the findings of the Delphi group.³⁸ Exceptions include their recommendations against the use of NSAIDs ± PPI in patients with a history of heart failure, inflammatory bowel disease, gastrointestinal ulceration and uncontrolled hypertension (see Appendix 2.2-2.4* for our detailed commentary). Notably, the guidance uses 65 years, rather than 75 years as in our study, as the threshold for initiating PPI co-prescription with non-selective NSAIDs. It also emphasises the importance of individualised risk-benefit analyses when prescribing NSAIDs, advocating for the lowest effective dose (e.g. ibuprofen 1.2 g/day ± PPI) for the shortest duration necessary to mitigate NSAID-related adverse events, particularly in patients over 75 years of age.

Methodological strengths include establishing a multidisciplinary Delphi panel. While a Delphi panel is expected to consist of members with expert knowledge of the subject at hand,³¹ identifying experts with deep clinical and/or pharmacological knowledge concerning perioperative administration of NSAIDs in patients with various comorbidities was not deemed feasible. Instead, a heterogeneous panel allowed critical appraisal from experienced orthopaedic surgeons, anaesthetists and physicians. To minimise bias from knowledge gaps, the panel could vote 'undecided' (4-6 on a nine-point Likert scale), and if any vote appeared unsafe, panellists could request reconsideration. Thus, safety-directed expert opinion would supersede consensus. Furthermore, the panel was encouraged to modify the preliminary list of patient characteristics to ensure that clinically relevant cases were considered, including high-risk fracture scenarios suggested by orthopaedic surgeons. Lastly, participation remained high in all three rounds, keeping attrition bias low.

Limitations include potential investigator selection bias as the researcher directly contacted the six participating anaesthetists to ensure equal inter-speciality representation; however, they all possess expertise in orthopaedic anaesthesia and thus represent the population of interest. Second, to encourage independent appraisals, a pre-emptive literature review was deferred. By round 2, the need for expert input prompted a targeted rapid review with internal and external specialists. While consensus achieved remained consistent with the evidence base, a literature review before starting the Delphi process would have allowed the panel to identify the questions that have clear data supporting certain clinical situations, thus limiting the number of scenarios being presented. For example, selective COX-2 inhibitors and non-selective NSAIDs + PPI confer a similar level of gastrointestinal protection in patients with moderate risk of gastrointestinal toxicity,³⁴ and reduce neither the risk of CVS adverse events^32,33 nor renal toxicity,³⁹ compared to non-selective NSAIDs only. Furthermore, this approach would have allowed the questions to be presented to all participants in the same form as they were in the final round. Third, the Delphi panel and all but one of the external subspecialty experts were affiliated with our institution. Despite professionalism and clinical work experience gained elsewhere, we encourage our fellow colleagues to undertake a larger scale study in South or Southern Africa to test the external validity of the NSAID tool. Fourth, with the paucity of data regarding the risk of short-term NSAID use, recommendations are based on clinical experience and extrapolation of data by experts mainly from published literature on adverse effects with long-term use. We await high-quality, well-designed studies that can inform us of SAEs associated with perioperative NSAID treatment in patients with single and multiple comorbidities.

 

Conclusion

In conclusion, our multidisciplinary Delphi group achieved consensus on safe short-term NSAID treatment in 42 patient characteristics in adult orthopaedic patients. The results were translated into an NSAID decision tool intended to aid clinicians in safe prescribing of NSAIDs as part of a multimodal analgesic strategy to improve postoperative pain control and hence quality of recovery.

Acknowledgements

We extend our sincere gratitude to A/Professor Erica Jones, Dr Kathleen Bateman, Professor Marius Coetzee, Professor Marc Blockman, Professor Jackie Hoare, Professor Jonny Peters, Professor Gillian Watermeyer, Dr Dee Batty, Professor Mark Sonderup and Professor Peter Meissner for their invaluable contributions to this study.

Ethics statement

The authors declare that this submission is in accordance with the principles laid down by the Responsible Research Publication Position Statements as developed at the 2nd World Conference on Research Integrity in Singapore, 2010. Prior to the commencement of the study ethical approval was obtained from the following ethical review board: University of Cape Town, Faculty of Health Sciences, Human Research Ethics Committee, HREC ref: 715/2022.

All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

The Delphi panel members all consented to participate in the study.

Declaration

The authors declare authorship of this article and that they have followed sound scientific research practice. This research is original and does not transgress plagiarism policies.

Author contributions

UP: contributed to study conceptualisation and design; data analysis and interpretation; drafting of the manuscript; critical revision for important intellectual content; final approval of the version to be published; and agrees to be accountable for all aspects of the work

ML: contributed to study conceptualisation and data acquisition; drafting the work for the third Delpi round and revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

MBN: involved in data collection; critically revised the manuscript for intellectual content; approved the final version; and accepts full responsibility for the integrity of the work

SM: contributed to data acquisition; reviewed the manuscript for important intellectual contributions; approved the final draft for submission; and agrees to be accountable for all aspects of the work

TH: contributed to data acquisition; revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

RD: contributed to data acquisition; revised the manuscript critically; approved the final version; and is accountable for the entire content of the work

SJLR: contributed to data acquisition; revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

MBN: contributed to the study's conceptualisation and design; participated in data acquisition; critically revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

AdV: contributed to data acquisition; revised the manuscript for imortant intellectual content; approved the final manuscript; and accepts responsibility for the integrity of the work

SE: contributed to data acquisition; revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

EC: contributed to data acquisition; revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

OSP: contributed to data acquisition; revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

LFMP: contributed to data acquisition; revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

VJL: contributed to study conceptualisation and design; data acquisition and interpretation; drafting the work for the third Delphi round and revised the manuscript for important intellectual content; approved the final version for publication; and agrees to be accountable for all aspects of the work

BH: contributed to data acquisition; drafting the work for the third Delphi round and revised the manuscript for important intellectual content; approved the final manuscript; and agrees to be accountable for all aspects of the work

MS: contributed to data acquisition; drafting the work for the third Delphi round and revised the manuscript for important intellectual content; approved the final manuscript; and agrees to be accountable for all aspects of the work

PJR: contributed to data acquisition; drafting the work for the third Delphi round and revised the manuscript for important intellectual content; approved the final manuscript; and agrees to be accountable for all aspects of the work

NW: contributed to data acquisition; drafting the work for the third Delphi round and revised the manuscript for important intellectual content; approved the final manuscript; and agrees to be accountable for all aspects of the work

AC: contributed to data acquisition; drafting the work for the third Delphi round and revised the manuscript for important intellectual content; approved the final manuscript; and agrees to be accountable for all aspects of the work

RP: contributed to study conceptualisation and design; interpretation of data; critical revision for important intellectual content; final approval of the version to be published; and agrees to be accountable for all aspects of the work

BMB: contributed to study conceptualisation and design; interpretation of data; critical revision for important intellectual content; final approval of the version to be published; and agrees to be accountable for all aspects of the work

ORCID

Plenge U https://orcid.org/0000-0003-3712-2469

Laubscher M https://orcid.org/0000-0002-5989-8383

Nortje MB https://orcid.org/0000-0002-7737-409X

Maqungo S https://orcid.org/0000-0002-8735-8341

Hilton T https://orcid.org/0000-0002-6178-5062

Dunn R https://orcid.org/0000-0002-3689-0346

Roche SJL https://orcid.org/0000-0002-5695-2751

Nejthardt MB https://orcid.org/0000-0002-8997-7242

Coetzee E https://orcid.org/0000-0002-2443-962X

Porrill OS https://orcid.org/0000-0003-0481-3941

Louw VJ https://orcid.org/0000-0002-2885-3342

Hodkinson B https://orcid.org/0000-0001-5360-9483

Setshedi M https://orcid.org/0000-0002-7979-2981

Raubenheimer PJ https://orcid.org/0000-0002-5416-1286

Wearne N https://orcid.org/0000-0001-9917-223X

Chin A https://orcid.org/0000-0001-6930-3673

Parker R https://orcid.org/0000-0003-4823-2487

Biccard BM https://orcid.org/0000-0001-5872-8369

 

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Received: December 2024
Accepted: March 2025
Published: August 2025

 

 

* Corresponding author: ullaplenge@gmail.com
* Please note that the appendices are available online.
Editor: Dr Luan Nieuwoudt, University of KwaZulu-Natal, Durban, South Africa
Funding: No funding was received for this study.
Conflict of interest: The authors declare they have no conflicts of interest that are directly or indirectly related to the research.