To the Editor:—

We read with interest the excellent review article of randomized, controlled trials involving the effects of nonsteroidal antiinflammatory drugs (NSAIDs) on bleeding after tonsillectomy. 1Although the results of this meta-analysis suggest “that the use of NSAID therapy after tonsillectomy should be abandoned both at the hospital and at home,”1we must remind the readers that the perioperative use of cyclooxygenase (COX)-2 selective NSAIDs may offer a safer alternative in the management of posttonsillectomy pain. Previous data have suggested that celecoxib, 2rofecoxib, 3and valdecoxib 4have analgesic effects similar to conventional NSAIDs when used for acute pain. Further, because platelets express only COX-1 and are incapable of expressing COX-2, 5selective COX-2 inhibitors do not inhibit platelet function. We have found that the preoperative administration of rofecoxib possesses a more favorable pharmacokinetic profile than the other COX-2 selective NSAIDs in the management of pediatric tonsillectomy pain. Rofecoxib provides onset of clinical analgesia within 27 min 6and has an elimination half-life of 17.5 h; therefore, it can be administered once daily. 3Rofecoxib is available as a strawberry-flavored oral suspension (containing 12.5 mg or 25 mg of rofecoxib per 5-ml solution), which makes pediatric dose titration easy to accomplish.

We recently evaluated the analgesic efficacy and safety of administering rofecoxib (1 mg/kg) prior to pediatric tonsillectomy. 7This study revealed no significant increase in measured intraoperative surgical bleeding or in the likelihood of reoperation for bleeding. Furthermore, the preoperative administration of rofecoxib resulted in a significant decrease in postoperative pain and more than a threefold reduction in the incidence of postoperative nausea and vomiting. The reduction in postoperative nausea and vomiting may be attributable to either the improved analgesic efficacy of rofecoxib or to its centrally mediated action. It has been demonstrated in an animal model that activation of the medullary vomiting center involves prostaglandins, and the preemptive administration of COX inhibitors significantly decreased lipopolysaccharide-induced emesis. 8NSAIDs with significant penetration into the central nervous system may be advantageous in reducing postoperative nausea and vomiting. Previous studies in rats have revealed that 35% of rofecoxib plasma concentrations penetrated into the cerebrospinal fluid 9; this relative penetration into the central nervous system was independent of dose (≤ 150 mg/day). 10 

Therefore, we believe the perioperative administration of rofecoxib, a selective COX-2 inhibitor, may offer significant advantageous over conventional NSAIDs in the management of tonsillectomy pain.

References

1.
Marret E, Flahault A, Samama C-M, Bonnet F: Effects of postoperative, nonsteroidal, anti-inflammatory drugs on bleeding risk after tonsillectomy: Meta-analysis of randomized, controlled trials. A nesthesiology 2003; 98: 1497–502
2.
Clemett D, Goa KL: Celecoxib: A review of its use in osteoarthritis, rheumatoid arthritis and acute pain. Drugs 2000; 59: 957–80
3.
Barden J, Edwards JE, McQuay HJ, Moore RA: Single-dose rofecoxib for acute postoperative pain in adults: A quantitative systematic review. BMC Anesthesiology 2002; 2: 4
4.
Ormrod D, Wellington K, Wagstaff AJ: Valdecoxib. Drugs 2002; 62: 2059–71
5.
Meade EA, Smith WL, DeWitt DL: Differential inhibition of prostaglandin endoperoxide synthase (cyclooxygenase) isozymes by aspirin and other nonsteroidal antiinflammatory drugs. J Biol Chem 1993; 268: 6610–14
6.
Chang DJ, Fricke JR, Bird SR, Bohidar NR, Dobbins TW, Geba GP: Rofecoxib versus codeine/acetaminophen in postoperative dental pain: A double-blind, randomized, placebo- and active comparator-controlled clinical trial. Clin Ther 2001; 23: 1446–55
7.
Joshi W, Connelly NR, Reuben SS, Wolkenhaar M, Thakkar N: Evaluation and safety of administering rofecoxib for postoperative pain management. Anesth Analg 2003; 97: 35–8
8.
Girod V, Dapzol J, Bouvier M, Grelot L: The COX inhibitors indomethacin and meloxicam exhibit anti-emetic activity against cisplatin-induced emesis in piglets. Neuropharmacology 2002; 42: 428–36
9.
Buvanendran A, Luk P, Kroin JS, Rodger IW, McCarthy RJ: Central nervous system penetration of rofecoxib, a selective COX-2 inhibitor, in rats (abstract). Anesthesiology 2001; 95: A-868
10.
Buvanendran A, Kroin JS, Luk P, Rodger IW, McCarthy RJ: Blood-brain barrier penetration of oral rofecoxib, a selective COX-2 inhibitor in dogs (abstact). Anesthesiology 2002; 96: A-465