A Trial Comparing Combination Therapy of Acetaminophen Plus Ibuprofen Versus Tylenol #3 for the Treatment of Pain After Outpatient Surgery

Condition(s) targeted: Laparoscopic Cholecystectomy; Inguinal Hernia; Abdominal Hernia; Umbilical Hernia

Intervention: Tylenol #3 (Drug); Combination Tylenol and Ibuprofen (Drug)

Phase: N/A

Status: Completed

Sponsored by: Capital District Health Authority, Canada

Official(s) and/or principal investigator(s):
Geoffrey A Porter, MD, FRCSC, Study Director, Affiliation: CDHA/Dalhousie University

Increasingly in general surgery, the investigators are conducting outpatient day surgery. Ambulatory surgery currently comprises 60 to 70% of surgeries performed in North America. These patients all require some form of analgesia which can be taken at home in the first few days after the surgery. The current standard at the investigators' centre and many others in the maritime provinces is to provide a prescription for oral acetaminophen plus codeine or oxycodone (Tylenol #3®, Percocet ®). Some patients may receive more potent opioids such as oral hydromorphone (Dilaudid®). Unfortunately, the most commonly prescribed medication (Tylenol #3®) is often poorly tolerated by patients, has several undesirable side effects, and may not provide effective pain relief. In the investigators' experience, non-steroidal anti-inflammatory drugs (NSAIDs) are uncommonly a routine addition to the home analgesic regimen.

Tylenol #3®, in the investigators' experience and opinion, is a poor post surgical pain medication. They hope to show that a combination of ibuprofen and acetaminophen is better for pain relief after these procedures. The combination of acetaminophen and ibuprofen would be a safe, cheap, and readily available regimen. Unfortunately, as the prescribing practices of surgeons are old habits, it will require a very convincing argument to get them to change their practices. A randomized controlled trial comparing these two regimens, the investigators hope, would be a powerful enough argument.

The hypothesis of this study, therefore, is that the pain control provided by a combination of acetaminophen plus ibuprofen (650 mg/400 mg four times per day) will be superior to Tylenol #3® (600 mg acetaminophen/60 mg codeine/15 mg caffeine four times per day).

This study will attempt to enroll 150 patients in total. Eligible patients will be identified by their attending surgeon and contacted by study personnel. Patients who enroll in the study will undergo their surgery in the usual manner. After the surgery, in the recovery room, once they are ready to go home, they will be randomized to receive combination A or B and be given a week's worth of pain medication. They will then go home and take this medication as directed. They will record their pain intensity and pain relief once per day using a diary provided in the study package. One week after their surgery, they will return to the hospital clinic and be seen by the study nurse. They will hand over the diary and any unused medication. They will also be asked several questions regarding their overall satisfaction, incidence of side effects, and how long until they were pain free.

The risks of participating in this study are minimal from the risks inherent to the procedures and medications the patients would receive within the standard of care. Ibuprofen is a commonly used NSAID which is widely available over the counter and has an established safety profile. The most common adverse effects of ibuprofen and other NSAIDs are gastrointestinal bleeding and ulceration. Other less common adverse effects include nephrotoxicity, hypersensitivity reactions, hepatic dysfunction (longterm use), and cognitive dysfunction. The investigators' patients will be selected to exclude those most at risk for these complications (see exclusion criteria). Acetaminophen has few side effects, with no adverse effects on platelet function and no evidence of gastric irritation.

Official title: A Randomized Controlled Trial Comparing Combination Therapy of Acetaminophen Plus Ibuprofen Versus Tylenol #3 for the Treatment of Pain After Outpatient Surgery

Study design: Treatment, Randomized, Double-Blind, Active Control, Parallel Assignment, Efficacy Study

Primary outcome:

Mean daily and final visual analog scale (VAS) scores

Mean daily and final Likert scores

Total pain relief

Sum of pain intensity differences

Cumulative weekly VAS scores

Secondary outcome:

Treatment failures

Amount of medication used

Days to stopping medication

Incidence of side effects

Compliance with regimen

Minimum age: 17 Years. Maximum age: 65 Years. Gender(s): Both.

Criteria:

Inclusion Criteria:

Patients may take part in this study if the answer is YES to all of these questions:

- Female or male between 17-65 years of age

- Going to have one of the following surgeries:

- umbilical hernia repair

- inguinal hernia repair

- small incisional or abdominal wall hernia repair

- laparoscopic cholecystectomy (gallbladder removed)

- Going home after their surgery the same day

- Have signed consent form.

Exclusion Criteria:

Patients have had or have:

- Been diagnosed with peptic ulcer disease or bleeding stomach ulcer in the recent past

and are not currently on a proton pump inhibitor (special antacid medication, eg. Losec®, Pantoloc®, Prevacid®, Nexium®).

- Suffered from asthma

- Allergies to codeine, non-steroidal anti-inflammatory drugs (Advil®, Ibuprofen),

aspirin, or acetaminophen

- Been taking other prescription pain medications prior to their surgery

- A history of chronic pain disorder

- Fibromyalgia (a chronic pain illness with symptoms of muscle aches, pain, stiffness,

general fatigue and sleep problems)

- Active kidney disease or failure

- Known liver disease

- Are females who are pregnant or nursing

- A problem with alcohol or drug abuse.

Dartmouth General Hospital, Dartmouth, Nova Scotia B2Y 4G8, Canada

Starting date: January 2005
Ending date: December 2005
Last updated: March 28, 2008