EXPERT ANALYSIS FROM THE ACMS ANNUAL MEETING
ORLANDO – An alternating schedule of ibuprofen and acetaminophen every 3 hours is an excellent method of managing postoperative pain associated with Mohs surgery, especially if the initial dose is taken at the start of the procedure.
By starting with ibuprofen, the regimen capitalizes on the drug’s anti-inflammatory component to reduce overall postoperative analgesic requirement, Dr. Bryan Carroll said at the annual meeting of the American College of Mohs Surgery.
Dr. Bryan Carroll
“This combination has even been shown to be superior to narcotics, both alone and in combination,” said Dr. Carroll, director of dermatologic surgery at Eastern Virginia Medical School, Norfolk. “This finding has been reinforced in the Mohs literature,” he added, citing a study that found the combination of acetaminophen and ibuprofen was more effective than acetaminophen alone or acetaminophen with codeine in controlling pain after Mohs surgery and reconstruction (Dermatol Surg. 2011 Jul;37[7]:1007-13).
Alternately layering the analgesics allows both to build to a maximum concentration in the blood without any nadirs where pain can get a foothold, an important concept in pain management, Dr. Carroll said.
And having two medications on board allows simultaneous targeting of different portions of the pain signaling pathway, he added. Ibuprofen works at the points of transduction and transmission, while acetaminophen works at the points of transmission and perception.
Dr. Carroll’s regimen starts at the time of surgery, when patients receive 400 mg ibuprofen. Three hours later, they receive 1 gram of acetaminophen; this dose should be adjusted for patients older than 60 years, who should not get more than 3 grams in 24 hours, and for those with liver failure, who should be limited to 2 grams over 24 hours.
This alternating dose is repeated every 3 hours. By the time of discharge, most patients have had at least two doses. This schedule is usually sufficient for patients at moderate to high risk of uncontrolled pain, who can then manage their discomfort with either drug the next day, he said.
Patients at higher risk of uncontrolled pain can use the regimen for the first day, and then titrate off according to their comfort. Some of these patients, however, may benefit from oxycodone, with the addition of laxative and an antiemetic, he noted.
The layering technique provides consistent postoperative pain relief that’s effective for most patients – even those who undergo substantial reconstruction, Dr. Carroll said in an interview. “This schedule is sufficient for all of our procedures, including larger reconstructions such as forehead flaps and cervicofacial rotation flaps. But additional interventions are indicated for patients with a high risk of uncontrolled pain. It’s the patient, not the procedure, which determines need for escalation.”
Teasing out those patients who may need more assertive pain management should be done in a preoperative assessment, Dr. Carroll said. A patient’s expectations of pain and history of chronic pain are some of the biggest factors in predicting a patient who will have uncontrolled pain.
“The experience of pain in Mohs surgery has limited studies,” he said. “Only a handful of investigations have looked at predictors that could help us plan. But of these, two things do stand out: a patient’s expectation of pain and a patient’s history of chronic pain.”
Surprisingly, he said, studies have determined that even a modestly elevated expectation of pain is enough to tip patients into a high-risk category. “If a patient predicted that his pain would be a 4 on a 1-10 scale, that was correlated with a lack of pain control during the operative experience. Maybe we’d expect this correlation if the expectation was an 8 or a 10, but a 4 was surprising. If a patient has even that amount of concern, I start thinking about additional interventions I can provide to maximize comfort.”
A patient’s past experience with pain is also a very large factor in how that person will experience postoperative pain. “Chronic pain does correlate with uncontrolled pain during surgery. I always ask about it. And this talk also helps drive your conversation about what you will be doing to keep them comfortable.”
That chat should include an explanation of how chronic and acute pain differ, Dr. Carroll said. “Chronic and acute pain involve different pathways and need different interventions. If the patient expresses fear, saying something like, ‘Tylenol is like water to me,’ believe him. It is like water for chronic pain. But you can also tell that patient that chronic pain is different from acute pain, and that acetaminophen will be a part of successfully managing it.”