Should OTC Painkillers Used After Tonsillectomy Instead of Standard of Care?October 24th, 2013
By Megan McNicol, Cedarville University PharmD Student
In the United States, a tonsillectomy is the second most common outpatient surgery for children younger than 15. Each year, an estimated 662,000 American children have a tonsillectomy.1 This procedure is performed when there are recurrent episodes of tonsillitis or bacterial infections causing tonsillitis that are not improving with the use of antibiotics. As a result, a procedure is often performed to remove the tonsils.2 While the surgery is usually successful, pain is a common side effect following a tonsillectomy and can lead to dehydration, difficulty swallowing and weight loss. For this reason, some sort of pain reliever is necessary to manage the symptoms. 1
The article, “After tonsillectomy, over-the-counter painkillers suffice” published by US News and Health discussed how researchers performed a study examining 25 children and adults after a tonsillectomy and the various painkillers used to accommodate post-operation pain. The study determined that ibuprofen managed the pain just as effectively as any prescription painkiller that has been used in the past. A common painkiller used was acetaminophen with codeine or acetaminophen with hydrocodone. Not only was ibuprofen proven just as effective in relieving pain as the prescription medications, but it also proved to be the safest alternative for children.1
Codeine is an opiate (narcotic) analgesic that changes the way the body senses pain by converting codeine into morphine in the body.3,4 As a result, many children experience side effects such as nausea, emesis, and constipation, especially if the child is a ‘CYP2D6 ultra-rapid codeine metabolizer’. In these patients, codeine is converted into morphine in the body at a faster rate than normal, resulting in high levels of morphine in the blood that can cause toxic effects such as breathing difficulties.4 An article published in the Journal of the American Academy of Physician Assistants reiterated the FDA’s recommendation to avoid using codeine in children after a tonsillectomy due to the risk of respiratory depression, a condition in which there fails to be full ventilation to the lungs.5 For this reason, I would agree with the article that if products containing codeine can be avoided, this would be a better treatment option, especially in children.
Another reason for this consensus is the proven effectiveness of ibuprofen. A study was done by the Department of Pediatrics at the University of California comparing the effectiveness of acetaminophen with codeine to ibuprofen for children ages 5-17. It was shown, when measuring pain levels from baseline of both medications, the ibuprofen group was favored because it was just as effective as acetaminophen with codeine without the health risks.6 Indiana University Medical Center also measured post operative pain using a validated pain scale for pediatric patients. It was determined that ibuprofen is at least as effective as acetaminophen with codeine for post-operative pain control in children.7
As mentioned above, there are many studies in support of the claim made by this US News and Health article. However, there are also limitations to the article and the claims that it makes. One limitation is that the article has yet to be published in a peer reviewed medical journal meaning that the quality of the article has not been assessed by an expert journal editor in the field.1 The benefit of a peer-reviewed article is that the reviewer will have checked for validity and rigor as well as made any additional suggestions to the study design.8 However, the study was presented in the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery in Vancouver, providing a peer review process until it is officially published in a medical review journal. In addition, the study also stated that, “An over the counter painkiller is as effective as prescription drugs in controlling pain after people have their tonsils removed”. However, in the following paragraphs, the study only examined the effects in twenty-five children and not in adults. This causes one to wonder if ibuprofen is just as effective for adults as well, or only in children. Thus, the results cannot be generalized to the adult population, and only a small sample size was tested creating some additional limitations in the research.1
Nonetheless, the use of ibuprofen is a valid treatment option in place of the standard treatment such as acetaminophen with codeine. This recommendation will affect the frequency and demand of ibuprofen as an over the counter medication.2 The effectiveness, safety, and limited side effects of ibuprofen make it a good treatment option for pain management following a tonsillectomy for those 6 months and older.6
As US News and Health states, it appears that an over the counter medication such as ibuprofen is just as effective as a prescription painkiller in children following tonsillectomy. Not only does it provide a cheaper and more convenient treatment option, but it is also a safer approach to treatment, especially in children.1 This leads one to wonder, would a similar treatment approach prove to be just as effective in adults?
- After tonsillectomy, over-the-counter painkillers suffice, study says. US News: Health Web site. http://health.usnews.com/health-news/news/articles/2013/10/03/after-tonsillectomy-over-the-counter-painkillers-suffice-study-says. Published October 3, 2013. Accessed October 10, 2013.
- Tonsillitis. Mayo Clinic Web site. http://www.mayoclinic.com/health/tonsillitis/DS00273/DSECTION=treatments%2Dand%2Ddrugs. Published August 4, 2012. Accessed October 10, 2013.
- Codeine. Medline Plus Web site. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682065.html. Published November 11, 2012. Accessed October 10, 2013.
- Restrictions on use of codeine for pain relief in children – CMDh endorses PRAC recommendation. Eurpoean Medicines Agency Web site. http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2013/06/news_detail_001829.jsp&mid=WC0b01ac058004d5c1. Published June 28, 2013. Accessed October 10, 2013.
- DeDea L, Bushardt R. PHARMACOLOGY CONSULT. Codeine and acetaminophen recommendations for children. JAAPA: Journal Of The American Academy Of Physician Assistants (Lippincott Williams & Wilkins) [serial online]. September 2013;26(9):11-12. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 10, 2013.
- Friday J, Kanegaye J, McCaslin I, Zheng A, Harley J. Ibuprofen provides analgesia equivalent to acetaminophen–codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial. Academic Emergency Medicine [serial online]. August 2009;16(8):711-716. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 10, 2013.
- St. Charles C. A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient . Science Direct. 1997;117(1):76-82.
- Evaluating information sources. Lloyd Sealy Library Web site. http://guides.lib.jjay.cuny.edu/content.php?pid=209679&sid=1746812. Published March 25, 2013. Accessed October 10, 2013.