Combination bupivacaine, meloxicam may reduce pain, opioid use after TKA
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KOLOA, Hawaii — Results showed use of Zynrelef as part of a multimodal analgesia protocol may significantly reduce pain and opioid use after total knee arthroplasty.
“Zynrelef [bupivacaine and meloxicam, Heron Therapeutics] is a new tool, if you will, to add to our analgesic tool kit and implement in our multimodal analgesic protocols for patients undergoing surgery where you would expect opioid medications to be utilized in the first 72 hours,” Kevin Warner, PharmD, of Covenant Healthcare, told Healio about results from a poster presented at Orthopedics Today Hawaii.
Warner and colleagues performed a retrospective chart review of data for 64 patients who were opioid naïve when they underwent TKA. Researchers noted all patients received a standardized, multimodal analgesia regimen that included acetaminophen, celecoxib and pregabalin, as well as either local infiltration of a joint cocktail or combination bupivacaine and meloxicam plus periarticular infiltration of ropivacaine. Researchers considered VAS pain scores and 24-hour morphine milligram equivalents as the primary outcomes, while secondary outcomes included the percentage of patients experiencing severe pain, percentage of opioid-free patients and length of stay.
“We saw about a 50% reduction overall in our VAS pain scores between the cocktail group and the Zynrelef group in favor of Zynrelef, which was statistically significant and clinically significant,” Warner said.
Warner also noted a more than 50% reduction in 24-hour morphine milligram equivalents among patients who received combination bupivacaine and meloxicam, with 45.5 morphine milligram equivalents for 24 hours in the joint cocktail group and 21.6 milligram morphine equivalents in the combination bupivacaine and meloxicam group. He added patients who received combination bupivacaine and meloxicam had a decreased length of stay by more than 24 hours, and 76% of patients did not experience severe pain vs. 45% of patients in the joint cocktail group.
“The only statistic that was not significant out of the primary and secondary outcomes was opioid-free patients,” Warner said. “There was an increase in opioid-free patients in our Zynrelef group, but we didn’t expect to have the majority of patients be opioid free, so that wasn’t necessarily surprising as far as statistical significance, although it was borderline at [P =] 0.053.”
According to Warner, combination bupivacaine and meloxicam may change the paradigm of discharge readiness in TKA by enhancing the same-day discharge model by providing patients with better pain control, reducing opioid consumption and related side effects, and possibly leading to better functional outcomes.
“I think [Zynrelef] is a game changer. It could be a paradigm shift of how we look at and what we expect from perioperative pain management in our patients,” Warner said.
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Warner K, et al. A retrospective review of a multi-modal analgesia protocol with bupivacaine and meloxicam (Zynrelef) local instillation vs. joint cocktail (ropivacaine/ketorolac/epinephrine/hydromorphone or morphine) local infiltration in primary total knee arthroplasty. Presented at: Orthopedics Today Hawaii; Jan. 8-12, 2023; Koloa, Hawaii.
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