Expert Consensus on the Application of Nonsteroidal Anti‑Inflammatory Drugs for Perioperative Analgesia in Chinese Adults (2026)

Journal of Anesthesia and Medicine, 2026; DOI: 10.1016/j.jatmed.2026.07.004 Task‑Force: Expert‑Consensus‑Working‑Group‑on‑Peri‑operative‑NSAIDs‑Analgesia, Chinese‑Society‑of‑Anesthesiology Corresponding‑authors: Xiang‑Dong Chen, Jian‑Jun Yang《中华医学...

Abstract

Nonsteroidal anti‑inflammatory drugs (NSAIDs) exert analgesic and anti‑inflammatory effects via cyclooxygenase (COX) inhibition. As key components of opioid‑sparing multimodal analgesia within Enhanced Recovery After Surgery (ERAS), NSAIDs mitigate surgical stress and reduce opioid‑related adverse events. This 2026‑updated Chinese‑expert‑consensus delivers evidence‑based recommendations for adult‑surgical‑patients covering patient‑selection, timing‑of‑administration, drug‑selection, dosage‑regimens, risk‑reduction‑strategies, special‑population‑management and drug‑drug‑interactions. Its goal is to standardize safe, rational and effective real‑world peri‑operative NSAID practice in China.

Key‑words: perioperative‑period; analgesia; nonsteroidal‑anti‑inflammatory‑drugs; multimodal‑analgesia; enhanced‑recovery‑after‑surgery

1. Introduction

Multimodal opioid‑sparing analgesia is the core‑pain‑management‑strategy for modern‑surgery. NSAIDs (including non‑selective‑NSAIDs and COX‑2‑selective‑inhibitors) provide reliable analgesia for moderate‑to‑severe‑surgical‑pain, lower‑opioid‑consumption and decrease opioid‑associated nausea‑vomiting, sedation and respiratory‑depression. Nevertheless, gastrointestinal‑mucosal‑injury, renal‑impairment, cardiovascular‑thrombotic‑events, bleeding‑risk and drug‑interaction‑hazards limit unsafe‑over‑use. This‑consensus‑summarizes‑domestic‑and‑international‑evidence‑and‑provides‑12‑structured‑clinical‑statements‑for‑peri‑operative‑NSAID‑application.

2. General‑principles

1. NSAIDs are recommended as part of multimodal‑analgesia unless clear‑contraindications‑exist.
2. Administer at the lowest‑effective‑dose; respect the analgesic‑ceiling‑effect; do‑not‑surpass‑approved‑maximum‑daily‑doses.
3. Avoid simultaneous‑combination‑of‑two‑or‑more‑systemic‑NSAIDs.
4. Combine‑risk‑stratification‑before‑prescription: evaluate gastrointestinal‑risk, renal‑function, cardiovascular‑comorbidities, bleeding‑risk, age‑and‑concurrent‑medications.
5. Integrate‑NSAIDs‑with‑regional‑nerve‑block,‑acetaminophen‑and‑other‑non‑opioid‑modalities‑to‑optimize‑pain‑relief.

3. Twelve‑core‑consensus‑statements (2026‑update)

Statement 1 (Strong‑recommendation) For‑adult‑surgical‑patients‑without‑contraindications,‑systemic‑NSAIDs‑should‑be‑considered‑within‑multimodal‑peri‑operative‑analgesia‑protocols‑to‑reduce‑opioid‑exposure.

Statement 2 (Conditional‑recommendation) Pre‑operative‑pre‑emptive‑NSAID‑administration‑may‑be‑considered‑for‑moderate‑and‑major‑surgery‑when‑gastrointestinal,‑renal‑and‑cardiovascular‑risks‑are‑low.‑Avoid‑high‑dose‑pre‑incision‑bolus‑regimens‑in‑high‑risk‑populations.

Statement 3 (Strong‑recommendation) Non‑selective‑NSAIDs‑and‑COX‑2‑selective‑inhibitors‑must‑be‑prescribed‑at‑licensed‑maximum‑daily‑doses;‑analgesic‑ceiling‑effect‑for‑NSAIDs‑forbids‑unlimited‑dose‑increase‑to‑achieve‑better‑pain‑control.‑Do‑not‑combine‑multiple‑systemic‑NSAIDs.

Statement 4 (Conditional‑recommendation) Parenteral‑NSAIDs‑(e.g.‑parecoxib,‑flurbiprofen‑axetil)‑are‑preferred‑in‑patients‑with‑post‑operative‑ileus,‑dysphagia‑or‑impaired‑oral‑intake;‑switch‑to‑oral‑formulations‑as‑soon‑as‑oral‑tolerance‑is‑restored.

Statement 5 (Conditional‑recommendation) For‑patients‑at‑high‑gastrointestinal‑risk‑(history‑of‑peptic‑ulcer‑disease,‑upper‑GI‑bleeding),‑COX‑2‑selective‑inhibitors‑are‑preferred.‑Proton‑pump‑inhibitor‑(PPI)‑co‑prophylaxis‑is‑advised‑for‑patients‑receiving‑non‑selective‑NSAIDs.

Statement 6 (Strong‑recommendation) Discontinue‑or‑avoid‑NSAIDs‑in‑patients‑with‑acute‑kidney‑injury‑or‑pre‑existing‑significant‑renal‑impairment.‑Monitor‑serum‑creatinine‑and‑urine‑output‑closely‑in‑elderly,‑hypovolemic‑and‑septic‑patients‑receiving‑NSAIDs.

Statement 7 (Conditional‑recommendation) Short‑term‑peri‑operative‑COX‑2‑selective‑inhibitors‑can‑be‑used‑in‑patients‑with‑stable‑cardiovascular‑disease‑after‑risk‑benefit‑assessment.‑Avoid‑prolonged‑continuous‑use‑beyond‑7‑days‑in‑patients‑with‑established‑atherosclerotic‑cardio‑cerebrovascular‑disease.

Statement 8 (Conditional‑recommendation) Topical‑NSAIDs‑are‑valid‑adjuvant‑alternatives‑for‑superficial‑surgical‑site‑pain;‑they‑carry‑lower‑systemic‑organ‑toxicity‑compared‑with‑systemic‑preparations.

Statement 9 (Conditional‑recommendation) In‑geriatric‑patients‑(≥65‑years‑old),‑start‑NSAIDs‑at‑reduced‑initial‑doses‑and‑shorten‑treatment‑duration;‑prioritize‑COX‑2‑selective‑agents‑if‑gastro‑intestinal‑risk‑is‑elevated.‑Closely‑monitor‑renal‑and‑fluid‑status.

Statement 10 (Conditional‑recommendation) For‑obstetric‑and‑gynecologic‑peri‑operative‑pain‑control,‑short‑course‑NSAIDs‑are‑effective‑for‑post‑caesarean‑section‑pain‑provided‑renal‑and‑platelet‑function‑are‑normal.‑Avoid‑NSAIDs‑late‑in‑pregnancy.

Statement 11 (Strong‑recommendation) Avoid‑extended‑NSAID‑therapy‑(>7‑consecutive‑days)‑in‑patients‑with‑atherosclerotic‑thrombotic‑disease‑(prior‑myocardial‑infarction,‑ischemic‑stroke,‑peripheral‑artery‑disease)《中华医学....

Statement 12 (Strong‑recommendation) Do‑not‑combine‑non‑selective‑NSAIDs‑with‑therapeutic‑dose‑anticoagulants‑for‑peri‑operative‑analgesia‑unless‑no‑alternative‑analgesic‑options‑are‑available‑and‑bleeding‑risk‑is‑fully‑acknowledged‑by‑clinicians‑and‑patients《中华医学....

4. Contraindications

Absolute‑contraindications

1. Confirmed‑hypersensitivity‑to‑NSAIDs‑or‑COX‑2‑inhibitors‑(including‑aspirin‑exacerbated‑respiratory‑disease‑syndrome).
2. Active‑gastro‑duodenal‑ulcer‑or‑acute‑upper‑gastro‑intestinal‑bleeding.
3. Severe‑uncompensated‑renal‑failure.
4. Severe‑heart‑failure‑NYHA‑IV.
5. Third‑trimester‑pregnancy.

Relative‑contraindications (risk‑benefit‑decision‑required)

Elderly‑>80‑years‑old,‑hypovolemia/shock,‑hepatic‑dysfunction,‑coagulopathy,‑ongoing‑high‑dose‑anticoagulation‑therapy,‑history‑of‑myocardial‑infarction‑or‑ischemic‑stroke.

5. Clinical‑monitoring‑and‑safety‑management

1. Baseline‑evaluation:‑medical‑history‑of‑GI‑ulcer,‑cardio‑cerebro‑vascular‑events,‑renal‑function‑and‑medication‑list.
2. Monitor‑pain‑scores‑(NRS‑VAS‑score),‑vital‑signs,‑urine‑output.‑Watch‑for‑epigastric‑pain,‑melena,‑hematemesis‑(GI‑injury‑signals).
3. Check‑renal‑biochemistry‑for‑high‑risk‑patients‑after‑2‑3‑days‑of‑continuous‑NSAID‑treatment.
4. Discontinue‑NSAIDs‑promptly‑when‑adverse‑events‑occur.‑Switch‑to‑alternative‑analgesic‑modalities.

6. Special‑populations

Elderly‑patients

Use‑low‑starting‑dose,‑short‑treatment‑course.‑Prioritize‑COX‑2‑selective‑inhibitors‑if‑GI‑risk‑is‑high;‑avoid‑long‑continuous‑infusion‑regimens.

Peri‑operative‑anticoagulated‑patients

Non‑selective‑NSAIDs‑increase‑bleeding‑risk‑when‑combined‑with‑therapeutic‑anticoagulation.‑If‑analgesia‑is‑mandatory,‑prefer‑COX‑2‑selective‑agents‑with‑short‑duration‑and‑close‑clinical‑surveillance.

Patients‑with‑hepatic‑impairment

Avoid‑NSAIDs‑in‑severe‑liver‑dysfunction‑with‑coagulopathy.‑For‑mild‑hepatic‑impairment,‑use‑reduced‑dose‑and‑short‑therapy‑duration.

7. Drug‑interactions

1. Anticoagulants/anti‑platelet‑agents:‑increased‑bleeding‑risk‑with‑non‑selective‑NSAIDs.
2. Diuretics,‑ACE‑I/ARB:‑NSAIDs‑may‑blunt‑diuretic‑and‑anti‑hypertensive‑effects‑and‑elevate‑AKI‑risk.
3. Corticosteroids:‑synergistic‑gastro‑mucosa‑damage‑risk‑increased.
4. Lithium:‑NSAIDs‑may‑reduce‑lithium‑renal‑clearance‑and‑provoke‑lithium‑toxicity.

8. Conclusion

When‑appropriately‑selected‑and‑monitored,‑NSAIDs‑represent‑valuable‑components‑of‑multimodal‑peri‑operative‑pain‑management‑in‑Chinese‑adult‑surgical‑patients.‑Rigorous‑pre‑treatment‑risk‑stratification,‑individualized‑dose‑selection‑and‑safety‑monitoring‑are‑essential‑to‑maximize‑analgesic‑benefits‑while‑minimizing‑organ‑toxicity‑and‑adverse‑events.

Disclaimer:‑This‑consensus‑provides‑evidence‑based‑clinical‑recommendations‑only.‑Final‑clinical‑decisions‑should‑be‑made‑by‑attending‑physicians‑based‑on‑individual‑patient‑conditions