Celecoxib After Tonsillectomy

This is a randomized, double-blind, placebo-controlled trial. Subjects will take acetaminophen plus either celecoxib or placebo in regular scheduled doses, and will supplement as needed with standard of care analgesic therapy (oxycodone/acetaminophen).

Celecoxib is approved by the FDA for use in children ages 2 and older for treatment of juvenile rheumatoid arthritis (JRA). Celecoxib is on the Children's Hospital of Philadelphia (CHOP) formulary for use in (1) patients >= 2 years old for JRA, (2) patients >= 12 years old and >=40 kg who have increased risk for gastrointestinal (GI) adverse effects or bleeding concerns precluding use of traditional nonsteroidal anti-inflammatory drugs (NSAIDs), and (3) oncology patients with surface area >= 0.4 square meters for anti-angiogenesis. Celecoxib is approved by the FDA for use in adults for treatment of arthritic conditions, acute/ postoperative pain, and primary dysmenorrhea, and has been widely used since its introduction in 1998.

Setting/Participants:Subjects are healthy children aged 3 to 11 years who undergo tonsillectomy with or without adenoidectomy at any Children's Hospital of Philadelphia (CHOP) location. Subjects with coagulation disorders are excluded. Approximately 300 subjects will be enrolled, 150 in each treatment group.

Study Interventions and Measures: Subjects are provided celecoxib or placebo in scheduled doses every 12 hours for 5 days, then continue until they are pain-free, for a maximum of 10 days. Throughout the study, they are allowed to use oxycodone/acetaminophen as needed for additional pain control, following standard clinical care. Acetaminophen is used around the clock for the first 5 days in all subjects. For 14 days following surgery, subjects record pain levels on validated pain scale instruments, quantity of narcotic medication and acetaminophen required, and time to return to normal diet. All Emergency Department and hospital admissions during the 30 postoperative days are recorded, noting incidence of excess pain, dehydration, hemorrhage, and other complications.

Pain control efficacy is assessed by comparing groups for number of days in which narcotic medication was used, and total quantity of rescue pain medication consumed. Rates of hospital readmission and postoperative hemorrhage, and the need for operative control, are also compared between groups.

• Drug: Celecoxib
  Dosing will be 6mg/kg twice a day with a maximum dose of 300mg twice a day. All ages will be given the suspension (concentration 100mg/5mL) orally
  Other Name: Celebrex
• Other: Placebo
  Placebo will have the same appearance, taste and consistency as celecoxib. Placebo will consist of calcium carbonate powder suspended in the same syrup as celecoxib. Dose of elemental calcium is 3 mg/kg/day.
  Other Name: Calcium carbonate placebo
• Drug: Acetaminophen
  Acetaminophen syrup at a dose of 15mg/kg/dose will be given every 4 hours for the first 5 days after surgery. After that point, is given as needed.
• Drug: Oxycodone
  Oxycodone may be used every 4 hours post-operatively to treat breakthrough pain. The most commonly prescribed dose is 0.075mg/kg/dose (suspension) every 4 hours as needed.

• Experimental: Acetaminophen/Oxycodone + Celecoxib
  Subjects will take acetaminophen orally (dose 15mg/kg/dose) in scheduled doses every 4 hours for the first 5 days. Subjects will also take celecoxib orally (dose is 6mg/kg twice a day with a maximum dose of 300mg twice a day). The first dose of celecoxib will be given preoperatively, within 1 hour prior to entering the operating room. The second dose will be given at bedtime on the night of surgery and subsequent doses will be given 12 hours apart. Supplemental standard of care oxycodone may be used to control breakthrough pain.
  Interventions:

  • Drug: Celecoxib
  • Drug: Acetaminophen
  • Drug: Oxycodone
• Active Comparator: Acetaminophen/Oxycodone + Placebo
  Subjects will take acetaminophen orally (dose 15mg/kg/dose) in scheduled doses every 4 hours for the first 5 days. Subjects will also take the placebo orally twice a day. The first dose of placebo will be given preoperatively, within 1 hour prior to entering the operating room. The second dose will be given at bedtime on the night of surgery and subsequent doses will be given 12 hours apart. Supplemental standard of care oxycodone may be used to control breakthrough pain.
  Interventions:

  • Other: Placebo
  • Drug: Acetaminophen
  • Drug: Oxycodone

Inclusion Criteria:

1. Males and females age 3 to 11 years inclusive.
2. Scheduled to undergo tonsillectomy (with or without adenoidectomy).
3. Weight ?10 kg.
4. Girls ? 11 years of age must have a negative urine/serum pregnancy test on the day of surgery and must use an acceptable method of contraception, including abstinence, a barrier method (diaphragm or condom), Depo-Provera, or an oral contraceptive, for the duration of the study.
5. Parental/guardian permission (informed consent) and if appropriate, child assent.

Exclusion Criteria:

1. Prior adenotonsillar surgery.
2. Concomitant surgical procedure that adds more than mild additional pain. Note: ear tubes are always permissible.
3. Coagulation disorder, or any other hematologic disorder that affects clotting or results in anemia.
4. Moderate to severe asthma, defined as subjects who either (1) have daily symptoms requiring daily use of short-acting bronchodilators, or (2) had an exacerbation in the last 3 months requiring admission, emergency department (ED) visit, or systemic corticosteroid administration.
5. Any degree of aspirin-sensitive asthma, or any history of asthma exacerbation caused by NSAID use.
6. Severe obstructive sleep apnea, defined as an obstructive apnea-hypopnea index >30 per hour and/or lowest oxygen saturation below 80%
7. Significant chronic pulmonary disease, defined as subjects requiring oxygen therapy, ventilator support, or positive pressure therapy.
8. Significant cardiac disease, defined as any one of the following: cardiovascular disease, structural cardiac anomalies, prior cardiac surgery, or requirement for cardiac anesthesia.
9. Severely obese (weight or body mass index > 95th percentile for age) or underweight (weight <5th percentile for age).
10. History of hepatic or renal disease, or condition that impairs hepatic or renal function.
11. Juvenile rheumatoid arthritis (JRA).
12. History of GI bleeding, or chronic GI condition that would increase risk of bleeding, ulceration, or perforation
13. Hypertension.
14. Craniofacial syndromes.
15. Syndrome or neurologic condition that would hinder accurate assessment of postoperative pain.
16. Inability to feed orally or take oral pain medication.
17. Chronic pain disorders, or otherwise requiring pain medication more than once weekly.

18. Laboratory abnormalities on the preoperative complete blood count (CBC):

    • Hemoglobin < 9 gm/dL
    • Platelet count < 100,000/mm3
19. Any investigational drug use within 30 days prior to enrollment.
20. Pregnant or lactating females.
21. Parents/guardians or subjects who, in the opinion of the Investigator, may be non-compliant with study schedules or procedures.
22. Hypersensitivity or allergic reactions to celecoxib, aspirin, or other NSAIDs, including asthma flare ups
23. Allergy to sulfonamides or calcium carbonate.