Hospital Pharmacy - December 2017 - 723

733477
editorial2017

HPXXXX10.1177/0018578717733477Hospital Pharmacy

Letter to the Editor

In Reply to "Postoperative Pain
Management With Liposomal Bupivacaine
in Patients Undergoing Orthopedic Knee
and Hip Arthroplasty at a Community
Hospital"

Hospital Pharmacy
2017, Vol. 52(11) 723-724
© The Author(s) 2017
Reprints and permissions:
sagepub.com/journalsPermissions.nav
https://doi.org/10.1177/0018578717733477
DOI: 10.1177/0018578717733477
journals.sagepub.com/home/hpx

Brian Faley1, Lani Dvorak1, and Meghan Faley2
We read with great interest the article by Jacob and colleagues, "Postoperative Pain Management With Liposomal
Bupivacaine in Patients Undergoing Orthopedic Knee and
Hip Arthroplasty at a Community Hospital."1 Many of these
authors' findings are in direct conflict with a recently published multicenter, prospective, randomized, double-blind,
controlled trial.2 The disparity may be due to the injection
technique, volume utilized, or the absence of bupivacaine
HCl utilization in the study drug arm by the single surgeon in
this study.
In an article recently published by Mont and colleagues,2
liposomal bupivacaine (LB) combined with bupivacaine HCl
was compared with bupivacaine HCl alone. The admixture
utilized in the LB group consisted of 266-mg LB (20 mL),
bupivacaine HCl 0.5% (20 mL), and normal saline 80 mL.
This was compared with bupivacaine HCl 0.5% (20 mL) and
normal saline 100 mL. The 2 solutions were infiltrated following a very specific technique, consisting of 80 to 120
total needle sticks in specific locations.3 Results from this
16-center study showed a 77% reduction in opioid consumption (20.9-mg morphine equivalents [ME] vs 93.6-mg ME,
P = .0108) in the first 72 hours after surgery favoring LB.
Also noted was a reduction in cumulative pain scores (measured as area under the pain curve) from 12 to 48 hours
(P = .0381). A notable finding is that 10% of patients in the
LB arm remained opioid free at 72 hours postoperatively
compared with zero in the control arm.
In addition, the authors state that their results are similar
to that of other studies reported in the literature. While that
may be the case, all of the studies cited by Jacobs and colleagues are single-center studies. To our knowledge, other
than the work by Mont et al, there are no multicenter, prospective, randomized, double-blind, controlled trials published to date. The article by Mont et al provides a
reproducible protocol that should yield similar results if followed accordingly.
The authors state that LB provided no benefit in overall
pain management and utilize the average change in the
Numeric Rating Scale (NRS) as the basis for this claim.
However, in their knee population, the difference in average

NRS scores was 0.32, whereas the difference was 0.52 in the
total hip arthroplasty population. Both values are well below
the accepted, clinically meaningful difference of 2.4
Similarly, the difference in knee flexion of 4° on postoperative days 2 and 3 reported in this article does not meet what
is considered the clinically meaningful definition.5
We would argue that contrary to the conclusion Jacob and
colleagues present, the results of their retrospective study do
show an overall benefit in pain control for patients receiving
LB. In their study, patient pain scores were similar, while LB
patients utilized 40-mg ME less than patients in the control
group. In addition, LB patients had a reduction in nausea
complaints and displayed similar ambulation and knee flexion outcomes. Finally, a reduction in hospitalization by 1 day
as reported in this study also has the potential to reduce overall health care costs in this patient population.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Both Brian Faley and Lani Dvorak are employees of Pacira
Pharmaceuticals, Inc, and own stock in Pacira Pharmaceuticals, Inc.
Meghan Faley's husband is employed by and owns stock in Pacira
Pharmaceuticals, Inc.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References
1.

Jacob B, Peasah S, Shogbon A, Perlow E. Postoperative pain
management with liposomal bupivacaine in patients undergoing orthopedic knee and hip arthroplasty at a community hospital. Hosp Pharm. 2017;52(5):367-373.

Pacira Pharmaceuticals Inc, Parsippany-Troy Hills, NJ, USA
Robert Wood Johnson University Hospital, East Brunswick, NJ, USA

Corresponding Author:
Brian Faley, 5 Sylvan Way Parsippany, NJ 07054, USA.
Email: brian.faley@pacira.com

https://us.sagepub.com/en-us/journals-permissions http://journals.sagepub.com/home/hpx

Table of Contents for the Digital Edition of Hospital Pharmacy - December 2017