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This review explains coagulation physiology in relation to NSAIDs and anticoagulants, evaluates surgical literature on limited-duration NSAID use in anticoagulated patients, identifies nonopioid pain alternatives, and pinpoints gaps requiring further research on nonopioid analgesia for this population.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/opioid-free-pain-management-strategies-for-patients-on-oral-anticoagulation-undergoing-soft-tissue-hand-surgery/456589/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/opioid-free-pain-management-strategies-for-patients-on-oral-anticoagulation-undergoing-soft-tissue-hand-surgery/456589.png","ImageObject",300,407,{"name":42,"@type":43},"anakgang17","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-09","2026-09-30",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Why is opioid-free multimodal analgesia emphasized after soft tissue hand surgery?","Question",{"text":63,"@type":64},"Opioid use is discouraged due to risks of dependence and adverse effects. Multimodal nonopioid regimens can provide comparable or superior pain relief by combining drugs with distinct mechanisms.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How do NSAIDs increase bleeding risk in anticoagulated patients?",{"text":68,"@type":64},"NSAIDs inhibit COX-1 and reduce thromboxane A2, impairing platelet aggregation and clot formation. They can also compromise GI mucosal protection, increasing vulnerability to GI bleeding.",{"name":70,"@type":61,"acceptedAnswer":71},"What alternatives to opioid analgesia does the review focus on?",{"text":72,"@type":64},"The review examines nonopioid options within multimodal strategies, including NSAID-related approaches with consideration of anticoagulant interactions, and highlights potential future research directions for nonopioid analgesia in anticoagulated patients.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},456589,1791033941,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,127],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},9,"Religion & Spirituality",20,"religion-spirituality",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":121,"show_sort_weight":118,"slug":122},"World Cup","world-cup",{"id":124,"doc_module":4,"doc_module_name":25,"category_name":125,"show_sort_weight":124,"slug":126},10,"Lifestyle","lifestyle",{"id":128,"doc_module":4,"doc_module_name":25,"category_name":129,"show_sort_weight":97,"slug":130},19,"General","general",{"code":4,"msg":82,"data":132},{"doc_id":79,"user_id":133,"nickname":42,"user_avatar":134,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":140,"language":141,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":142,"faqs":143,"seo_title":144,"seo_description":12,"update_tm":145,"read_time":146,"preview_page_count":4},962090883568,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","VA Author Manuscr ipt VA Author Manuscr ipt VA Author Manuscript  \n\n| | U.S. Department of Veterans Affairs\u003Cbr>Public Access Author manuscript\u003Cbr>J Hand Surg Am. Author manuscript; available in PMC 2026 January 08. |\n| --- | --- |\n\nPublished in final edited form as:  \nJ Hand Surg Am. 2025 November ; 50(11): 1392–1398. doi:10.1016/j.jhsa.2025.07.020 .  \nOpioid-Free Pain Management Strategies for Patients on Oral Anticoagulation Undergoing Soft Tissue Hand Surgery  \nEllis M. Berns, MD* , Thompson Zhuang, MD, MBA* , Hannah H. Lee, MD, PhD*,†  \n* Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA †Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.  \nAbstract  \nNon-narcotic multimodal analgesia has become standard for patients undergoing soft tissue hand surgery. These regimens often include nonsteroidal anti-inflammatory drugs such as ketorolac and ibuprofen, which can elevate bleeding risks in patients on anticoagulation therapy. This review aims to (1) elucidate the physiology of coagulation in relation to nonsteroidal anti-inflammatory drugs and anticoagulants,(2) examine the current surgical literature on risks and benefits of limited-duration nonsteroidal anti-inflammatory drug use in anticoagulated patients,(3) identify viable pain management alternatives, and (4) highlight areas warranting further research in nonopioid analgesia for anticoagulated patients.  \nKeywords  \nAnticoagulation; bleeding; NSAID; opioid  \nPostoperative pain control is critical following soft tissue hand surgery; however, opioid use is increasingly discouraged because of its associated risks of dependence and adverse effects.1 Nonopioid multimodal analgesia regimens, which synergistically combine medications with distinct mechanisms, can provide comparable or superior pain relief to opioids and are widely endorsed.1-4 Nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a cornerstone of multimodal regimens, but their use in patients on anticoagulantsis complicated by an elevated bleeding risk with coprescription.5 The number of patients on anticoagulants is increasing, with direct oral anticoagulants (DOACs) being the most frequently prescribed class, accounting for 70% of oral anticoagulants.6 This review examines NSAID—anticoagulant interactions, explores alternative nonopioid analgesic options for postoperative pain management after soft tissue hand surgery, and proposes future directions for research.  \nThis is an open access article under the CC BY-NC license ([http://creativecommons.org/licenses/by-nc/4.0/](http://creativecommons.org/licenses/by-nc/4.0/)).  \nCorresponding author: Hannah H. Lee, MD, PhD, Department of Orthopedic Surgery, University of Pennsylvania, 3737 Market Street, 6th floor, Philadelphia, PA, 19104; Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104; [hoeunhlee@gmail.com](hoeunhlee@gmail.com).  \nCONFLICTS OF INTEREST  \nNo benefits in any form have been received or will be received by the other authors related directly to this article.  \nVA Author Manuscr ipt VA Author Manuscr ipt VA Author Manuscript  \nBerns et al. Page 2  \nROLE OF NSAIDS IN POSTOPERATIVE PAIN MANAGEMENT  \nNonsteroidal anti-inflammatory drugs provide robust analgesic and anti-inflammatory effects by inhibiting cyclooxygenase 1 and 2 (COX-1 and COX-2, respectively) enzymes, reducing prostaglandin production and thus inflammation-driven pain.7 Meta-analyses consistently validate NSAIDs’ effectiveness in postoperative pain control across surgical fields.7,8 In soft tissue hand surgery, NSAID-based multimodal regimens, including ibuprofen, ketorolac, meloxicam, celecoxib, and naproxen, achieve pain relief comparable, or even superior to opioids.1,3,4 These findings support the use of NSAIDs as a key element in postoperative analgesic protocols.  \nHOW NSAIDS INTERACT WITH THE COAGULATION CASCADE Effect of NSAIDs on platelet aggregation  \nBy inhibiting COX-1, NS","cbCairQ0uN3TIWwV","https://ap.wps.com/l/cbCairQ0uN3TIWwV","pdf",624280,11,"English","# Abstract\n# Role of NSAIDs in Postoperative Pain Management\n## Effect of NSAIDs on platelet aggregation\n## The synergistic effects of NSAIDs with anticoagulation","[{\"question\":\"Why is opioid-free multimodal analgesia emphasized after soft tissue hand surgery?\",\"answer\":\"Opioid use is discouraged due to risks of dependence and adverse effects. Multimodal nonopioid regimens can provide comparable or superior pain relief by combining drugs with distinct mechanisms.\"},{\"question\":\"How do NSAIDs increase bleeding risk in anticoagulated patients?\",\"answer\":\"NSAIDs inhibit COX-1 and reduce thromboxane A2, impairing platelet aggregation and clot formation. They can also compromise GI mucosal protection, increasing vulnerability to GI bleeding.\"},{\"question\":\"What alternatives to opioid analgesia does the review focus on?\",\"answer\":\"The review examines nonopioid options within multimodal strategies, including NSAID-related approaches with consideration of anticoagulant interactions, and highlights potential future research directions for nonopioid analgesia in anticoagulated patients.\"}]","Opioid-Free Pain Management Strategies for Patients on Oral Anticoagulation Undergoing Soft Tissue Hand Surgery | PDF",1790746452,28]