Tramadol and its combination with piroxicam in post-cesarean pain management: a comparative study


  • Banapura Ambika Department of Pharmacology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
  • Mamatha K. R. Department of Pharmacology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
  • Prabha P. Department of Anaesthesia, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India



Tramadol, Piroxicam, Post-cesarean pain


Background: Cesarean delivery is a major surgical procedure, requiring high quality pain relief to facilitate early ambulation, infant care and prevention of post-operative morbidity. There is no gold standard for post-cesarean pain management.

Methods: Cases were randomly assigned to 2 groups of 30 cases each. One group received Tramadol 100mg and another, Tramadol 100mg+ Piroxicam 20mg. Injections were given intramuscularly, postoperatively after skin closure. Diclofenac 75mg was the rescue analgesia. Primary outcome measure was control of pain, assessed by visual analogue scale (VAS). Secondary outcomes were sedation and time to rescue analgesia. Safety of the drugs was assessed by adverse drug reactions. Data was analysed by student’s t test, analysis of variance and post-hoc test.

Results: Multimodal group showed better analgesia compared to unimodal group (p<0001). Drowsiness was the main adverse effect in both treatment groups.

Conclusions: Multimodal analgesic combination of tramadol and piroxicam showed superior analgesic effect with better pain control and longer duration of action compared to tramadol alone.


Kuczkowski KM. Postoperative pain control in the parturient: new challenges (and their solutions). J Clin Anesth. 2004;16(1):1-3.

Leung AY. Postoperative pain management in obstetric anaesthesia- new challenges and solutions. J Clin Anesth. 2004;16(1):57-65.

Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesth Analg. 2007;105(1):205-21.

Kaur J, Singh S, Kaur K. Current trend of caesarean sections and vaginal births. Adv. Appl. Sci. Res., 2013;4(4):196-202.

Bonnet MP, Mignon A, Mazoit JX, Ozier Y, Marret E. Analgesic effect and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systemic review. Eur J Pain. 2010;14:894-9.

Teng YH, Hu JS, Tsai SK, Liew C, Lui PW. Efficacy and adverse effects of patient-controlled epidural or intravenous analgesia after major surgery. Chang Gung Med J. 2004;27(12):877-86.

Ismail S, Shahzad K, Shafiq F. Observational study to assess the effectiveness of postoperative pain management of patients undergoing elective cesarean section. J Anaesthesiol Clin Pharmacol. 2012;28(1):36-40.

Vanderah TW. Pathophysiology of pain. Med Clin North Am. 2007;91(1):1-12.

Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: A prospective study of 856 cases, Reg Anesth. 1991;16:137-40.

Wilder-Smith CH, Hill L, Dyer RA, Torr G, Coetzee E. Postoperative sensitization and pain after Cesarean delivery and the effects of single IM doses of tramadol and diclofenac alone and in combination. Anesth Analg. 2003;97:526-33.

Kehlet H, Dahl JB. The value of multimodal or balanced analgesia in the postoperative pain treatment. Anesth Analg. 1993;77:1048-56.

Raffa RB, Friderichs E, Reimann W, Shank RP, Codd EE, Vaught JL. Opioid and non-opioid components independently contribute to the mechanism of action of tramadol, an ‘atypical’ opioid analgesic. J Pharmacol Exp Ther. 1992;260(1):275-85.

Vickers MD. The efficacy of tramadol hydrochloride in the treatment of postoperative pain. Rev Contemp Pharmacother. 1995;6:499-506.

Moore RA, McQuay HJ. Single-patient data meta-analysis of 3453 postoperative patients: oral tramadol versus placebo, codeine and combination analgesics. Pain. 1997;69:287-94.

Olofsson CI, Legeby MH, Nygards EB, Ostman KM. Diclofenac in the treatment of pain after caesarean delivery. An opioid-saving strategy. Eur J Obstet Gynecol Reprod Biol. 2000;88(2):143-6.

RobertsII LJ, Morrow JD. Analgesicc-antipyretic and antiinflammatory agents and drugs employed in the treatment of gout. In: Hardman JG, Limbard LE, Goodman gilman A. The pharmacological basis of therapeutics. 10th ed. New York: Mc Grow Hill; 2001:713-714.

Yaksh TL, Malmberg A. Central pharmacology of nociceptive transmission. In: Wall PD, Melzack R, eds. Textbook of pain. 3rd ed. Edinburgh: Churchill Livingstone; 1994:165-200.

Kehlet H, Werner M, Perkins F. Balanced analgesia: what is it and what are its advantages in postoperative pain? Drugs. 1999;58:793-7.

Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606-17.

Kolawole IK, Fawole AA. Postoperative pain management following caesarean section in University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria. West Afr J Med. 2003;22(4):305-9. [homepage on the Internet]. WHO’s cancer pain ladder for adults. World Health Organization; 2012 [cited July 28, 2013]. Available from: Accessed June 27, 2014.

Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol. 2009;22(5):588-93.

Adeniji AO, Oluseyi OA. Randomized comparison of effectiveness of unimodal analgesia with multimodal analgesia in post-cesarean section pain management. Journal of pain research. 2013;6:419-24.

Alton Barron O, Clark L, Lipman AG. Advances in Postoperative Pain Management: Novel Approaches to Optimum Care. New York, NY: Medscape Education; 2012. Available from: Accessed January 10, 2013

Chandanwale AS, Sundar S, Latchoumibady K, Biswas S, Gabhane M, Naik M, et al. Efficacy and safety profile of combination of tramadol-diclofenac versus tramadol-paracetamol in patients with acute musculoskeletal conditions, postoperative pain, and acute flare of osteoarthritis and rheumatoid arthritis: a Phase III, 5-day open-label study. J Pain Res. 2014;7:455-63.

Khalili G, Salimianfard M, Zarehzadeh A. Comparison between paracetamol, piroxicam, their combination, and placebo in postoperative pain management of upper limb orthopedic surgery (a randomized double blind clinical trial). Adv Biomed Res. 2016;5:114.

Farshchi A, Ghiasi G. Comparison the analgesic effects of single dose administration of tramadol or piroxicam on postoperative pain after cesarean delivery. Acta Med Iran. 2010;48(3):148-53.

Mitra S, Khandelwal P, Sehgal A. Diclofenac-tramadol vs diclofenac-acetaminophen combinations for pain relief after caesarean section. ActaAnaesthesiol Scand. 2012;56(6).




How to Cite

Ambika, B., K. R., M., & P., P. (2017). Tramadol and its combination with piroxicam in post-cesarean pain management: a comparative study. International Journal of Basic & Clinical Pharmacology, 6(2), 404–409.



Original Research Articles