ORTHOPEDIC SURGERY

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Indication and limitations of use

ZYNRELEF is indicated in adults for soft tissue or periarticular instillation to produce postsurgical analgesia for up to 72 hours after bunionectomy, open inguinal herniorrhaphy and total knee arthroplasty. Limitations of Use: Safety and efficacy have not been established in highly vascular surgeries, such as intrathoracic, large multilevel spinal, and head and neck procedures.

Efficacy in total knee arthroplasty

EPOCH TKA Study Design
Follow-On Study Design

Greater pain reduction

TKA patients treated with ZYNRELEF showed a 23% reduction in pain intensity in the first 72 hours following surgery compared to those treated with placebo.1

In the sensitivity analysis, which is not adjusted for the use of opioid rescue medication and therefore reflects the level of pain the patient is actually experiencing, TKA patients treated with ZYNRELEF showed a 38% reduction in pain intensity in the first 72 hours following surgery compared to those treated with placebo.1

37% of TKA patients experienced no severe pain through 72 hours when treated with ZYNRELEF plus a non-opioid MMA regimen.2

When treated with ZYNRELEF plus a non-opioid MMA regimen, the majority of patients rated their pain control as “good” or “excellent”: 88% on day 1 of recovery, 90% on day 2 of recovery, and 100% on day 3 of recovery.3

More opioid-free patients

The mean consumption of opioids in the EPOCH TKA Single-Arm Follow-On study was 1 to 2 pills of oxycodone 10 mg per day through 72 hours (25 MME).3

39% of TKA patients received no opioid discharge prescription and had no callbacks through day 11 of recovery when treated with ZYNRELEF and a non-opioid MMA regimen.3

Efficacy in bunionectomy

EPOCH 1 Bunion Study Design
Follow-On Study Design

Greater pain reduction

Bunionectomy patients treated with ZYNRELEF showed an 18% reduction in pain intensity compared to those treated with bupivacaine HCl solution.4,5

46% of bunionectomy patients treated with ZYNRELEF experienced no severe pain in the first 72 hours—a 90% increase over patients treated with bupivacaine HCl solution.4,5

More opioid-free patients

29% of bunionectomy patients treated with ZYNRELEF required no opioids in the first 72 hours following surgery, compared with 11% of patients treated with bupivacaine HCl solution.4,5

Of bunionectomy patients treated with ZYNRELEF who were opioid-free at 72 hours, 82% remained opioid-free through day 28.5

When bunionectomy patients treated with ZYNRELEF also received a scheduled, non-opioid, multimodal regimen of over-the-counter oral acetaminophen and ibuprofen, 77% required no opioids through 72 hours.6

Of bunionectomy patients receiving ZYNRELEF plus the scheduled, non-opioid, multimodal regimen who were opioid free at 72 hours, 100% remained opioid-free through 28 days.6

Resources for you

FDA Approval Letter

FDA Approval Letter

TKA Administration Card

TKA Administration Card

TKA Administration Video

TKA Administration Video

Find Additional Resources  

Adding ZYNRELEF to formulary

Interested in seeing ZYNRELEF added to your institution’s formulary? Contact a Heron representative today to find out more information about becoming a champion for the next generation of postoperative pain management.

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Important Safety Information and Indication

Indication

ZYNRELEF is indicated in adults for soft tissue or periarticular instillation to produce postsurgical analgesia for up to 72 hours after bunionectomy, open inguinal herniorrhaphy and total knee arthroplasty.

Limitations of Use: Safety and efficacy have not been established in highly vascular surgeries, such as intrathoracic, large multilevel spinal, and head and neck procedures.

Important Safety Information

WARNING: RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL EVENTS

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use.
  • ZYNRELEF is contraindicated in the setting of coronary artery bypass graft (CABG) surgery.
  • NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events.

Contraindications

ZYNRELEF is contraindicated in patients with known hypersensitivity (eg, anaphylactic reactions and serious skin reactions) to any amide local anesthetic, NSAIDs, or other components of ZYNRELEF; with history of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs (severe, sometimes fatal, anaphylactic reactions to NSAIDS have been reported in such patients); undergoing obstetrical paracervical block anesthesia; or undergoing coronary artery bypass graft (CABG) surgery.

Warnings and Precautions

Dose-Related Toxicity: Monitor cardiovascular and respiratory vital signs and patient’s state of consciousness after application of ZYNRELEF. When using ZYNRELEF with other local anesthetics, overall local anesthetic exposure must be considered through 72 hours.

Hepatotoxicity: If abnormal liver tests persist or worsen, perform a clinical evaluation of the patient.

Hypertension: Patients taking some antihypertensive medication may have impaired response to these therapies when taking NSAIDs. Monitor blood pressure.

Heart Failure and Edema: Avoid use of ZYNRELEF in patients with severe heart failure unless benefits are expected to outweigh risk of worsening heart failure.

Renal Toxicity: Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia. Avoid use of ZYNRELEF in patients with advanced renal disease unless benefits are expected to outweigh risk of worsening renal failure.

Anaphylactic Reactions: Seek emergency help if an anaphylactic reaction occurs.

Methemoglobinemia: Cases have been reported with local anesthetic use.

Serious Skin Reactions: NSAIDs, including meloxicam, can cause serious skin adverse reactions. If symptoms present, evaluate clinically.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): If symptoms are present, evaluate clinically.

Fetal Toxicity: Due to the risk of oligohydramnios/fetal renal dysfunction and premature closure of the ductus arteriosus with NSAIDS, limit use of ZYNRELEF between about 20 to 30 weeks gestation, and avoid use after about 30 weeks.

Hematologic Toxicity: Monitor hemoglobin and hematocrit in patients with any signs or symptoms of anemia.

Drug Interactions

Drugs That Interfere with Hemostasis: Monitor patients for bleeding who are using ZYNRELEF with drugs that interfere with hemostasis (eg, warfarin, aspirin, SSRIs/SNRIs). 

ACE Inhibitors, Angiotensin Receptor Blockers (ARBs), or Beta-Blockers: Use with ZYNRELEF may diminish the antihypertensive effect of these drugs. Monitor blood pressure.

ACE Inhibitors and ARBs: Use with ZYNRELEF in elderly, volume-depleted, or those with renal impairment may result in deterioration of renal function. In such high-risk patients, monitor for signs of worsening renal function.

Diuretics: NSAIDs can reduce natriuretic effect of furosemide and thiazide diuretics. Monitor patients to assure diuretic efficacy including antihypertensive effect.

Use in Specific Populations

Infertility: NSAIDs are associated with reversible infertility. Consider avoidance of ZYNRELEF in women who have difficulties conceiving.

Severe Hepatic Impairment: Only use if benefits are expected to outweigh risks; monitor for signs of worsening liver function.

Severe Renal Impairment: Not recommended.

Adverse Reactions

Most common adverse reactions (incidence ≥10%) in controlled clinical trials with ZYNRELEF are constipation, vomiting, and headache.

Report side effects to Heron at 1-844-437-6611 or to FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Indication

ZYNRELEF is indicated in adults for soft tissue or periarticular instillation to produce postsurgical analgesia for up to 72 hours after bunionectomy, open inguinal herniorrhaphy and total knee arthroplasty.

Limitations of Use: Safety and efficacy have not been established in highly vascular surgeries, such as intrathoracic, large multilevel spinal, and head and neck procedures.

Please see full Prescribing Information, including Boxed Warning.

References:  1. Lachiewicz PF, Lee G-C, Pollak R, Leiman D, Hu J, Sah A. HTX-011 reduced pain and opioid use after primary total knee arthroplasty: results of a randomized Phase 2b trial. J Arthroplasty. 2020;35(10):2843-2851. doi:10.1016/j.arth.2020.05.044. 2. Hacker S. Postoperative pain management of total knee arthroplasty using HTX-011 with multimodal analgesia: results from a Phase 3b open-label study. Poster presented at: Orthopedics Today Hawaii 2020; January 12-16, 2020; Koloa, HI. 3. Data on file. Study HTX-011-306. San Diego, CA: Heron Therapeutics Inc; 2019. 4. ZYNRELEF [package insert]. San Diego, CA: Heron Therapeutics Inc; 2021. 5. Viscusi E, Gimbel JS, Pollack RA, Hu J, Lee G-C. HTX-011 reduced pain intensity and opioid consumption versus bupivacaine HCl in bunionectomy: Phase III results from the randomized EPOCH 1 study. Reg Anesth Pain Med. 2019;44(7):700-706. doi:10.1136/rapm-2019-100531. 6. Pollak R, Cai D, Gan TJ. Opioid-free recovery from bunionectomy with HTX-011, a dual-acting local anesthetic combining bupivacaine and meloxicam, as the foundation of non-opioid multimodal analgesia [published online January 19, 2021]. J Am Podiatr Med Assoc. 2021:20-204. doi:10.7547/20-204.