NSAIDs for cancer pain
Sübutlu məlumatların xülasələri
29.01.2018 • Sonuncu dəyişiklik 29.01.2018
Editors
Oral NSAIDs might possibly have pain-relieving effects in some people with cancer pain but the evidence is insufficient.
The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding), by inconsistency (variability in results), and by imprecise results (few patients and outcome events).
Summary
A Cochrane review included 11 studies lasting one week or longer, with a total of 949 subjects with mostly moderate or severe cancer pain. None had a placebo only control; 8 compared different NSAIDs, 3 an NSAID with opioid or opioid combination, and 1 both. None compared an NSAID plus opioid with the same dose of opioid alone. It was not possible to compare NSAIDs as a group with another treatment, or one NSAID with another NSAID. Results for all NSAIDs are reported as a randomized cohort. With NSAID, initially moderate or severe pain was reduced to no worse than mild pain after 1 or 2 weeks in 4 studies (n=415), with a range of estimates between 26% and 51% in individual studies.
Adverse event and withdrawal reporting was inconsistent. Two serious adverse events were reported with NSAIDs, and 22 deaths, but these were not clearly related to any pain treatment. Common adverse events were thirst/dry mouth (15%), loss of appetite (14%), somnolence (11%), and dyspepsia (11%). Withdrawals were common, mostly because of lack of efficacy (24%) or adverse events (5%).
A Cochrane review [withdrawn from publication] included 42 studies with a total of 3 084 subjects with cancer pain. Studies of 16 NSAIDs and paracetamol and dipyrone were identified. Comparisons investigated efficacy and/or adverse event profiles for NSAIDs vs. placebo, NSAIDs vs. opioids, NSAIDs vs. NSAIDs plus opioids, opioids vs. NSAIDs plus opioids, and high vs. low dose NSAIDs. In only 16 of the 42 trials the study duration was one week or longer.
Comparisons between NSAID vs. placebo (8 trials): Seven studies demonstrated superior efficacy of NSAID with no difference in side effects. Comparisons between NSAID vs. another NSAID or high vs. low dose NSAIDs (13 trials): only 4 studies demonstrated significant differences: Ketoprofen 400 mg proved significantly more effective than both 100 mg ketoprofen and 1000 mg of acetylsalicylate for VAS (n=36). Single doses of ketorolac 30 mg suppositories reduced pain to a significantly greater degree than diclofenac 100 mg suppositories, although clinically the differences were minimal (n=60).Ketorolac was more successful in promoting complete relief of pain compared with dipyridone (p<0.05; n=50).Diflunisal 500 mg orally twice-daily reduced the pain score more effectively than dipyrone 500 mg orally thrice-daily (p<0.001).Comparisons between NSAID plus or without opioid (23 trials): The results were inconclusive. Comparisons between various NSAIDs vs. opioids (10 trials): Four trials demonstrated increased efficacy of NSAIDs over opioids. Only 2 studies did not show that NSAID was either more efficacious, had less side effects or both. Comparisons between NSAID vs. NSAID plus opioid (8 trials): Four studies demonstrated superiority of NSAID plus opioid combination versus NSAID alone, although the clinical difference was less than 25% of the analgesic outcome measure in each case (e.g., pain relief). Meta-analyses of 3 and 6 of the trials failed to show a significant difference between NSAID and NSAID plus opioid for number of patients withdrawing due to intervention-related adverse events and number of patients reporting adverse events, respectively. Comparisons between opioid vs. opioid plus NSAID (6 trials): Five studies demonstrated an increased efficacy with combination vs. opioid alone. Comparisons between NSAID/opioid vs. NSAID/opioid (3 trials): Two studies found no difference between selected commercially available opioid/NSAID combinations (n=48). In one trial adding ibuprofen to an existing regimen of oral, as required, oxycodone/acetaminophen reduced its' total requirements without increasing side effects (n=30).
Comment: The quality of evidence is downgraded by study quality (short follow-up) and inconsistency (heterogeneity in patients and interventions).
Ədəbiyyat
- Derry S, Wiffen PJ, Moore RA et al. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) for cancer pain in adults. Cochrane Database Syst Rev 2017;(7):CD012638. McNicol ED, Strassels S, Goudas L et al. WITHDRAWN: NSAIDS or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database Syst Rev 2015;(7):CD005180.