Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin-like medications, reduce inflammation (and hence pain) arising from injured tissue. Such medications have analgesic, anti-inflammatory, and antipyretic effects, and they inhibit platelet aggregation by inhibiting the cyclooxygenase (COX) enzyme. NSAIDs are associated with adverse gastrointestinal effects, particularly with long-term use. Most NSAIDs are taken by mouth. NSAIDs are also available for topical use, although topical effects are unknown.
Recommended for Practice
Miaskowski, C., Cleary, J., Burney, R., Coyne, P., Foster, R., Grossman, S., . . . Zahrbock, C. (2005). Guideline for the management of cancer pain in adults and children. APS Clinical Practice Guidelines Series. Glenview, IL: American Pain Society.
Type of Resource/Evidence-Based Process:
PROCESS OF DEVELOPMENT: An interdisciplinary panel of experts in cancer pain management prepared these guidelines. When unavailable, recommendations were not made or were made on the recommendation of experts in that area.
Results Provided in the Reference:
Guidelines & Recommendations:
- Make patient and family caregiver education about pain management a part of the treatment plan, and encourage patient and family caregivers to participate actively in pain management.
- Collaborate with patients and family caregivers, taking costs and availability of treatment options into account when selecting pain management strategies. (Panel consensus)
- Perform a comprehensive pain assessment of all patients with cancer at each outpatient visit or hospital admission and use each patient’s self-report as the foundation for the assessment.
- Include in the comprehensive pain assessment a detailed history to determine the presence of persistent and breakthrough pain and its effects on function; a psychosocial assessment; a physical examination; and a diagnostic evaluation of signs and symptoms associated with common cancer pain presentations and syndromes.
- Develop a systematic approach to cancer pain management and teach patients and family caregivers how to use effective strategies to achieve optimal pain control.
- Begin a bowel regimen to prevent constipation when the patient is started on an opioid analgesic.
- Administer a long-acting opioid on an around-the-clock basis, along with an immediate-release opioid to be used on an as-needed basis, for breakthrough pain once the patient’s pain intensity and dose are stabilized.
- Do not use meperidine in the management of chronic cancer pain.
- Adjust opioid doses for each patient to achieve pain relief with an acceptable level of side effects.
- Avoid intramuscular administration because it is painful and absorption is unreliable.
- Use optimally titrated doses of opioids and maximal safe and tolerable doses of coanalgesics through other routes of administration before considering spinal analgesics. (Panel consensus)
- Monitor for and prophylactically treat opioid-induced side effects.
- Clarify myths and misconceptions about pain management, and reassure patients and family caregivers that cancer pain can be relieved and that addiction and tolerance are not problems associated with effective cancer pain management.
- Use cognitive and behavioral strategies as part of a multimodal approach to cancer pain management, not as a replacement for analgesic medications.
- Offer patients who decline to have procedural sedation nonpharmacologic alternatives to decrease procedure-related pain.
- Implement a formal process to evaluate and improve the quality of cancer pain management across all stages of the disease process and across all practice settings.
- Evaluate the quality of cancer pain management at points of transition in the provision of services (e.g., from the hospital to the home) to ensure that optimal pain management is achieved and maintained.
McNichol, E., Strassels, S.A., Goudas, L., Lau, J., & Carr, D.B. (2005). NSAIDs or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005180.doi: 10.1002/14651858.CD005180
- Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL) (2nd quarter 2002), MEDLINE (January 1966–March 2003), EMBASE (January 1980–2nd quarter 2002), LILACS (January 1984–December 2001). Investigators also searched the reference lists of relevant publications.
- Search keywords were neoplasm, anti-inflammatory drugs, nonsteroidal, and pain.
- Studies were included in the review if they were published in any language.
- Studies were excluded if they involved animals.
The search retrieved 42 trials. Eight trials compared an NSAID with a placebo, 13 compared one NSAID with another, 23 compared an NSAID with an opioid or an NSAID-opioid combination, and 9 assessed the effect of increasing the NSAID dose. Sixteen of the 42 studies were conducted over seven days or longer, and 11 studies were single-dose studies. No study lasted longer than 12 weeks. Treatments studied included weak opioids, strong opioids, and agonist or antagonists. Nine studies examined dose range. Outcomes measured included differences in pain intensity, pain relief, and incidence and severity of adverse effects. Many studies used a visual analog scale; few studies used validated scales.
The 42 trials reviewed included 3,084 patients.
On the basis of limited data, NSAIDs appear to be more effective than placebo in treating cancer pain. Data to support the use of one NSAID over another, in regard to safety or efficacy, are insufficient. Compared to an NSAID alone or an opiod alone, NSAID-opioid combinations were no more effective or, at most, had a slight statistical advantage. The World Health Organization (WHO) method of cancer pain relief is considered the gold standard. Regarding the first step in the WHO method, the management of mild pain, results of this review support the WHO recommendations: Results strongly suggest that an NSAID alone is superior to placebo and adequate for at least short-term pain relief. Regarding the second step: Evidence is insufficient to refute or support the WHO recommendation to use an NSAID-opioid combination as a means to manage moderate cancer pain. Increasing the dose of an NSAID or adjuvant drug to the maximum acceptable dose may be the better course.
- Heterogeneity precluded meta-analysis.
- Short duration of studies undermines generalizability.
- Studies were too short to demonstrate the safety or efficacy of long-term NSAID use.
Clinicians should be cautious regarding the use of NSAIDs, especially in the population studied. This population takes many prescription drugs, some of which may increase NSAID-related toxicity.