Cancer Pain (PDQ®) - PDQ Cancer Information Summaries. Acetaminophen and Nonsteroidal Anti- inflammatory Drugs (NSAIDs)Often initiated when an individual has mild pain, acetaminophen and NSAIDs are useful in managing moderate and severe pain as adjunct agents to opioids. No single NSAID is preferred over others, and all are better than placebo for analgesia.[1] As opioid adjuncts, acetaminophen and NSAIDs have shown benefit both in improved analgesia and in decreased opioid use.
During the United Kingdom Prospective Diabetes Study (UKPDS), patients with type 2 diabetes mellitus who received intensive glucose therapy had a lower risk of. Type or paste a DOI name into the text box. Click Go. Your browser will take you to a Web page (URL) associated with that DOI name. Send questions or comments to doi.
These agents are used with care or perhaps avoided in patients who are elderly or have renal, hepatic, or cardiac disease.[1] (Refer to the Geriatric cancer patients section in the Treatment of Pain in Specific Patient Populations section of this summary for more information.)While acetaminophen and NSAIDs provide analgesia on their own, a number of randomized controlled trials have reported that the addition of either agent to opioids may improve pain control and decrease opioid need in cancer patients.[2- 4] However, these benefits were not consistently observed across trials.[5,6]High- potency NSAIDs such as ketorolac and diclofenac are more studied and have shown benefit in the management of cancer pain, but there are no comparative data with older agents to show superiority of one product over others. Prominent side effects are gastrointestinal irritation, ulcer formation, and dyspepsia, with other side effects of concern being cardiotoxicity, nephrotoxicity, hepatotoxicity, and hematologic effects.[7,8] Cyclooxygenase- 2 (COX- 2)–specific agents such as celecoxib may have a more favorable gastrointestinal side effect profile at a higher monetary cost.[7] Long- term safety and efficacy data remain unclear. Table 1. Acetaminophen and Selected Nonsteroidal Anti- inflammatory Analgesics. View in own window. Drug. Dosage. Comments. Reference(s)Acetaminophen< 4,0. Dosed every 4 to 8 hours, depending on dose and product used.[2]Celecoxib.
COX- 2 specific. Minimal antiplatelet effects compared with nonselective NSAIDs.[7]Diclofenac. Available as immediate- and delayed/extended–release products.[9]Ibuprofen. Ketoprofen. 10. 0–3. Available as parenteral in some parts of the world, which may be preferred.[7,1. Ketorolac. 40–6. 0 mg/d, generally dosed every 6 hours.
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PubMed comprises more than 27 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full. In finance, a foreign exchange option (commonly shortened to just FX option or currency option) is a derivative financial instrument that gives the right but not the. · General Information About Cancer Pain. Pain is one of the most common symptoms in cancer patients and often has a negative impact on patients’ functional. Those who prefer Total War’s historical games to its Warhammer outing should keep an eye on Total War Saga, a new series of “standalone spin-off titles focusing.
Parenteral (IV, IM) ketorolac is used ≤5 days because of concerns about GI adverse events. May also be given PO.[7]Opioids. General principles. The use of opioids for the relief of moderate to severe cancer pain is considered necessary for most patients.[1] For moderate pain, weak opioids (e.
For severe pain, strong opioids are routinely used; although no agent has shown itself to be more effective than another, morphine is often considered the opioid of choice because of provider familiarity, broad availability, and lower cost.[1] In one well- designed review, most individuals with moderate to severe cancer pain obtained significant pain relief from oral morphine.[1. One study has also noted that low- dose morphine (up to 3. Management of acute pain begins with an immediate- release opioid formulation.
Once pain is stabilized, the opioid consumption over the past 2. MEDD]). Randomized controlled trials have shown that long- acting opioids given every 1. Use of the immediate- release product is continued for management of breakthrough pain.[1] During ongoing pain management, the immediate- release opioids inform the titration of long- acting medication. Rapid- acting oral, buccal, sublingual, transmucosal, rectal, and intranasal products are all acceptable for treatment of breakthrough pain. In people unable to take oral medications, a subcutaneous method of delivery is as effective as the intravenous route for morphine and hydromorphone. Table 2. Selected Opioid Analgesics.
View in own window. Opioid Drug. Equianalgesic Dosing. Comments. Reference(s)Buprenorphine. No consensus. Transdermal product and sublingual available. May cause less constipation and nausea than do other opioids.[1. Codeine. 10. 0 mg.
Maximum of 3. 60 mg/d. Used with or without acetaminophen.[1,1. Diamorphine. Unavailable. Used primarily in the United Kingdom.[1.
Fentanyl. 7. 5 µg/h × 2. Delivered transdermally, transmucosally, or intravenously. Cachectic patients have decreased absorption from transdermal patch.[1. Hydrocodone. 10 mg. Generally used with acetaminophen, for moderate pain only.[2. Hydromorphone. 3 mg[1. Methadone. 3 mg (equianalgesic ratio varies widely by dose)Used primarily for severe pain in non–opioid- naïve patients.
Unusual pharmacokinetics require experienced practitioner.[1]Morphine. Randomized trials supporting use. First- choice opioid because of familiarity, availability, and cost.[1,1. Oxycodone. 10 mg. Randomized trials supporting use.[1. Oxymorphone. 5 mg[1. Tapentadol. 75 mg.
Similar to morphine 4. Level of evidence: I]Tramadol. Use at < 4. 00 mg/d with or without acetaminophen. Used for moderate pain.[1]Table 3. Routes of Analgesic Medication Administration.
View in own window. Route. Agent. Comments. Reference(s)Buccal. Fentanyl. Used primarily for breakthrough pain.[2. Epidural. Opioids, local anesthetics.
Consider if inadequate analgesia or intolerable side effects with oral or intravenous analgesics.[1]Intramuscular injection. Opioids, acetaminophen, ketorolac. Typically avoided because of pain from injection.[1. Intranasal. Fentanyl. Onset faster than that of transmucosal fentanyl or oral morphine.
Used for breakthrough pain.[2. Intrathecal. Opioids.
Consider if inadequate analgesia or intolerable side effects with oral or intravenous analgesics.[1]Intravenous Most strong opioids (except oxycodone) and some NSAIDs. Availability varies by world region.[1. Oral. Most opioids except fentanyl and buprenorphine. Most common and preferred method of administration.[1. Rectal. Morphine, methadone. Onset similar to that of oral; possibly better absorption. May be useful for pediatric and end- of- life patients.[1]Subcutaneous.
Morphine. diamorphine, fentanyl, hydromorphone. Benefit similar to that of intravenous; considered an alternative if no oral capacity.[1,2,2.
Sublingual. Fentanyl, buprenorphine. Used primarily for breakthrough pain.[1. Topical. Lidocaine. Primarily application of topical anesthetics.[1. Transdermal. Fentanyl, buprenorphine.
Efficacy similar to that of oral agents for moderate to severe pain in opioid- naïve patients.[1]Transmucosal. Fentanyl. Used primarily for breakthrough pain.[2. Rapid- onset fentanyl formulations. Rapid- onset opioids are developed to provide fast analgesia without using a parenteral route. Fentanyl, a synthetic opioid 5. Along with rapid onset of action, these products avoid first- pass hepatic metabolism and intestinal digestion. All rapid- acting fentanyl products are intended for use only in patients already tolerant to opioids and are not initiated in the opioid naïve.
However, none are bioequivalent to others, making dose interchange complicated and requiring dose titration of each product individually, without regard to previous doses of another fentanyl product. The dose titration schedule is unique to each product, and it is critical that product information is reviewed individually when each product is used. The risk of addiction with these rapid- onset agents has not been elucidated. In the United States, prescription of these agents requires enrollment in the U. S. Food and Drug Administration’s (FDA’s) Risk Evaluation and Mitigation Strategies (REMS) program.
Table 4. Routes of Fentanyl Administration. View in own window. Drug. Starting Dose (µg)Tmax (median, minutes)Comments. Evidence. Transmucosal fentanyl lozenges (Actiq, generic)2. Lozenge on stick, rubbed against cheek. Sugar content may increase dental caries. Multiple RCTs showing benefit over placebo and oral morphine.
Fentanyl buccal tablet (Fentora)1. Absorption may be affected by mucositis. Before use, wet mouth if dry.
RCT showing benefit over placebo, and open- label study showing benefit for pain rescue; more rapid than oxycodone. Fentanyl buccal film (Onsolis)2. Before use, wet mouth if dry.