Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis

Update on pain management for advanced genitourinary cancer

PURPOSE

Pain is a significant problem in many patients with genitourinary malignancy at all stages of disease. Optimal pain control becomes a primary concern as disease progresses and other therapies are exhausted. The selection of the most appropriate therapy becomes difficult without an understanding of the underlying mechanisms of pain and the available therapies.

MATERIALS AND METHODS

A review of the literature regarding the mechanisms and assessment of pain syndromes was performed. All available therapies were investigated with respect to conservative management with opioid medications and adjuvant drugs, and the indications for invasive techniques.

RESULTS

Increased understanding of the mechanisms and classification of pain syndromes has led to improved assessment and treatment. Despite these advances a significant number of patients have inadequate pain control and the education of treating physicians remains an important target for improving this situation.

CONCLUSIONS

Opioid medication is the mainstay of therapy in the majority of patients but with the appropriate addition of other adjuvant drugs patients may achieve optimal pain control without unwanted side effects. A few patients benefit from more invasive techniques, including plexus blocks and neuraxial infusion therapy, and the indications for these treatments are discussed. These therapies have largely superseded neuroablative procedures that are more destructive and associated with higher morbidity.

Pain assessment and management

Assessment and management of pain is crucial to the success of any program of care for dying patients and their families. With appropriate assessment and management, often using home health or hospice teams, pain can be controlled in more than 90% of patients. This article focuses on the symptomatic care of patients who are dying. The legal and regulatory issues that may inhibit delivery of adequate opioid therapy are also reviewed.

Treatment of advanced prostate cancer

OBJECTIVES

To review the management of advanced prostate cancer, including symptom management, hormonal therapy, and the use of chemotherapy.

DATA SOURCES

Published articles and book chapters on advanced prostate cancer.

CONCLUSIONS

Advanced prostate cancer is a common problem that has a significant impact on the patient's quality of life. Multiple complications may develop during the course of the disease. Treatment may include local and systemic approaches. Advances in disease treatment include hormonal therapies and chemotherapy. Additional research is needed to determine the optimal treatment for these men.

IMPLICATIONS FOR NURSING PRACTICE

Patient education is crucial to the management of advanced prostate cancer in all practice settings. Early and prompt recognition of disease complications will enhance the patient's quality of life.

Prophylaxis of oral mucositis in irradiated head-and-neck cancer patients: a proposed classification scheme of interventions and meta-analysis of randomized controlled trials

PURPOSE

To identify, classify, and evaluate agents used in the prophylaxis of oral mucositis in irradiated head and neck cancer patients.

METHODS

Data sources included multiple databases and manual citation review of relevant literature. Based on the eligibility criteria, 59 studies were independently reviewed by two reviewers. Forty-two studies were included in the classification scheme, of which 15 met the criteria for inclusion in the meta-analysis. Data were extracted by duplicate independent review, with disagreement resolved by consensus.

RESULTS

Overall, the interventions reduced the odds of developing severe oral mucositis, when assessed by clinicians, by 36% (OR: 0.64; 95% CI: 0.46, 0.88). Subgroup analysis suggested that only the narrow-spectrum antibacterial lozenges were effective (OR: 0.45; 95% CI: 0.23, 0.86); however, the power of the aggregated data in the other classes may have been insufficient to detect differences. When the outcome was assessed by patients, no significant difference was seen in the outcome between the treatment and the control groups (OR: 0.79; 95% CI: 0.56-1.12).

CONCLUSIONS

Overall, interventions chosen on a sound biologic basis to prevent severe oral mucositis are effective. In particular, when oral mucositis is assessed by clinicians, narrow-spectrum antibiotic lozenges appear to be beneficial. Methodologic limitations were evident in many of the studies. Further research using validated measurement tools in larger, methodologically sound trials is warranted.

The use of anti-inflammatory drugs in cancer pain

The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and also alone or in association with opioids for the treatment of moderate to severe pain. Acutely, NSAIDs may be more than mild analgesics, and may provide additional analgesia when combined with opioids. However, NSAIDs have ceiling effects and there is no therapeutic gain from increasing dosages beyond those recommended. As there is no clearly superior NSAID, the choice should be based on experience and the toxicity profile that probably relates to the COX-1:COX-2 ratio. Among the older drugs, ibuprofen seems to have these properties.Non-steroidal anti-inflammatory drugs have been shown to have an opioid-sparing effect. Although the value of a simple narcotic-sparing effect may be questioned in cancer pain treatment, the use of NSAIDs may be useful when the increase in opioid dosage determine the occurrence of opioid toxicity. Like opioids, NSAIDs should not be considered analgesics for a specific type or cause of pain. There is a lack of evidence for any difference between different routes of NSAIDs administration. The long-term toxicity of NSAIDs in cancer pain is poorly defined due to a lack of studies. A variety of strategies have been used in an attempt to reduce the risks associated with NSAID therapy. Those NSAIDs that are weak COX-1 inhibitors may be preferred. In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications.

Pain management in older adults: prevention and treatment

The release of guidelines in 1998 by the American Geriatrics Society on "The Management of Chronic Pain in Older Persons" was a breakthrough in helping to manage pain in this population. Already advances have fostered a need to update recommendations. This article focuses on the treatment strategies available for seniors that are likely to help to fulfill the obligation to relieve pain and suffering in patients. A review was done of the literature using Medline and other search techniques. New pain scales have been developed with seniors in mind and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. Advances in cyclooxygenase inhibition selectivity, alternative medicine, and progress in the identification of nonopioid pain receptors and the development of products to target them are just a few of changes that have altered the way clinicians think about treating pain. The use of hospice in end-of-life palliative care is a valuable resource for clinicians managing pain at that phase in care as well. Tools are available to prevent and treat pain successfully in seniors. Educating clinicians about available assessment tools, techniques and interventions may be the biggest challenge to comforting the older adult in pain.

The pharmacological basis of contemporary pain management

Pain management has become an increasingly well researched area in medicine over recent years, and there have been advances in a number of areas. While opioids remain an integral part of pain-management strategies, there is now an emphasis on the use of adjuvant drugs, such as paracetamol and anti-inflammatory agents, which through physiological or pharmacological synergism, both enhance pain control and reduce opioid use. The management of neuropathic pain continues to be a challenge. Anti-epileptics and antidepressants, together with clonidine and ketamine, provide the foundations for treatment. Another area of interest has been the widespread use of patient-controlled analgesia and the administration of some drugs, especially opioids, by means other than traditional oral and parenteral routes. The number of new drugs that have reached the stage of clinical trials has been small, yet they offer exciting possibilities. The epibatidine analogue ABT-594 and zinconitide both offer novel approaches to the management of neuropathic pain states, while selective cyclo-oxygenase-2 inhibitors and nitroaspirins may see advances in the management of nociceptive pain states.

Limitations of NSAIDs for pain management: Toxicity or lack of efficacy?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in the management of arthritis and acute and chronic pain of many etiologies, including cancer-related pain. These drugs are indicated for use as single agents in mild to moderate pain and in combination with opioid analgesics or adjuvant analgesic drugs in severe pain. NSAIDs, which nonselectively inhibit the cyclooxygenase enzymes (isoenzymes 1 and 2), pose a potentially serious risk of gastrointestinal toxicity with acute and chronic use, hematologic toxicity with acute use, and nephrotoxicity with chronic use. Patients experiencing acute and chronic pain associated with serious and even life-threatening medical illness such as cancer and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) fall into a high-risk group with respect to the use of NSAIDs. This is so because the occurrence of gastrointestinal bleeding and the masking of opportunistic infections related to the antipyretic effects of NSAIDs pose particular risk and might even cause lethal complications in patients who are neutropenic, thrombocytopenic, or otherwise immuno-compromised.

Meta-analysis in hematology and oncology

In 1992, a review article about meta-analysis identified only 15 meta-analyses of randomized, controlled trials of cancer therapy. Since then, the total number of meta-analyses in this field has increased almost sixfold. More importantly, the number of randomized, controlled trials in this discipline has also grown tremendously. The expansion in the literature will provide a fertile ground for future meta-analyses. The quality of the recent publications has also improved. An ongoing world-wide effort, the Cochrane Collaboration, is systematically assembling and synthesizing several hundred thousand randomized, controlled trials to improve the delivery of health care. Meta-analysis has many important advantages. It allows the viewing of the complete picture of the evidence. The advent of meta-analysis has sensitized researchers to issues of quality and has improved methodology in clinical research. Detection and explanation of bias and heterogeneity are prime objectives of meta-analysis in clinical research. An array of methods has been developed that allows a better understanding of bias and heterogeneity, beyond simple averaging of results from diverse studies. Meta-analyses of individual patient data, in particular, may promote the development of international collaborations. Several examples of their application are already available in oncology. Meta-analysis may point out deficiencies in the study design of past and current studies, suggest the need for new studies, and inform researchers about the size and design of these studies. In the end, meta-analysis helps to integrate evidence and make recommendations for medical care and medical practice.

Advances in pain management for older adult patients

Management of pain is crucial to the success of any program of care and support for dying patients and their families. Pain can be controlled in more than 90% of older adults. Components of an effective program include comprehensive, repeated pain assessment; detection and treatment of complicating medical and psychological disorders (e.g., delirium); spiritual concerns; and the judicious use of nonpharmacologic and pharmacologic therapies, radiation, and radiopharmaceuticals. Strategies that enable clinicians to prevent and treat the expected complications of nonsteroidal anti-inflammatory and opioid therapies are reviewed. Strategies to change opioid agents or routes to minimize opioid-induced side effects and to provide effective pain relief as death nears are presented.

Chronic sodium salicylate treatment exacerbates brain neurodegeneration in rats infected with Trypanosoma brucei

We have reported previously that axonal degeneration in specific brain regions occurs in rats infected with the parasite Trypanosoma brucei. These degenerative changes occur in spatiotemporal association with over-expression of pro-inflammatory cytokine messenger RNAs in the brain. To test how aspirin-like anti-inflammatory drugs might alter the disease process, we fed trypanosome-infected rats with 200mg/kg of sodium salicylate (the first metabolite of aspirin) daily in their drinking water. Sodium salicylate treatment in uninfected rats did not cause any neural damage. However, sodium salicylate treatment greatly exacerbated neurodegeneration in trypanosome-infected rats, resulting in extensive terminal and neuronal cell body degeneration in the cortex, hippocampus, striatum, thalamus, and anterior olfactory nucleus. The exaggerated neurodegeneration, which occurred in late stages of infection, was temporally and somewhat spatially associated with a late-appearing enhancement of messenger RNA expression of interleukin-1beta, interleukin-1beta converting enzyme, tumor necrosis factor-alpha, and inhibitory factor kappaBalpha in the brain parenchyma. Restricted areas showed elevations in messenger RNA expression of interleukin-1 receptor antagonist, interleukin-6, inducible nitric oxide synthase, interferon-gamma, and inducible cyclooxygenase. The association suggests that increased production of pro-inflammatory cytokines in the brain may be an underlying mechanism for neural damage induced by the chronic sodium salicylate treatment. Furthermore, the results reveal a serious complication in using aspirin-like drugs for the treatment of trypanosome infection.

Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use

Randomised controlled trials (RCTs) alone are unlikely to provide reliable estimates of the incidence of rare events because of their limited size. Cohort, case control, and other observational studies have large numbers but are vulnerable to various kinds of bias. Wanting to estimate the risk of death from bleeding or perforated gastroduodenal ulcers with chronic usage of non-steroidal anti-inflammatory drugs (NSAIDs) with greater precision, we developed a model to quantify the frequency of rare adverse events which follow a biological progression. The model combined data from both RCTs and observational studies. We searched systematically for any report of chronic (>/=2 months) use of NSAIDs which gave information on gastroduodenal ulcer, bleed or perforation, death due to these complications, or progression from one level of harm to the next. Fifteen RCTs (19364 patients exposed to NSAIDs for 2-60 months), three cohort studies (215076 patients redeeming a NSAID prescription over a 3-12 month period), six case-control studies (2957 cases) and 20 case series (7406), and case reports (4447) were analysed. In RCTs the incidence of bleeding or perforation in 6822 patients exposed to NSAIDs was 0.69%; two deaths occurred. Of 11040 patients with bleeding or perforation with or without NSAID exposure across all reports, 6-16% (average 12%) died; the risk was lowest in RCTs and highest in case reports. Death from bleeding or perforation in all controls not exposed to NSAIDs occurred in 18 out of 849489 (0.002%). From these numbers we calculated the number-needed-to-treat for one patient to die due to gastroduodenal complications with chronic (>/=2 months) NSAIDs as 1/((0.69x¿6-16%, average 12%¿)-0.002%))=909-2500 (average 1220). On average 1 in 1200 patients taking NSAIDs for at least 2 months will die from gastroduodenal complications who would not have died had they not taken NSAIDs. This extrapolates to about 2000 deaths each year in the UK.

Management of cancer pain. Safe, adequate analgesia to improve quality of life

Pain is one of the most common problems for cancer patients, and its management is often hindered by barriers created by patients and physicians alike. By avoiding potential barriers and understanding the principles of pain management and drug selection and titration provided here by Dr Hartmann and colleagues, physicians can safely administer adequate pain relief to their patients in need.

High-dose tramadol in comparison to low-dose morphine for cancer pain relief

Cancer pain treatment following the World Health Organization guidelines is effective and feasible. However, the evidence supporting the use of opioids for mild to moderate pain on the second step of the analgesic ladder is widely discussed. The present evaluation compares the efficacy and safety of high doses of oral tramadol (> or = 300 mg/d) with low doses of oral morphine (< or = 60 mg/d). Patients were included in this nonblinded and nonrandomized study if the combination of a nonopioid analgesic and up to 250 mg/d of oral tramadol was inadequate. 810 patients received oral tramadol for a total of 23,497 days, and 848 patients received oral morphine for a total of 24,695 days. The average dose of tramadol was 428 +/- 101 mg/d (range 300-600 mg/d); the average dose of morphine was 42 +/- 13 mg/d (range 10-60 mg/d). Additional nonopioid analgesics were given on more than 95% of days. Antiemetics, laxatives, neuroleptics, and steroids were prescribed significantly more frequently in the morphine group; the use of other adjuvants was similar in both groups. The mean pain intensity on a 0-100 numerical rating scale (NRS) was 27 +/- 21 (95% CI 26-29) in the tramadol and 26 +/- 20 (95% CI 24-27) in the morphine group (NS). The analgesic efficacy was good in 74% and 78%, satisfactory in 10% and 7%, and inadequate in 16% and 15% of patients receiving tramadol and morphine, respectively (NS). Constipation, neuropsychological symptoms, and pruritus were observed significantly more frequently with low-dose morphine; other symptoms had similar frequencies in both groups. These data suggest that tramadol can be used for the treatment of cancer pain, when nonopioids alone are not effective. High doses of tramadol are effective and safe.

Management of pain and spinal cord compression in patients with advanced cancer. ACP-ASIM End-of-life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine

General internists often care for patients with advanced cancer. These patients have substantial morbidity caused by moderate to severe pain and by spinal cord compression. With appropriate multidisciplinary care, pain can be controlled in 90% of patients who have advanced malignant conditions, and 90% of ambulatory patients with spinal cord compression can remain ambulatory. Guidelines have been developed for assessing and managing patients with these problems, but implementing the guidelines can be problematic for physicians who infrequently need to use them. This paper traces the last year of life of Mr. Simmons, a hypothetical patient who is dying of refractory prostate cancer. Mr. Simmons and his family interact with professionals from various disciplines during this year. Advance care planning is completed and activated. Practical suggestions are offered for assessment and treatment of all aspects of his pain, including its physical, psychological, social, and spiritual dimensions. The methods of pain relief used or discussed include nonpharmacologic techniques, nonopioid analgesics, opioids, adjuvant medications, radiation therapy, and radiopharmaceutical agents. Overcoming resistance to taking opioids; initiating, titrating, and changing opioid routes and agents; and preventing or relieving the side effects they induce are also covered. Data on assessment and treatment of spinal cord compression are reviewed. Physicians can use the techniques described to more readily implement existing guidelines and provide comfort and optimize quality of life for patients with advanced cancer.

Nonsteroidal anti-inflammatory drugs as adjuvant analgesics in cancer patients

The role of nonsteroidal anti-inflammatory drugs (NSAIDs) is examined in the control of cancer pain with a particular focus on their use as adjuvants to opioids in advanced cancer pain. These agents have both a peripheral effect on inflammation and a role in attenuating central pain pathways. The possibility of obtaining the benefits of NSAIDs with fewer side-effects by using COX-2-specific agents is discussed. The gastrointestinal, renal, haemostatic, cognitive and hypersensitivity side-effects of NSAIDs are reviewed and their potential impact assessed. The evidence for the efficacy of NSAIDs as single agents for cancer pain is reviewed together with the nine papers which have reported the effects of NSAIDs as adjuvants to opioids in cancer pain. All of these papers reported positive results of NSAIDs, but, in the absence of any randomized, double-blind controlled trials, where NSAIDs were used as adjuvants on a long-term basis alongside optimal opioid use, definite conclusions cannot be reached. Guidelines for the safe use of NSAIDs are suggested. Finally, suggestions for future research are made.

Pain treatment and outcomes for patients with advanced cancer who receive follow-up care at home

BACKGROUND

A small sample size, a high rate of exclusions, inadequate follow-up in different settings, and a lack of comparison with previous levels of analgesia have recently been reported to be the principal limitations of the World Health Organization (WHO) guidelines regarding cancer pain.

METHODS

A total of 3678 consecutive patients with advanced cancer referred to a home palliative care program were enrolled in an open prospective study over a 9-year period, from June 1988 to June 1997, to determine the effectiveness, safety, and feasibility of implementing the WHO guidelines. Age, gender, Eastern Cooperative Oncology Group performance status, pain mechanism at referral, pain and symptom intensity, and doses and days of drug administration during the course of the treatment were recorded at regular intervals.

RESULTS

Therapy was required for 70.3% of patients for a mean duration of 64 days. The mean duration periods of the 3 steps were 18, 27, and 19 days, respectively. At referral, most patients received inadequate treatment. In the last week of life, 16%, 49%, and 35% of patients were taking nonopioid drugs, moderate opioids, and strong opioids, respectively. A significant improvement in pain and symptom intensity was achieved after referral. Symptom intensity worsened in the last week of life. A minority of patients (2.65%) underwent invasive procedures.

CONCLUSIONS

This study demonstrates that a managed home care system enables patients to receive adequate pain treatment, according to WHO guidelines, in the comfort of their own homes.

Pain Management in the Cancer Patient

Of the over one million patients diagnosed with cancer each year, 30 percent will have pain at diagnosis and up to 85 percent will have pain as their disease progresses. Adequate pain management continues to be hindered by multiple patient-and clinician-related barriers; however, with increased awareness and knowledge, the pharmacy practitioner can play a key role in facilitating pain management. This review will focus on the mechanisms of cancer pain, the role of non-opioids, opioids, and adjuvant agents in the treatment of cancer pain, and the basic principles of cancer pain management that allow 70 to 90 percent of patients to achieve excellent pain control.

Nursing management of the patient with bone metastases

OBJECTIVES

To review the problem of bone metastases and strategies aimed at the management of bone metastases.

DATA SOURCES

Review articles, book chapters, research studies, and clinical practice.

CONCLUSIONS

As patients survive for longer periods, effective management of bone metastases becomes critical to maintaining or improving quality of life. Controlling pain, preventing fractures and oncologic emergencies, and promoting mobility and function are the outcomes of successful management.

IMPLICATIONS FOR NURSING PRACTICE

Use of a clinical algorithm may assist the nurse in identifying bone metastases and managing the clinical sequelae, such as pain.

Promoting symptom control in palliative care

OBJECTIVES

To describe management of common physical problems that occur in patients with advanced cancer.

DATA SOURCES

Research and review articles, book chapters, and published guidelines.

CONCLUSIONS

Effective symptom control for patients with advanced cancer requires the coordinated efforts of a multidisciplinary team. Excellent palliation can be achieved in patients suffering from pain, as well as from gastrointestinal, respiratory, or dermatologic disorders.

IMPLICATIONS FOR NURSING PRACTICE

Nursing is the cornerstone of effective palliative care. Through accurate assessments and expertise in delivering pharmacologic and nonpharmacologic treatments, nurses ensure optimal palliation of physical symptoms.

Managing the pain of bone metastases in the home environment

This article presents an in-depth review of the medical, pharmacological and nursing interventions needed to relieve the pain experienced with bone metastases. Covered areas include: Pathophysiology. Clinical presentation of bone pain. Treatment options. Therapeutic interventions. The hospice nurse as an agent of hope. In addition, a comprehensive presentation of nonopioid medications used in managing bone pain is provided in table format.

Opioid-sparing effect of diclofenac in cancer pain

This study investigated the opioid-sparing effect of diclofenac using patient-controlled analgesia with oral methadone. Fifteen patients with advanced cancer participated. After achieving adequate analgesia with regular dosing of oral methadone (T1), patient-controlled analgesia with methadone was administered for 3 days (T2). Intramuscular diclofenac 75 mg twice daily was then added to this regimen for 3 days (T3). Compared to T2 values, methadone dose was significantly reduced at T2 and T2, and pain report (recorded on a visual analogue scale) was significantly reduced at T3. A reduction in methadone plasma concentration was also observed at T2 and T3, although it did not attain statistical significance. Significant decreases in the intensity of several symptoms other than pain were also found at T2 and T3. Diclofenac appears to have a relevant opioid-sparing effect when using patient-controlled analgesia with oral methadone.

Analgesic efficacy and safety of paracetamol-codeine combinations versus paracetamol alone: a systematic review

OBJECTIVES

To assess whether adding codeine to paracetamol has an additive analgesic effect; to assess the safety of paracetamol-codeine combinations versus paracetamol alone.

DESIGN

Systematic literature review with meta-analysis, methodological quality of published trials being scored by means of 13 predefined criteria.

TRIALS

24 of 29 trials that met the inclusion criteria. Models studied in the trials were postsurgical pain (21), postpartum pain (one), osteoarthritic pain (one), and experimentally induced pain (one).

INTERVENTIONS

Dosages ranged from 400 to 1000 mg paracetamol and 10 to 60 mg codeine.

MAIN OUTCOME MEASURES

The sum pain intensity difference (efficacy analysis) and the proportion of patients reporting a side effect (safety analysis).

RESULTS

Most trials were considered of good to very good quality. Only the single dose studies could be combined for analysis of analgesic efficacy. Pooled efficacy results indicated that codeine added to paracetamol provided a 5% increase in analgesia on the sum pain intensity difference. This effect was comparable to the difference in analgesic effect between codeine and placebo. The cumulative incidence of side effects with each treatment was comparable in the single dose trials. In the multidose studies a significantly higher proportion of side effects occurred with paracetamol-codeine preparations.

CONCLUSION

The difference is analgesic effect between paracetamol-codeine combinations and paracetamol alone was small but statistically significant. In the multidose studies the proportion of patients reporting a side effect was significantly higher with paracetamol-codeine combinations. For occasional pain relief a paracetamol-codeine combination might be appropriate but repeated use increases the occurrence of side effects.

Analgesic efficacy of paracetamol and its combination with codeine and caffeine in surgical pain--a meta-analysis

The objective of this study was to quantify the analgesic efficacy of paracetamol and its combination with codeine or caffeine through a systematic overview and meta-analysis of relevant randomized controlled trials (RCTs). Systematic retrieval of relevant clinical trials was carried out using computerized searches, historical searches and communication with manufacturers. The results of RCTs were pooled to estimate (i) the difference in percentage improvement of total pain relief (TOTPAR%) and the sum of pain intensity difference (SPID%); (ii) the proportions of patients obtaining moderate to excellent pain relief relative to placebo (ResRR) and (iii) the ratio of patients requiring analgesic re-medication (RemRR). Head-to-head comparisons were also undertaken for paracetamol versus its combination with codeine or caffeine. A total of 80 RCT reports describing 103 placebo comparisons and 26 head-to-head comparisons were identified. The total pain relief score in the single dose studies increased by 38 percentage points for paracetamol and by 24 points for placebo. The difference (d) in TOTPAR% between the two was highly significant (d = 14, 95% CI: 12, 16). For the difference in SPID%, d = 12, 95% CI: 11, 13. Patients were more than twice as likely to obtain moderate to excellent pain relief on paracetamol than on placebo (ResRR = 2.39, 95% CI: 1.89, 3.02), and less likely to require re-medication (RemRR = 0.78, 95% CI: 0.69, 0.88). There was no significant (P > 0.05) dose-response relationship. The analgesic efficacy of paracetamol 600 mg was enhanced with the addition of codeine 60 mg (using TOTPAR% as outcome) in both indirect and head-to-head comparisons. SPID%, but not ResRR and RemRR, data supported this conclusion. Much weaker effects were observed with the caffeine combination. Adverse effects were mild. Surprisingly, drowsiness was seen more often with paracetamol and paracetamol-codeine combinations than with placebo. The relative risks (95% CI) were 1.83 (1.29, 2.59) and 2.39 (1.58, 3.57), respectively. In conclusion paracetamol is an effective analgesic for post-surgical pain. Caffeine adds little to the analgesic effect of paracetamol. However, there is some evidence that codeine 60 mg adds to the analgesic effects of paracetamol 600 mg, using pain relief or pain intensity scores as outcomes, but this is not necessarily translated into an increase in number of patients who obtain moderate to excellent pain relief.

Management of painful paraneoplastic syndromes

The majority of patients with advanced malignant disease experience pain, so pain is commonly present in patients with paraneoplastic syndromes. It is rare, however, that the pain itself is a paraneoplastic manifestation of cancer. Usually, the pain in this context is associated with a paraneoplastic syndrome but is not a direct result of that syndrome. Three syndromes in which pain is part of the syndrome and a paraneoplastic manifestation of malignant disease--neuropathy, ganglionitis, and monolitis--have been described in the literature. These syndromes and their management are discussed in this article.

Pain and Symptom Management in Palliative Care

BACKGROUND: Pain, dyspnea, and anorexia are common symptoms experienced by patients with cancer and often are poorly managed. METHODS: The incidence and causes of these symptoms are described, as well as factors that exacerbate or ameliorate their impact. RESULTS: Pharmacologic management of cancer pain is based on the use of a sequential "ladder" that incorporates nonopioid, opioid, and adjuvant drugs, depending on the severity of the pain. This approach usually is effective. Other symptoms of advanced disease may be more difficult to control. CONCLUSIONS: Adherence to an adequate pain-control strategy will significantly enhance palliation of pain in patients with cancer.

Comparative analgesic efficacy of patient-controlled analgesia with ketorolac versus morphine after elective intraabdominal operations

We conducted a randomized, double-blind trial to compare analgesia and side effects produced by ketorolac and morphine during postoperative patient-controlled analgesia (PCA). Fifty-one patients (ASA classes I and II) undergoing elective intraabdominal procedures were assigned to one of two groups. When postoperative pain first increased to 4/10 (by visual analog scale [VAS]), patients were randomly assigned to one of two groups. Group 1 (n = 25) received up to two intravenous (IV) boluses of 5 mg of morphine followed by IV morphine PCA, whereas those in Group 2 (n = 26) received up to two IV boluses of 30 mg ketorolac, then IV ketorolac PCA. Up to two rescue doses of morphine (5 mg per dose, subcutaneously) were given in either group when pain during deep inhalation exceeded 5/10 on VAS. Ten patients from Group 1 required rescue doses of morphine compared to 22 patients from Group 2 (P < 0.0011). Two and 16 patients from Groups 1 and 2, respectively, were withdrawn because of inadequate analgesia (P < 0.01). Mean pain scores were less in Group 1 than in Group 2 at each time, but only significantly so at 15 min (P < 0.0021), 30 min (P < 0.0336), and 24 h (P < 0.0358) after starting PCA. Time to acceptance of oral liquids was equivalent in Groups 1 and 2 (22 h and 21 h, respectively). IV ketorolac PCA, although well tolerated, has limited effectiveness as the sole postoperative analgesic after intraabdominal operations.