Use of nonsteroidal anti-inflammatory drugs in cancer

Dosage plan of a flurbiprofen injection product using inhibition of protein binding by lipid emulsion in rats

Flurbiprofen-axetil (FP-ax), a bolus injection product of a non-steroidal anti-inflammatory drug (NSAID), is a prodrug of flurbiprofen, an NSAID. As flurbiprofen strongly binds to site II of human serum albumin (HSA), the free (unbound) concentration of flurbiprofen after injection of FP-ax is low. We have examined the inhibitory effect of free fatty acid (FFA), a binding inhibitor for site II of HSA, on the binding of flurbiprofen in-vitro and in-vivo by ultrafiltration, to establish an effective dosage of FP-ax. In-vitro, fatty acid mixtures (FAs) inhibited the binding of flurbiprofen to rat serum albumin. The free fraction of flurbiprofen was remarkably increased by FAs in rat serum. In-vivo, FP-ax was injected into a control group (low FFA concentration in serum) and a lipid emulsion group (high FFA concentration in serum). The area under the curve of the free concentration of flurbiprofen during the alpha phase and the distribution volume of the central compartment of flurbiprofen were significantly higher in the lipid emulsion group than the control group (5.0- and 1.2-times, respectively). When FP-ax was administered at high FFA concentration, the free concentration of flurbiprofen and distribution of flurbiprofen to tissues increased transiently. This administration method may be useful for patients with cancer pain, having a potent analgesic effect.

Anti-ulcer role of herbomineral Siddha drug - Thamira parpam on experimentally induced gastric mucosal damage in rats

Anti-ulcerogenic activity of Thamira parpam (TP) was investigated in two ulcer models (aspirin + pylorus ligation and HCl-ethanol). Aspirin-pylorus ligation (Asp 200 mg/kg-7 days + PL-4 hours) and HCl-ethanol (150 mM HCl in 70% ethanol) induction in rat resulted in elevation of thiobarbituric acid reactive substances (TBARS) and depletion of antioxidants (superoxide dismutase [SOD], glutathione [GSH], glutathione peroxidase [GPx]) with high ulcer scores (p < .01). In Asp + PL model, TP treatment showed mild inhibition on ulcer scores, changes in pH, gastric volume, total and free acidity, and elevation of TBARS and depletion of antioxidants. Compared to the ulcer-untreated rats (HCl-ethanol), the herbomineral drug TP treatment (0.5, 1, 2 mg/kg, per oral [p.o.]) attenuated the elevation of TBARS, decrease of antioxidants and nitrite (p < .05). Histopathological examinations were correlated with the antioxidant profile. In conclusion, the prophylactic cytoprotective nature of the herbomineral drug in experimentally induced ulcers could be mediated by its free radical quenching property.

Healing properties of malabaricone B and malabaricone C, against indomethacin-induced gastric ulceration and mechanism of action

The healing activity of malabaricone B and malabaricone C, the major antioxidant constituents of the spice Myristica malabarica against the indomethacin-induced gastric ulceration in mice has been studied. The histological indices revealed maximum ulceration on the 3rd day after indomethacin administration, which was effectively healed by malabaricone B, malabaricone C (each 10 mg/kg body weight/day) and omeprazole (3 mg/kg body weight/day) for 3 days. Compared to the untreated ulcerated mice, treatment with malabaricone B, malabaricone C and omeprazole reduced the ulcer indices by 60.3% (P<0.01), 88.4% and 86.1% respectively (P<0.001). All the test samples accelerated ulcer healing than observed in natural recovery even after 7 days. Stomach ulceration reduced the total antioxidant status of plasma by 41% (P<0.05), which was significantly increased by malabaricone B (36%, P<0.01), malabaricone C (61%, P<0.001) and omeprazole (53%, P<0.001). Compared to the ulcerated untreated mice, those treated with malabaricone B reduced the levels of thiobarbituric acid reactive substances and protein carbonyls by 17% and approximately 34% respectively (P<0.05), while malabaricone C and omeprazole reduced the parameters almost equally (approximately 30%, P<0.01, and approximately 40%, P<0.01 respectively). Likewise, all the test samples reduced the oxidation of protein and non-protein thiols significantly (P<0.05). The antioxidant activity of the test samples could partly account their healing capacities. However, the differential potency of them was explainable by considering their relative abilities to modulate mucin secretion, PGE(2) synthesis and expression of EGF receptor and COX isoforms, malabaricone C being most effective in controlling all these factors.

Healing property of the Piper betel phenol, allylpyrocatechol against indomethacin-induced stomach ulceration and mechanism of action

AIM: To evaluate the protective activity of allylpyrocatechol (APC), the major antioxidant constituent of Piper betel, against the indomethacin-induced stomach ulceration in the rat model and correlates with its antioxidative and mucin protecting properties.

METHODS: Male Sprague-Dawley rats were divided into five groups. Normal control rats (group I) were given the vehicle oral dose of gum acacia in distilled water (1 mL per rat); ulcerated control and treated rats (groups II-V) were given a single dose of indomethacin (30 mg/kg body wt.); group II rats were sacrificed 4 h after indomethacin administration; groups III-V rats were given the vehicle (1 mL per rat) or APC (2 mg/kg body wt.) or misoprostol (1.43 μg/kg body wt.) once daily by oral intubation for 7 d starting from 4 h after the indomethacin administration. After 7 d, the stomach tissues were excised for histological examination and biochemical analysis.

RESULTS: Treatment with APC (2 mg/kg body wt per day) and misoprostol (1.43 μg/kg body wt per day) for 7 d could effectively heal the stomach ulceration as revealed from the ulcer index and histopathological studies. Compared to the zero day ulcerated group, treatment with APC and misoprostol reduced the ulcer index by 93.4% and 85.4% respectively (P < 0.05). Both APC and misoprostol accelerated ulcer healing observed in natural recovery (P < 0.05), their respective healing capacities not being significantly different. The healing capacities of APC and misoprostol could be attributed to their antioxidant activity as well as the ability to enhance the mucin content of the gastric tissues. Compared to the ulcerated untreated rats, those treated with APC and misoprostol showed near normal MDA levels, while the protein levels were 86% and 78% of the normal value respectively (P < 0.05). Likewise, both APC and misoprostol increased the SOD, catalase, and mucin levels significantly (P < 0.05), the effect of APC being better.

CONCLUSION: APC can protect indomethacin-induced gastric ulceration due to its antioxidative and mucin protecting properties.

Palliating Patients Who Have Unresectable Colorectal Cancer: Creating the Right Framework and Salient Symptom Management

The last phases of colorectal malignant illness may be the most challenging and saddening for all involved, but they offer opportunities to become the most rewarding. This transformation of hopelessness to fulfillment requires a willingness by surgeon, patient, and patient's family to trust one another to realistically set goals of care, stick together, and not let the treatment of the disease become a surrogate for treating the suffering that characterizes grave illness.

NSAIDs: gastroprotection or selective COX-2 inhibitor?

Conventional nonsteroidal anti-inflammatory drugs (NSAIDs) are effective adjuvant analgesics commonly encountered in palliative care. However, these drugs are associated with adverse effects that are primarily due to gastrointestinal toxicity, with resultant serious complications such as gastroduodenal perforations, ulcers and bleeds. This toxicity has been attributed to inhibition of cyclooxygenase-1 (COX-1). Factors known to increase this risk of toxicity include age above 65 years, classification of NSAID in terms of COX-1/COX-2 selectivity, previous history of complications and coadministration of aspirin, anticoagulants and corticosteroids. Selective inhibitors of cyclooxygenase-2 (COX-2) were developed in an attempt to reduce this association; trials to date confirm that these drugs do indeed have reduced incidence of gastroduodenal toxicity. Prior to the introduction of the COX-2 selective inhibitors, patients at high risk were often coprescribed a gastroprotective agent (such as misoprostol or a proton pump inhibitor) with a conventional NSAID. This review discusses the merits of both options and devises a treatment strategy for the safe and cost-effective use of these drugs in the palliative care population.

Double-blind evaluation of short-term analgesic efficacy of orally administered dexketoprofen trometamol and ketorolac in bone cancer pain

The analgesic efficacy and safety of dexketoprofen trometamol (the active enantiomer of the racemic compound ketoprofen) (25mg q.i.d.) vs. ketorolac (10mg q.i.d.) was assessed in 115 patients with bone cancer pain included in a multicenter, randomized, double-blind, parallel group study. A level of >/=40 mm on the 100 mm visual analog scale (VAS) and >/=10 in the pain rating index were required for inclusion. At the end of treatment on day 7 (+1 day), mean values of VAS were 32+/-24 mm for dexketoprofen and 40+/-30 mm for ketorolac (P=0.12) but the pain rating index was significantly lower in patients given dexketoprofen (8.5+/-2.3 vs. 9.7+/-2.9, P=0.04). Moreover, most of the patients reached a pain intensity difference from baseline >/=20 mm (75% of patients for dexketoprofen and 65% of patients for ketorolac). Around half of patients in both treatments had a pain intensity <30 mm on VAS at the end of treatment (55% for dexketoprofen and 47% for ketorolac). In the overall assessment of efficacy, a higher percentage of both patients and physicians rated dexketoprofen as 'quite effective' or 'very effective' compared to ketorolac. The percentage of patients withdrawn from the study for any reason as well as for insufficient therapeutic effect or due to adverse events was lower in the dexketoprofen group than in the ketorolac group. Treatment-related adverse events occurred in 16% of patients given dexketoprofen and in 24% given ketorolac. Serious adverse events occurred in 3.5% of patients from both groups but only one case of gastrointestinal hemorrhage was considered related to ketorolac. We conclude that dexketoprofen trometamol 25 mg q.i.d. oral route is a good analgesic therapy in the treatment of bone cancer pain, comparable to ketorolac 10 mg q.i.d., with a good tolerability profile.

Ibuprofen to rofecoxib: what does it all mean and what do I do now?

NSAIDs are used throughout the World Health Organization three-step analgesic ladder, and are indicated for pain in all stages of malignancy. Side-effects are common with NSAIDs. Much has been written about NSAIDs and COX, since the discovery of COX-1 and COX-2 isoforms. How do you choose the appropriate NSAID? The choice of NSAID continues to be dependent upon associated gastroduodenal toxicity and the related risk factors of individual patients. Choosing the appropriate NSAID should minimize the likelihood of needing additional medications to manage adverse effects and symptoms caused by the NSAID therapy itself.

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.

The gastroduodenal toxicity of nonsteroidal anti-inflammatory drugs: a review of the literature

Nonsteroidal anti-inflammatory drugs (NSAIDs) are popular and important for the treatment of inflammation and pain. However, conventional NSAIDs are intrinsically toxic to the gastroduodenal (GD) mucosa. The literature can, and should, guide us towards safer prescribing of NSAIDs. Factors known to increase the risk of GD toxicity include: history of peptic ulcer disease; advanced age; high doses; and coadministration of aspirin, anticoagulants or corticosteroids. Patients with any one of these risk factors, with the possible exception of age alone, should receive gastroprotective prophylaxis with proton pump inhibitors or misoprostol. Standard dose H2 antagonists do not protect against NSAID-induced gastric ulcers and are unsuitable for prophylaxis. Awareness of risk factors and appropriate prophylactic agents will minimize the risk to patients. Whether the new generation of highly selective COX-2 inhibitors and nitric oxide-donating NSAIDs are safer drugs in long-term use be remains to be proven, though initial clinical trial data are positive.

Analgesic effects of nonsteroidal anti-inflammatory drugs in cancer pain due to somatic or visceral mechanisms

The role of nonsteroidal anti-inflammatory drugs (NSAIDs) is well established in the treatment of cancer pain. This class of drugs is considered particularly effective in pain due to somatic mechanisms, although proof of this observation is lacking. To ascertain whether NSAIDs are more effective in specific nociceptive forms of cancer pain, they were administered alone or added to opioids in 32 patients with a sole pain mechanism, somatic pain due to bone metastases (17 patients) or visceral pain (15 patients), respectively. Pain intensity, mean doses of opioids used, and symptoms were recorded after starting NSAID. A significant reduction in pain intensity was found at 3, 7, and 14 days. No differences in pain intensity between the two groups were observed. However, patients with a visceral mechanism required higher opioid doses after a week of treatment. No differences in adverse effects were reported. NSAIDs may be useful drugs in the management of cancer pain, regardless of the mechanism of pain involved. The incidence of adverse effects during prolonged administration should be assessed in future studies.

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.

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.

New approaches to pain control in patients with cancer

Pain affects most patients with malignant disease, and the prevalence of severe pain increases in the advanced stages of the condition. One in 5 patients with cancer has uncontrolled pain, even after 10 years of the use of the World Health Organization programme for cancer pain control and its 'three-step ladder' for the rational use of analgesics including morphine. Morphine has long been the 'gold standard' for the treatment of severe cancer pain. However, its side-effects, particularly sedation, cognitive impairment and myoclonus at high doses, have provoked the use of 'opioid rotation' to alternatives such as methadone and hydromorphone. The new 72-h transdermal patch for fentanyl also offers advantages of reduced side-effects and increased convenience over oral morphine. Intravenous strontium-89 and bisphosphonate therapy are effective for both short- and long-term control of metastatic bone pain. The spinal N-methyl-D-aspartate (NMDA) receptor is important in modulating the plasticity of the central nervous system and in aggravating chronic pain through the phenomenon of 'wind-up'. The NMDA antagonist ketamine, an anaesthetic, can be used at low doses for the management of refractory and neuropathic pains. Among adjuvant drugs, ketorolac has emerged as a potent non-steroidal anti-inflammatory drug. Palliative care is gaining acceptance as a new discipline in healthcare. Its strategic role is being reviewed as an adjunct to cancer therapy at all stages and its use is no longer confined to the terminal phase of disease after curative treatment has failed. Pain control and other aspects of symptom control are, therefore, viewed as an integral part of cancer management.

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.