Use of non-steroidal anti-inflammatory drugs in the treatment of pain in cancer

Regenerative and Protective Actions of the GHK-Cu Peptide in the Light of the New Gene Data

The human peptide GHK (glycyl-l-histidyl-l-lysine) has multiple biological actions, all of which, according to our current knowledge, appear to be health positive. It stimulates blood vessel and nerve outgrowth, increases collagen, elastin, and glycosaminoglycan synthesis, as well as supports the function of dermal fibroblasts. GHK’s ability to improve tissue repair has been demonstrated for skin, lung connective tissue, boney tissue, liver, and stomach lining. GHK has also been found to possess powerful cell protective actions, such as multiple anti-cancer activities and anti-inflammatory actions, lung protection and restoration of chronic obstructive pulmonary disease (COPD) fibroblasts, suppression of molecules thought to accelerate the diseases of aging such as NFκB, anti-anxiety, anti-pain and anti-aggression activities, DNA repair, and activation of cell cleansing via the proteasome system. Recent genetic data may explain such diverse protective and healing actions of one molecule, revealing multiple biochemical pathways regulated by GHK.

Percutaneous Image-Guided Cryoablation as Second-Line Therapy of Soft-Tissue Venous Vascular Malformations of Extremities: A Prospective Study of Safety and 6-Month Efficacy

PURPOSE

To report the safety and short-term efficacy of percutaneous image-guided cryoablation performed as second-line therapy of venous vascular malformations (VVM) of extremities.

MATERIALS AND METHODS

In this non-blinded, no-randomized trial, cryoablation was proposed in 14 patients presenting with symptomatic VVM for recurrences after treatment. Eligibility criteria were: cryoablation feasible, localization at least 5 mm from skin and nerves, absence of contra-indication for anesthesia. Safety was evaluated by the common terminology criteria for adverse events (AE). Clinical response was assessed by evaluating pain at day 7, month 2 and 6 using visual analog scale; quality of life before cryoablation and at 2 and 6 months after using questionnaire. Evolution of volume was evaluated by MRI at 6 months. Comparison was performed using the Wilcoxon test.

RESULTS

A technical success was observed in all cases. While 11 patients (78.6%) presented AE (13 grade 1-2 and 3 grade 3), only two severe AE (grade 3) related to cryoablation occurred in two patients (14.3%) during the 6-month follow-up: one immediate sciatic paralysis and one delayed paresthesia. A clinical response was observed in 12 patients (85.7%) at 6 months. Pain decreased significantly from 42.5 ± 14.2 mm before the intervention to 11.8 ± 17.9 mm at 6 months (P = 0.002). A significant decrease in the mean volume from 12.8 ± 14.3 to 3 ± 2.7 cm³ was observed at 6 months (P = 0.002).

CONCLUSION

Percutaneous cryoablation is a promising alternative treatment for sclerotherapy-resistant venous malformations. However, to improve safety, careful patient selection and treatment planning will be mandatory.

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.

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.

The opioid-sparing effects of intravenous ketorolac as an adjuvant analgesic in cancer pain: application in bone metastases and the opioid bowel syndrome

Side effects of morphine are common when given in titrated doses to control severe pain in advanced cancer. We report a case series of acutely ill cancer patients suffering from pain, complications of advanced disease, and opioid side effects. They were treated with intravenous (i.v.) ketorolac along with i.v. morphine using repeated dosing. Excellent pain relief with improvement in the opioid bowel syndrome was achieved. We found it possible to switch from IV ketorolac to oral ketorolac along with oral morphine for long-term pain control. Ketorolac can be well tolerated in high-dose, long-term use even in this frail patient population. An algorithm is presented for the suggested use of ketorolac as a morphine sparing agent. Potential methods for studying ketorolac further in this role are discussed.

Use of nonsteroidal anti-inflammatory drugs in cancer

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in cancer, yet they are also responsible for many, often serious, adverse effects. This review examines the various mechanisms through which NSAIDs work. It looks at the experience built up in using NSAIDs in cancer pain in general, but then particularly examines whether the evidence available supports the claim often made that these drugs have a specific role in relief of pain from bony metastases. Criteria for choosing one NSAID over another, including adverse effect profiles, efficacy and tolerability, are considered, as are methods for improving the safe use of these drugs.

[Drug therapy for tumor pain I. Properties of non-opioids and opioids.]

Analgesic pharmacotherapy represents one of the major approaches to the treatment of cancer pain, since it is used in almost every patient. A thorough evaluation of the physical and mental status of the patient and of the pain is as necessary as a sound understanding of the pharmacokinetic and pharmacodynamic characteristics of the analgesics selected. The World Health Organization (WHO) has issued a basic 3 stage progression for the treatment of cancer pain, the "WHO Analgesic Ladder". Assignment to the stages depends mainly on the intensity of the pain rather than on its specific aetiology. Mild to moderate pain is treated with non-opioid drugs; moderate to severe pain, with a combination of a "weak" opioid and a non-opioid; and "strong" opioids should be used in combination with a non-opioid in the case of severe pain. Adjuvant drugs can be added if specifically indicated. Nonopioid analgesics include non-acidic compounds, e. g. paracetamol and metamizole, and acidic non-opioids, e. g. acetylsalicylic acid and newer non-steroidal anti-inflammatory drugs (NSAID). In contrast to most of the opioid analgesics, they have a ceiling effect for analgesia. Addiction and tolerance are extremely rare concerns. Opioids can be subgrouped into "weak" (e. g., codeine, dextropropoxyphene) and "strong" opioids (e. g., morphine) and also into drugs interacting with different opioid-receptor subtypes. Whereas pure agonists (e. g., morphine) produce increasingly intense analgesia with increasing dose, partial agonists and agonist-antagonists have a ceiling effect for analgesia and therefore have only a minor role in the treatment of chronic pain in cancer patients. Adverse effects occur in most patients in a dose-dependent manner. The most common of these is constipation; nausea, vomiting and sedation occur mostly at the start and can usually be treated effectively. The appropriate dosage, route of administration and dosage scheme of analgesics needs to be worked out for each individual patient in intensive work with the patient and a close follow-up, for years if necessary. Some analgesics may not be available in some countries, or only in specific preparations.

Use of ketorolac by continuous subcutaneous infusion for the control of cancer-related pain

Ketorolac tromethamine is a newly available non-steroidal anti-inflammatory drug which is suitable for parenteral administration. We have given it by continuous subcutaneous infusion to 36 patients with pain due to advanced cancer. Improvement in pain control occurred in 29 (80%). A reduction in the dose of concomitant opioid analgesia was possible in 22 (76%) and a reduction in opioid-related adverse effects occurred in 16 (73%) of these. Ketorolac was most effective in patients who had bone or visceral pain. It was mixed safely with diamorphine in a syringe driver at concentrations up to 4 g diamorphine/10 ml and 120 mg ketorolac/10 ml. Infusion was well tolerated for periods of up to 115 days (mean 21 days; median 15 days; range 3-115 days). Four patients experienced gastrointestinal bleeding and one colonic perforation to which treatment with ketorolac may have been a contributory factor. No other clinically significant adverse effects were observed.

The efficacy of choline magnesium trisalicylate (CMT) in the management of metastatic bone pain: a pilot study

Twenty-six patients with painful, bony metastases were recruited into a randomized, double-blind, single dose, two-treatment, three-part crossover study of choline magnesium trisalicylate (CMT) and placebo. Assessments were made prior to and at one, two, three and four hours after dosing. Bone pain caused by metastatic cancer was significantly relieved one hour after the administration of 1500 mg CMT (p = 0.04). At all four time points the pain was less than baseline with CMT and at three time points greater than baseline with placebo but these results did not reach statistical significance. The summed pain intensity difference for patients was greater with CMT than with placebo, but this also did not reach significance. The incidence of volunteered side-effects was similar for both treatments. The results suggest that a nonacetylating, nonsteroidal anti-inflammatory drug may have a role complementary to that of an opioid in the management of metastatic bone pain.

Nimesulide in the treatment of advanced cancer pain. Double-blind comparison with naproxen

The analgesic efficacy and tolerability of nimesulide and naproxen were compared in 68 patients with advanced cancer who needed to be treated with nonsteroidal anti-inflammatory drugs according to the first step of the pharmacological analgesic scale of the WHO. Patients received either nimesulide 200mg or naproxen 500mg twice daily. The analgesic efficacy and tolerability of the 2 drugs appeared to be similar. Both drugs were effective and were associated with a low incidence of adverse reactions.

Morphine-sparing effect of diclofenac in cancer pain

The effectiveness of diclofenac 50 mg t.i.d. as additive treatment to parenteral patient-controlled administration therapy (PCAT) with morphine in cancer pain has been investigated in a double-blind study. In the fifteen patients who completed the study, morphine i.v. was titrated to optimal pain relief over 5 days. The mean total morphine consumption was significantly reduced during diclofenac administration (82.8 mg morphine per day) compared to placebo (95.0 mg morphine per day). The reduction in mean morphine consumption during active treatment with diclofenac was independent of the initial dose of self-titrated morphine. Pain, self-assessed according to VAS, tended to be lower during the diclofenac period, although the difference did not reach statistical significance. No adverse events were recorded among the 15 patients who completed the study. The present findings show that a non-steroidal anti-inflammatory agent, such as diclofenac, has a morphine-sparing effect in morphine-treated patients with cancer pain.

Subcutaneous ketorolac--a new development in pain control

Pain due to advanced malignant disease does not always respond to opioids, or the possible use of opioids may be limited by the occurrence of adverse effects. This paper describes the successful use of ketorolac, a new nonsteroidal anti-inflammatory drug, given by continuous subcutaneous infusion. Seven patients with pain due to advanced malignant disease taking opioid analgesia were considered to have inadequate symptom control because of opioid unresponsiveness (n = 1), opioid-related adverse effects (n = 2) or both (n = 4). All patients became symptom-free with the introduction of ketorolac by subcutaneous infusion and the total daily opioid requirement was substantially reduced in three and reduced to zero in four patients.

Nimesulide and diclofenac in the control of cancer-related pain. Comparison between oral and rectal administration

64 patients with pain associated with advanced cancer were treated with either nimesulide or diclofenac as initial analgesia. Patients were randomly allocated to 1 of 4 treatment groups: oral nimesulide 300 mg/day; oral diclofenac 150 mg/day; rectal nimesulide 400 mg/day; and rectal diclofenac 200 mg/day. After 1 week of treatment, both drugs provided an adequate degree of pain relief and allowed an increase in sleep duration. There were no significant differences in efficacy between the drugs or routes of administration. Fewer side effects were observed with nimesulide, giving this agent a better therapeutic index than the reference compound.

Non-steroidal anti-inflammatory drugs as the first step in cancer pain therapy: double-blind, within-patient study comparing nine drugs

The efficacy and tolerability of acetylsalicylic acid, paracetamol, diclofenac, ibuprofen, indomethacin, pirprofen, sulindac, naproxen and suprofen were compared in the treatment of cancer pain. In a double-blind, within-patient randomized study, each drug was given for 1 week to eight patients and for another week to a further eight patients. A total of 65 patients were effectively treated; only 48 completed week 1 and 41 completed week 2. Naproxen, diclofenac and indomethacin were highly effective in pain relief (tested by means of a 100 mm visual analogue scale) and were relatively well tolerated. It is concluded that these non-steroidal anti-inflammatory drugs can be considered as first choice in the treatment of cancer pain.

Control of pain in cancer patients

Almost three quarters of patients with cancer have severe pain, from invasion of the cancer itself, from effects of therapy, or from causes unrelated to the cancer (but often exacerbated by it). With the proper pain-management strategy, however, pain can be controlled in most patients. The analgesic ladder for pain control, promoted by the World Health Organization, begins with a nonnarcotic agent, progresses to a weak narcotic plus a nonnarcotic, and finally reaches a strong narcotic. Adjuvant agents, which increase the analgesic potency of the drug being used, may be added at any level. The most common reasons for inadequate pain control in cancer patients are incorrect narcotic dosing and incorrect switching from one narcotic to another and from one route of administration to another. Factors that influence pain management (eg, fear, anxiety, sleep disturbance) should be treated as well with appropriate medications, behavioral therapy, counseling, hypnosis, and other supportive techniques. These points are illustrated in the case report (see box, page 328).

A double-blind parallel evaluation of the efficacy and safety of a single dose of ketoprofen in cancer pain

The analgesic effects of single oral doses of ketoprofen 100 and 300 mg, the combination of aspirin 650 mg plus codeine 60 mg, and placebo were compared under double-blind conditions in 160 hospitalized patients with cancer pain. At baseline and at 30 minutes and hourly for 6 hours after treatment, patients evaluated their pain intensity and pain relief. The 100 mg ketoprofen dose was significantly (P less than 0.05) superior to placebo for all 14 derived efficacy parameters; the 300 mg dose was significantly superior to placebo in all assessments except derived onset of relief. Aspirin plus codeine was significantly (P less than 0.05) superior to placebo for nine of the 14 assessments. No statistically significant differences were observed among active treatments for any of the 14 derived parameters. The number of patients with a "good" response was greatest in the ketoprofen 100 mg group (55%); the numbers of good responders in the aspirin plus codeine (37.5%) and the ketoprofen 300 mg (30%) groups were comparable. The three active treatment groups were not significantly different from each other for patient response. The numbers of patients requiring rescue analgesic were significantly (P less than 0.05) lower for both ketoprofen groups, but not for the aspirin plus codeine group, as compared with the placebo group. Twenty-three percent of the 160 patients reported adverse experiences, but there were no significant differences between the treatment groups in the number or type of experience. These results show that ketoprofen is as effective and well tolerated as aspirin plus codeine in relieving cancer pain.

Piroxicam and doxepin--an alternative to narcotic analgesics in managing advanced cancer pain

To provide an effective continuum of the relief of severe carcinomatous pain with minimal side reactions, we initiated treatment with piroxicam (60 to 120 mg per day) and doxepin hydrochloride (25 to 225 mg per day). Of 30 patients presenting with severe pain of cancer of various origins, 7 continued to death with piroxicam and doxepin therapy. An additional 17 were successfully treated for 6 to 66 weeks with therapy reported here but, as disease progressed, required supplemental narcotics. The remaining six abandoned the use of piroxicam due to complications of therapy, which ranged from diarrhea to gastric perforation; serious complications were associated with patients' failure to adhere to a prescribed regimen of sucralfate. Therapy with piroxicam and doxepin proved to be safe and efficacious.

A validation study of the WHO method for cancer pain relief

The method for cancer pain relief proposed by the World Health Organization (WHO) consists of guidelines for a three-step treatment, from non-opioids to weak and then strong opioids, according to need. Adjuvant drugs can be added to each step. This report presents the 2-year experience of the WHO Collaborating Centre at the National Cancer Institute of Milan in the use of this method. This retrospective study shows that a correct use of the analgesic ladder can reduce pain to a third of its initial intensity. The use of non-opioids had an average duration of 19.2 days; in 52% of the cases treatment was discontinued due to inefficacy and in 42%, to side effects. Weak opioids were administered on an average for 28.0 days. A shift to Strong opioids was made in 92% of the cases due to inefficacy and in 8% because of side effects. Treatment with strong opioids lasted for an average of 46.6 days and can be considered the mainstay of cancer pain therapy. Performance status was not altered considerably during the study and hours of sleep were doubled. The analgesic ladder proved efficacious in 71% of the cases. Neurolytic procedures had to be used in 29%. The authors conclude that analgesics, as proposed by WHO, are the most suitable treatment arm in controlling pain in palliative treatment for advanced cancer patients. Lack of availability or underuse of opioids constitute the real obstacle to the application of this method.

Combination therapy with ibuprofen and methadone for chronic cancer pain

This randomized double-blind crossover study compares the narcotic methadone alone with methadone in combination with the peripherally acting, antiprostaglandin agent ibuprofen (Motrin, Upjohn) in 28 patients with moderate to severe cancer-related pain, who were already using a narcotic for pain relief. Results show that the addition of 600 mg of ibuprofen to either 2.5 or 5 mg of methadone significantly increased analgesia, without concomitantly increasing side effects or euphoria.

Injectable ketoprofen vs. acetylsalicylic acid for the relief of severe cancer pain: a double-blind, crossover trial

Thirty-six patients suffering from severe pain due to bone involvement from cancer participated in an analgesic study that compared single doses of ketoprofen 100 or 400 mg iv or injectable acetylsalicylic acid 1 g. A double-blind, balanced incomplete block design was adopted, in which each patient received two of the three test treatments, with an interval of 24 hours. Ketoprofen 400 mg proved significantly superior to 100 mg of the same drug, and was superior to 1 g of the acetylsalicylic acid derivative in the patients' assessment of the overall response. This was expressed by a visual analog scale and preferences. No adverse reaction was observed with any treatment.

Review of the comparative analgesic efficacy of salicylates, acetaminophen, and pyrazolones

Use of salicylates, acetaminophen, and pyrazolones has become increasingly complex, extending from the treatment of acute, mild pain to chronic, moderately severe pain. The intensity, rather than the nature, of the pain determines the efficacy of aspirin. A clinical dose-response relationship has been established, and time-effect curves indicate that the total threshold-raising effect depends on dosage frequency. Contrary to popular belief, aspirin and acetaminophen appear to be equipotent and equianalgesic for the relief of most pain. The combination of aspirin (650 mg) plus codeine (30 mg) is only slightly more effective than aspirin alone. The same holds true for acetaminophen (600 mg) plus codeine (60 mg); the efficacy of the combination is only slightly better than that of acetaminophen alone.

Organizing pain control and rehabilitation service in a cancer centre

A unique programme of rehabilitation and pain control has been created within the Istituto Nazionale per lo Studio e la Cura dei Tumori in Milan. Rehabilitation of mastectomy, amputee and ostomy patients has been very active and, particularly in this last group, a good rehabilitative outcome may be observed. Pain evaluation was one of the main problems. The treatment modalities have been refined in order to obtain the maximum pain relief with the minimum trauma possible. These treatments are based on a closely monitored analgesic drug administration and on percutaneous thermocontrolled lesions. The growing needs of the Cancer Institution have brought to about 30 000 the number of treatments performed by the Service during the last year. Nevertheless, enormous efforts are necessary to break the barrier of indifference to this problem that still persists in the oncologic field.