Systematic review on the role of paracetamol and non steroid anti-inflammatory drugs for cancer pain (EPCRC opioid guidelines project)

Transcription

1 Systematic review on the role of paracetamol and non steroid anti-inflammatory drugs for cancer pain (EPCRC opioid guidelines project) Maria Nabal MDPhD Silvia Librada MD Mª Jose Redondo MD

2 Summary Aim Method Results Conclusions 2

3 Aim Establish the role of Paracetamol and NSAIDS as adjuvant analgesics in cancer chronic pain to establish an evidence based recommendation for their use in Palliative Care. Key points The roll of Acetaminophen or NSAIDs for pain control The best NSAID for pain control in advance cancer The efficacy of the association of weak opioids and NSAID for pain control The analgesic effect of the combination of Major Opioids (Morphine y Methadone) and NSAID or Acetaminophen NSAIDs side effects on treating chronic cancer pain 3

4 Material and Method Data base: MedLine, EMBASE and Cochrane data base Search strategy: Key words: neoplasm pain - anti inflammatory agents non-steroidal. Limits: Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Clinical Trial, Phase III, Clinical Trial, Phase IV, Comparative Study, English, Cancer, All Adult: 19+ years Data were extracted on type of study, study limitations, number of participants, main outcomes on pain control and side effects. 4

5 Results (I) 5

6 Results (II) N = 38 Type of studies D Blind Randomized 26 Randomized not blind 1 Uncontrolled: 6 Reviews: 5 (only 1 systematic) Years of publication: Number of patients: (Syst Review 3084) Duration of the studies: from hours to 3 weeks 6

7 Results (III) Paracetamol and NSAIDs, as the first step of the WHO s ladder, are superior to placebo and adequate for mild cancer pain treatment, at least in short term use. 8 papers compared Paracteamol / NSAID and placebo: Martino 1978, Lomen 1986, Staquet 1989, Carlson 1990, Ventafrida 1990, Bergmann 1994, Levick 1998, Mercadante 1999, Stockler 2004 Type of evidence B 7

8 Results (IV) There is not enough evidence to establish a general recommendation on the best NSAID agent for pain control in cancer patients. 11 papers compared an NSAID with at least one other NSAID: Martino 1978 Minotti 1989, Ventafrida 1990, Ventafrida1990, Toscani 1993, Yalcin 1998, Mercadante 1999 (non randomized) Minotti 1998, Pannuti 1999, Rodriguez 2002, y Rodriguez 2004 Ketorolac in 5, Naproxen in 4, Diclofenac in 7, Indoprofen in 1, Ketoprofen in 1, Dexketoprofen in 1, Diflunisal in 1, ASA in 1, Indometacin in 1, Dipyrone 1 Type of evidence C 8

9 Results (V) The association of weak opioids and NSAID for pain control do not seams to improve the analgesic effect of each type of drugs alone. Only 4 studies compare this association: Lomen 1986, Minotti 1989, Carlson 1990, Minotti 1998 Type of evidence C 9

10 Results (VI) The combination of Major Opioids (Morphine y Metadona) and NSAID or Acetaminophen improves the analgesic effect and allows opioids doses to be reduced. 11 studies: 7 Rand / 4 series Samples: 7-47 patients Duarte-Souza 2007, Mercadante 2002, Bianchi 1999, Joishy 1998, Mercadante 1997, Johnson 1994, Myers 1994, Dellemijn 1994 Bjorman 1993, Blackwell 1993, Ferrer-Brechner Type of evidence C 10

11 Results (VII) With the actual evidence available, we can not establish the risk of side effects using NSAID in long term treatments The duration of the trials is very different: from hours in Pannuti s to 3 weeks in Mercadante s. The outcomes assessed are different: dyspepsia, gastrointestinal disconfort, gastrointestinal bleeding, nauseas and vomiting The assessment systems are very different from author to author: VAS, Open questionnaires, Likert scales, spontaneous telling Type of evidence C 11

12 Conclusions Acetaminophen and NSAIDs are better than placebo for chronic cancer pain control There is not enough high quality evidence to establish: the best NSAID treatment. The evidence on the efficacy of combining Opioids (weak and strong) and NSAID is weak There is a need of high quality trials using NSAIDs in patients with advanced cancer It will be necessary, as well, to establish common criteria to assess and classify patients characteristics and pain in order to have homogeneous populations to be compared 12

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