What non opioid analgesics are appropriate for patients with cancer pain?
The selection of a nonopioid analgesic as a first-line agent for opioid naïve patients is encouraged, and if well-tolerated, that analgesic may be continued during initiation and up-titration of opioids. Consider NSAIDs or acetaminophen for mild to moderate pain, utilizing caution in patients with renal or hepatic impairment. There is good medical evidence for the efficacy of NSAIDs in patients following surgery or other painful procedures; they are considered first-line treatment for inflammatory pain such as that caused by bone metastasis. The use of NSAIDs for cancer pain may be limited by their adverse effect on renal function and by potential gastric mucosal irritation or ulceration as well as cardiovascular risk.
Bisphosphonates have some efficacy for treatment of bone metastasis, possibly through stabilization of the metastatic focus. Corticosteroids are effective for management of bone as well as brain metastases and for nerve compression, but their use may be limited by tolerance issues such as sodium and water retention, hyperglycemia, or gastric ulceration.
Acetaminophen, while a useful antipyretic at therapeutic doses, is a relatively weak analgesic whose use may be limited due to hepatotoxicity, which can occur at dosages of 3 to 4 g/day.
Topical analgesic options may be useful for patients who can pinpoint a localized focus of pain. These include topical NSAIDs, capsaicin, or lidocaine, among others. Anticonvulsants and antidepressants are considered to be first-line treatment for neuropathic pain.