Oral nonsteroidal anti-inflammatory drugs (NSAIDs) for cancer pain in adults

New
Authors: 
Derry S, Wiffen PJ, Moore R, McNicol ED, Bell RF, Carr DB, McIntyre M, Wee B

Bottom line

There is no high-quality evidence to prove that NSAIDs are useful in treating people with cancer pain. Nor is there evidence to disprove that they are useful. Very low-quality evidence shows that some people with moderate or severe cancer pain have pain much reduced within one or two weeks.

Background

One person in two or three who gets cancer will suffer from pain that becomes moderate or severe in intensity. The pain tends to get worse as the cancer progresses. In 1986, the World Health Organization (WHO) recommended taking morphine-like drugs (opioids) for moderate to severe pain from cancer, and non-opioid drugs like NSAIDs, alone for mild to moderate pain, or alongside opioids in people with moderate to severe pain. There are many different types of NSAIDs. Common NSAIDs are ibuprofen and diclofenac.

Study characteristics

In this review we set out to examine the evidence on how well NSAIDs worked (alone or with morphine-like drugs) in adults with cancer pain. We also wanted to know how many people had side effects, and how severe they were.

In April 2017, we found 11 studies with 949 participants. They compared NSAID with NSAID, or NSAID with opioid drug (morphine or codeine). No studies looked at using NSAID together with an opioid-like morphine, which is how they are often used. The studies were small and of poor quality. They used different designs and different ways of showing their pain results. Outcomes important to people with cancer pain were often not reported. Many different NSAIDs were tested, and it was not possible to make sensible comparisons.

Key findings

With an NSAID, initially moderate or severe cancer pain was reduced to no worse than mild pain after one or two weeks in 1 in 4 (26%) to 1 in 2 (51%) people in four studies.

Side-effect reporting was poor. Two serious side effects were reported with NSAIDs, and 22 deaths, but these were not related to pain treatment. Common side effects were thirst/dry mouth (1 in 7; 15%), loss of appetite (1 in 7; 14%), sleepiness (1 in 10; 11%), and heartburn (1 in 10; 11%). One in four people stopped taking NSAIDs because the drug did not work, and 1 in 20 stopped because of side effects.

Quality of the evidence

The quality of the evidence was very low. Very low-quality evidence means that we are very uncertain about the impact of an NSAID alone for treating cancer pain. We do not know whether using NSAIDs together with an opioid such as codeine or morphine is worthwhile.

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