Health Questions and Answers

Question: Which medications are commonly used for cancer pain?

Answer:

As elucidated in the World Health Organization guidelines, pain medications are to be administered in a three-step ladder according to the intensity and pathophysiology of symptoms and individual requirements. For mild pain, the recommended baseline drugs are NSAIDs. Patients with moderate-to-severe pain generally require an opioid agent such as codeine or oxycodone; severe pain requires a stronger opioid such as morphine.

NONOPIOID AND ADJUVANT ANALGESIC DRUGS FOR CANCER PAIN
Class/Drug Indications Starting Oral Dose (mg/day and range/day) Comments
NSAIDs
Aspirin Soft-tissue and bone pain 650
650-1000
GI and hematologic effects when used with opioids, avoid combining with steroids
Acetaminophen Soft-tissue and bone pain 650
650-1000
Fewer GI effects than aspirin, no effects on platelet function, no significant anti-inflammatory effects
Ibuprofen Soft-tissue and bone pain 400
200-800
Higher analgesic potential than aspirin, fewer GI and hematologic effects than aspirin
Choline magnesium trisalicylate Soft tissue and bone pain 1500
1000-4000
Anti-inflammatory and analgesic effects, similar to aspirin without hematologic effects
Fenoprofen Soft-tissue and bone pain 200
200-400
Like ibuprofen
Diflunisal Soft-tissue and bone pain 500
500-1000
Longer duration of action than ibuprofen, higher analgesic potential than aspirin
Naproxen Soft-tissue and bone pain 250
250-500
Like diflunisal
Celecoxib For mild to moderate pain, osteoarthritis, rheumatoid arthritis 100-600 Less GI and renal toxicity; not evaluated in patients with cancer
Rofecoxib For mild to moderate acute pain, osteoarthritis 12.5-60 Less GI and renal toxicity; not evaluated in patients with cancer
Anticonvulsants
Phenytoin Neuropathic pain (acute lancinating type) 100
100-300
Start with low dose, titrate slowly
Carbamazepine Neuropathic 100
200-800
Useful in paroxysmal nerve pain
Gabapentin Neuropathic pain, lancinating and burning pain 300-1800 Titrate to effect; sedation is a major side effect
Antidepressants
Amitriptyline
Imipramine
Desipramine
Nortriptyline
Paroxetine
Neuropathic pain (e.g., posther- petic neuralgia, diabetic neu- ropathy, tumor- and radiation- induced plexo- pathy, neuropathy 10-200
10-150
10-150
10-150
10-40
Start at a low dose and titrate slowly; drug selection based on patient’s ability to tolerate drug
Antihistamine
Hydroxyzine Somatic and visceral pain 25
25-100
Additive analgesia in combination with opioids; antiemetic and antianxiety effects
Phenothiazine
Methotrimeprazine Somatic and visceral pain 5-15 IM Anxiolytic and antiemetic effects, available only in IM preparation, useful in opioid-tolerant patients with GI obstruction and pain
Steroids
Prednisone Somatic and neuropathic pain (e.g., inflammatory bone pain) 5
5-60
Anti-inflammatory, antiemetic, and analgesic effects
Dexamethasone Reflex sympathe- tic dystrophy, brachial and lumbar plex- opathy, bone and nerve pain 0.5
0.5-16
Analgesic and anti-inflammatory effects in epidural compression and brain metastases
Neurostimulants
Dextroampheta- mine Somatic and vis- ceral pain (e.g., postoperative pain) 2.5
2.5-10
Additive analgesia in combination with opioids, reduces sedative effects
Methylphenidate Opioid- induced sedation 5
5-15
Additive analgesia in combination with opioids, reduces sedative effects
Caffeine Somatic and vis- ceral pain, opioid-induced sedation 300
300-600
Additive analgesia in combination with opioids, reduces sedative effects

IM = intramuscular.
Adapted from Foley KM: Controlling cancer pain. Hosp Pract (Off Ed) 35(4):101-108, 111-112, 2000.

 
OPIOID DRUGS COMMONLY USED IN CANCER PAIN MANAGEMENT

Equianalgesic Doses (mg)

   
Drug Intramuscular Oral Half-Life (h) Duration of Action (h)
Codeine 130 100 2-3 2-4
Oxycodone1 15 30 2-3 2-4
Propoxyphene 50 100 2-3 2-4
Morphine1 10 60 (single dose) 30 (repeated dose) 2-3 3-4
Hydromorphone1 1.5 7.5 2-3 2-4
Methadone 10 20 15-30 4-8
Oxymorphone 1 10 (per rectum) 2-3 3-4
Levorphanol 2 4 12-15 4-8
Fentanyl (parenteral) 0.1   1-2 1-3
Fentanyl (transdermal)2 1-2 48-72
Fentanyl (transmucosal) 1-2 1-2
1Oxycodone, morphine, and hydromorphone are also available in slow-release preparations.
2100 μg/hr transdermal fentanyl approximately equal to 4 mg/h IM morphine.
Adapted from Foley KM: Controlling cancer pain. Hosp Pract (Off Ed) 35(4):101-108, 111-112, 2000.

One Response to “Question: Which medications are commonly used for cancer pain?”

  1. Dane Gruby Says:

    Anyone know

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