Co-Analgesics for Use in Cancer Pain
| Summary of Adjuvant Drugs (Co-analgesics) for Use in Cancer Pain | ||
|---|---|---|
| Type of Pain | Adjuvant Treatment | Dosage |
| Bone pain | NSAIDs | If pain is severe, or if patient has pain at rest, starting at step 3 of the WHO analgesic ladder is justified, combining a strong opioid with paracetamol or an NSAID.1 |
| Bisphosphonates | Sodium clodronate 1600mg daily as a single dose or in two divided doses; max 3200mg daily. Some sources recommend a 1.5g iv loading dose (unlicensed).2 | |
| Disodium clodronate 1040–2080mg daily as a single dose or in two divided doses. | ||
| Disodium pamidronate 90mg by slow inf every 4 weeks (may be given every 3 weeks in breast cancer to coincide with chemotherapy). | ||
| Zoledronic acid2,3 and ibandronic acid2,3 have also been used to treat bone pain (unlicensed). | ||
| Bowel colic | Antispasmodics | Hyoscine butylbromide 20mg qds orally. Hyoscine butylbromide 10–25mg up to three times daily by sc, iv or im inj (unlicensed).1 |
| Muscle spasm | Muscle relaxants | Diazepam 5mg nocte (range 2–10mg nocte).2 Using a single dose at night is recommended to reduce the impact of side effects such as drowsiness.1 However, some sources recommend 5mg two to three times daily orally or rectally.4 |
| Baclofen initially 5mg tds, increasing by 5mg tds at 3-day intervals as required; max 100mg daily. | ||
| Neuropathic pain* | Corticosteroids | Pain caused by nerve compression may be relieved by corticosteroids, e.g. dexamethasone 4–8mg od.2,3 Corticosteroids may also be used to relieve pain caused by spinal cord compression, e.g. dexamethasone 12–16mg od.2 |
| Tricyclic antidepressants | Amitriptyline 10mg–25mg nocte, titrating gradually upwards until pain controlled; 1-4 maintenance 25–75mg nocte (unlicensed).1 | |
| Imipramine, nortriptyline – 10mg nocte, titrating gradually upwards until pain controlled; maintenance 25–75mg nocte (unlicensed).1 | ||
| Anticonvulsants | Carbamazepine (unlicensed), use same dose as for epilepsy.2 Alternatively, week 1 – 100mg nocte, week 2 – 100mg bd, week 3 – 100mg tds, week 4 – 200mg bd, then 200mg tds; maintenance, 200mg two to four times daily.1 | |
| Gabapentin day 1 – 300mg od, day 2 – 300mg bd, day 3 – 300mg tds or start at 300mg tds on day 1. Then increase by 300mg/day every 2–3 days to max 3600mg/day in 3 divided doses. | ||
| Pregabalin initially 150mg daily in two or three divided doses. Increase if necessary after 3–7 days to 300mg, then to max 600mg daily if needed after a further 7 days. | ||
| Sodium valproate (unlicensed) 200–500mg nocte, increasing to 1.5g daily if required.2 Other sources recommend starting dose of 100mg bd, increasing by 200mg/day at 3-day intervals; usual maintenance 1–2g daily.3 | ||
| NMDA-receptor-channel blockers | Ketamine – dosage recommendations vary. May be given orally or by sc inj or inf.2 Suggested oral dose: 10–25mg tds to qds increasing in 10–25mg increments up to 50mg qds (unlicensed).2,3 | |
| Methadone – may be useful in neuropathic pain because of its NMDA-antagonist properties.2 | ||
*Suggested treatment path for neuropathic pain caused by cancer if pain unresponsive to a strong opioid plus an NSAID:2
Step 1 = corticosteroid; Step 2 = tricyclic antidepressant or anticonvulsant; Step 3 = tricyclic antidepressant and anticonvulsant; Step 4 = NMDA-receptor-channel blocker; Step 5 = spinal analgesia.
REFERENCES
- CKS (2007) Palliative Care (Topic Review), Clinical Knowledge Summaries Service. www.cks.library.nhs.uk/palliative_care_pain [Accessed: 05.12.07]
- Twycross R, Wilcock A. Palliative Care Formulary. 3rd ed. Nottingham: Palliativedrugs.com Ltd, 2007. www.palliativedrugs.com
- Watson M, Lucas C, Hoy A, Back I. Oxford Handbook of Palliative Care. Oxford: Oxford University Press, 2005.
- World Health Organisation (2004). Palliative care: Symptom Management and End-of-Life Care – Integrated Management of Adolescent and Adult Illness (IMAI). Available at www.who.int
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