Co-Analgesics for Use in Cancer Pain

Agents and doses for different types of cancer pain.

Summary of Adjuvant Drugs (Co-analgesics) for Use in Cancer Pain
Type of PainAdjuvant TreatmentDosage
Bone pain Bisphosphonates Sodium clodronate 600–1500mg daily by iv inf repeated prn (unlicensed).1
Disodium pamidronate 90mg by slow iv inf every 3–4 weeks.1
Ibandronic acid 50mg od orally or 6mg by iv inf over 15 mins every 3–4 weeks has also been used to treat bone pain (unlicensed).1
Zoledronic acid 4mg by iv inf every 3–4 weeks (unlicensed).1
Bowel colic Antispasmodics Hyoscine butylbromide 40–300mg by sc inf over 24 hrs via a syringe driver.2 Or 10–20mg prn by sc inj, repeated every 2 hrs (unlicensed).2
Muscle spasm Muscle relaxants Diazepam 2mg or 5mg tds or 2–10mg nocte (consider upper range of these doses if there is co-existing anxiety).1,2
Baclofen initially 5mg bd to tds, increasing by 5mg bd to tds at 3-day intervals as required;1 suggested dose 5–10mg tds.2
Neuropathic pain* Corticosteroids Pain caused by nerve compression may be relieved by corticosteroids.2 Corticosteroids may also be used to relieve pain caused by spinal cord compression eg, dexamethasone 16mg od.1,2
Tricyclic antidepressants Amitriptyline 10mg nocte, titrating gradually until pain controlled; max 75mg nocte (unlicensed).2
Serotonin noradrenaline reuptake inhibitors Duloxetine initially 60mg daily, increasing if necessary to max 120mg daily in two divided doses (unlicensed).2
Anticonvulsants 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 3.6g daily in three divided doses. Alternatively, day 1 – 100mg nocte increasing by 100mg/day according to response; max 3.6g daily.2
Pregabalin initially 150mg daily in two or three divided doses. Increase if necessary after 3–7 days to 300mg daily, then to max 600mg daily if needed after a further 7 days.2
Sodium valproate initially 150–200mg modified-release nocte. Increase if necessary by 150–200mg/day every 2–3 days in two divided doses. Some patients may require 2g daily (unlicensed).1
NMDA antagonists Ketamine – dosage recommendations vary. May be given orally or by sc inj or inf.1 Suggested oral dose: 10–25mg tds to qds prn increasing if necessary in 10–25mg increments up to 100mg qds (unlicensed). Suggested sc dose: 10–25mg prn increasing if necessary in 25–33% increments (unlicensed).1
Methadone – may be useful in neuropathic pain because of its NMDA-antagonist properties.1

*Suggested adjuvant analgesics for neuropathic pain:1

Step 1 = amitriptyline or gabapentin; Step 2 = amitriptyline and gabapentin; Step 3 = amitriptyline and an alternative anticonvulsant eg, valproate; Step 4 = specialist measures eg, NMDA antagonist and/or interventional anaesthesia.

REFERENCES

  1. Twycross R, Wilcock A, Howard P. Palliative Care Formulary. 5th ed. Nottingham: Palliativedrugs.com Ltd, 2014. (www.palliativedrugs.com).
  2. NICE CKS (cks.nice.org.uk) [accessed January 2016].

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