Mercadante, S., & Giarratano, A. (2013). The long and winding road of non steroidal antinflammatory drugs and paracetamol in cancer pain management: A critical review. Critical Reviews in Oncology/Hematology, 87, 140–145.

STUDY PURPOSE: To evaluate the role of acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) for cancer pain

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE, PubMed, CANCERLIT, EMBASE

KEYWORDS: Anti-inflammatory drugs or paracetamol or acetaminophen and/or cancer pain

INCLUSION CRITERIA: Randomized, controlled trial in patients with cancer

EXCLUSION CRITERIA: Not specified, but did exclude several studies in which patients were treated with a combination of hydrocodone or oxycodone and in which patients received transdermal fentanyl or morphine

TOTAL REFERENCES RETRIEVED = 3,703

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No specific quality rating was applied–study limitations are described in the summary of findings of each study

• FINAL NUMBER STUDIES INCLUDED = 9
• TOTAL PATIENTS INCLUDED IN REVIEW = 175
• SAMPLE RANGE ACROSS STUDIES: 22–172
• KEY SAMPLE CHARACTERISTICS: Studies involved a mix of patients who did and did not also receive morphine for chronic pain management

APPLICATIONS: Palliative care

Five studies evaluated paracetamol. None of these demonstrated a meaningful benefit on pain intensity. Only one study reported a significant difference in pain intensity, but this difference was only 0.4 on a 10-point scale. Four studies evaluated NSAIDs. In all of these, patients were also on opioids. One of these compared two different NSAIDs. In the following three studies, use of NSAIDs appeared to have an opioid-sparing effect. Multiple study limitations were identified.

No proof exists that paracetamol or NSAIDs should be used as the first step of the analgesic ladder. No evidence exists of benefit of paracetamol in combination with opioids. NSAIDs may have benefit in patients receiving opioids; however, further research is needed to confirm this.

• Relatively few studies
• Although one inclusion criterion was randomized, controlled trial, one study included was a non-randomized trial.

Findings show that no evidence exists to show efficacy of the addition of acetaminophen to opioids for cancer pain management. Findings suggest that NSAIDs may provide additional benefit to patients on opioids for cancer pain; however, the evidence is limited, and studies done have not involved prolonged use. Nurses need to be aware of potential complications of long-term use of NSAIDs and educate patients regarding these. Selection of adjuvant pain management approaches needs to be made on an individual basis, and continued use needs to be determined on the basis of patient response.