Cancer pain management: Use of acetaminophen and nonsteroidal antiinflammatory drugs
- Russell K Portenoy, MD
Russell K Portenoy, MD
- Chief Medical Officer
- MJHS Hospice and Palliative Care
- Professor of Neurology and Family and Social Medicine
- Albert Einstein College of Medicine
- Ebtesam Ahmed, PharmD, MS
Ebtesam Ahmed, PharmD, MS
- Clinical Professor,
- St. John's University College of Pharmacy
- Clinical Pharmacy Specialist Innovative Institute for Palliative Care
- Yair Y Keilson, MD
Yair Y Keilson, MD
- Adjunct Clinical Assistant Professor of Medicine
- Touro College of Osteopathic Medicine
Opioid therapy is the first-line approach for moderate or severe chronic pain in populations with active cancer. (See "Cancer pain management with opioids: Optimizing analgesia".) However, the comprehensive management of pain in patients with cancer also requires expertise in the use of the nonopioid analgesics, such as acetaminophen (also known as paracetamol), non-steroidal antiinflammatory agents (NSAIDs), and a group of drugs referred to as "adjuvant" analgesics or coanalgesics.
A stepwise approach to management of cancer pain that includes both opioid and nonopioid drugs has been codified in the World Health Organization (WHO) "analgesic ladder" approach to cancer pain management (figure 1) :
●Step 1, which represents mild to moderate cancer-related pain, suggests the use of acetaminophen or an NSAID, possibly combined with an adjuvant drug to provide additional analgesia, treat a side effect, or manage a coexisting symptom. (See "Cancer pain management: Adjuvant analgesics (coanalgesics)".)
●For patients with moderate or severe pain, and for those who do not achieve adequate relief with acetaminophen or a NSAID alone, treatment with a step 2 opioid (conventionally used for moderate pain) or a step 3 opioid (conventionally used for severe pain) is appropriate. On both steps 2 and 3, the use of acetaminophen or an NSAID could be considered, as well as other drugs to enhance analgesia or treat side effects.
The analgesic ladder approach is not an evidence-based guideline, but it provides a framework for the stepwise and systematic approach to managing cancer pain. (See "Cancer pain management: General principles and risk management for patients receiving opioids", section on 'General principles of pain management'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- Intravenous acetaminophen
- Hepatic toxicity
- NONSTEROIDAL ANTIINFLAMMATORY AGENTS
- Side effects
- - Cardiovascular toxicity
- - Gastrointestinal toxicity
- - Bleeding
- - Nephrotoxicity
- - Hepatotoxicity
- Indications and contraindications
- Improving the therapeutic ratio: choice of drug, dose and use of gastroprotectants
- Intravenous NSAIDs
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS