NSAIDs (ANTI-INFLAMMATORIES)

Non-steroidal anti-inflammatory drugs (NSAIDs) are thought to work by inhibiting prostaglandin synthesis (prostaglandin being one of the mediators of the inflammatory response). Bone metastases are thought to release prostaglandins. Single doses of NSAIDs are analgesic, repeated doses are anti-inflammatory.

Indications for NSAIDs:

• Bone pain from metastases

• Arthritis

• Night sweats

• Skin pain

«  NSAIDs reduce or abolish bone pain in about 80% of cases.

Which NSAID? — A patient on a mild NSAID such as ibuprofen who still has bone pain should be changed to one of the stronger drugs listed below.

First choice is often naproxen 500mg 2 times a day either by tablet, or suspension. Oral indomethacin 50mg 4 times a day, or two 50mg suppositories 2 times a day, is more potent (but more frequently causes side effects).

The more potent NSAIDs are more effective, but also tend to cause more side effects. Good comparative trials have not been done, so it is difficult to know which are best. If a patient fails to respond to one NSAID (or has adverse reactions) it is sometimes advisable to try a drug from a different group (although there is no evidence to support this idea).

Useful NSAIDs from different groups include:

• Naproxen — a proprionic acid

• Diclofenac — an acetic acid

• Piroxicam — an oxicam

• Indomethacin — an indole

• Choline magnesium trisalicylate — a salicylic acid

NSAID side effects:

• Fluid retention

• Dyspepsia (about 20% of patients)

• Peptic ulceration

• Skin rashes

• Urticaria

• Aplastic anemia

• Headache, dizziness (from indomethacin)

• Renal damage

Dyspepsia can still occur when NSAIDs are given in suppository form, although it may be less severe than with oral NSAIDs. Oral NSAIDs should be taken after food. Concurrent H₂-receptor inhibition (ranitidine 150mg 2 times a day) may be indicated to prevent dyspepsia.

If a patient has a history of peptic ulceration it is still safe to use NSAIDs covered by ranitidine. In most patients the bone pain will be reduced or abolished, without gastric irritation. (If dyspepsia occurs, the NSAID should be stopped.) (see Bone Pain)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.