Nonsteroidal Anti-Inflammatory Drugs
44. Why should the use of an NSAID be considered for A.J.'s spinal pain?
Pain from tumor metastasis to bone is particularly distressing and difficult to treat. Although the most effective therapy for the relief of bone pain is radiation to the site of the pain,151 prostaglandin inhibitors may be another reasonable alternative to increased doses of opioids. Osseous metastases induce the production of prostaglandins that can cause osteolysis, sensitize free nerve endings, and augment pain perception. NSAIDs effectively decrease prostaglandin and endoperoxide production and may be useful in treating metastatic bone pain if administered on a scheduled basis. Usual analgesic doses of NSAIDs often are effective, but maximal therapeutic doses may be necessary. Some specialists in treating cancer pain advocate doses considerably larger than the manufacturers' recommendations. Sometimes IV ketorolac is used for this purpose.152 In extremely painful cases, IV ketorolac has been used as a continuous infusion for managing metastatic bone pain.152 Beside an NSAID, strontium, and radiopharmaceuticals (e.g., phosphorus 32, strontium 89, samarium 153, rhenium 186, and tin 117m) have been used to treat metastatic bone pain, but occasionally with limited benefit. Nevertheless, they can be considered for severe bony metastatic pain unresponsive to corticosteroids or an NSAID.
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