title: Nonsteroidal anti-inflammatory drugs, alone or combined with opioids, for cancer pain: a systematic review.
abstract: OBJECTIVE
  To assess the safety and efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), alone or combined with opioids, for the treatment of cancer pain.
  
  
  METHODS
  Forty-two trials involving 3,084 patients met inclusion criteria: eight compared NSAID with placebo; 13 compared one NSAID with another; 23 compared NSAID with opioid, NSAID or opioid versus NSAID plus opioid combinations, or NSAID plus opioid combinations versus NSAID plus opioid combinations; and nine studies assessed the effect of increasing NSAID dose.
  
  
  RESULTS
  Sixteen studies lasted 1 week or longer and 11 evaluated a single dose. Seven of eight trials demonstrated superior efficacy of single doses of NSAID compared with placebo. Only four of 13 studies reported increased efficacy of one NSAID compared with another; four other studies found that one NSAID had fewer side effects than one or more others. Thirteen of 14 studies found no difference, or minimal clinical difference, when comparing an NSAID plus opioid combination versus either drug alone. Comparisons between various NSAID plus opioid combinations were inconclusive. Four studies demonstrated increased efficacy with increased NSAID dose, without dose-dependent increases in side effects.
  
  
  CONCLUSIONS
  Heterogeneity of study methods and outcomes precluded meta-analyses. Short duration of studies undermines generalization of findings on efficacy and safety. On the basis of limited data, NSAIDs appear to be more effective than placebo for cancer pain; clear evidence to support superior safety or efficacy of one NSAID compared with another is lacking; and trials of combinations of an NSAID with an opioid have disclosed either no significant difference, or at most a slight but statistically significant advantage, compared with either single entity.
authors.affiliation: Department of Anesthesia and Division of Clinical Care Research, New England Medical Center and Tufts University School of Medicine, Boston, MA 02111, USA. EMcNicol@tufts-nemc.org
authors.forename: Ewan
authors.initials: E
authors.lastname: McNicol
authors.forename: Scott
authors.initials: S
authors.lastname: Strassels
authors.forename: Leonidas
authors.initials: L
authors.lastname: Goudas
authors.forename: Joseph
authors.initials: J
authors.lastname: Lau
authors.forename: Daniel
authors.initials: D
authors.lastname: Carr
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage*; D004338:Drug Combinations; D006801:Humans; D009369:Neoplasms; D010147:Pain Measurement; D010148:Intractable Pain / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D004338:Drug Combinations