title: Management of pain in advanced disease.
abstract: BACKGROUND
  Pain is common in advanced malignancy but also prevalent in other non-malignant life-limiting diseases such as advanced heart disease; end stage renal failure and multiple sclerosis. Patients with renal or liver impairment need specific consideration, as most analgesics rely on either or both for their metabolism and excretion.
  
  
  METHODS
  Recent evidence-based guidelines and the systematic reviews that have informed their recommendations.
  
  
  RESULTS
  The principles of the WHO (World Health Organisation) analgesic ladder are commonly endorsed as a structured approach to the management of pain. For neuropathic pain, the efficacy of different agents is similar and choice of drug more guided by side effects, drug interactions and cost.
  
  
  RESULTS
  Evidence supporting the WHO analgesic ladder is disputed and alternatives suggested, but no overwhelming evidence for an alternative approach exists to date.
  
  
  CONCLUSIONS
  Alternative approaches to the WHO analgesic ladder, new analgesic agents, e.g. rapid onset oral/intranasal fentanyl.
authors.affiliation: Department of Palliative Care, Prince Charles Hospital, Merthyr Tydfil, South Wales CF479DT, UK dgharris@doctors.org.uk.
authors.forename: Dylan G
authors.initials: DG
authors.lastname: Harris
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage; D004334:Drug Administration Schedule; D006801:Humans; D007668:Kidney / Q000503:physiopathology; D008099:Liver / Q000503:physiopathology; D010146:Pain / Q000188:drug therapy / Q000503:physiopathology; D059408:Pain Management / Q000379:methods* / Q000592:standards; D017410:Practice Guidelines as Topic; D014944:World Health Organization
chemical_list: D000701:Analgesics, Opioid
keywords: analgesic ladder; cancer; heart failure; human immunodeficiency virus; liver failure; motor neurone disease; multiple sclerosis; pain; palliative; renal failure