For cancer patients, bone pain can be one of the most distressing symptoms to manage. Whether it’s due to metastasis, chemotherapy-induced effects, or other factors, finding effective pain relief is crucial for improving quality of life. In the realm of pain management, there exists a drug of choice along with various alternatives, each with its benefits and considerations.

Opioids

Opioids, such as morphine, oxycodone, and fentanyl, are often considered the cornerstone of pain management in cancer patients, including those experiencing bone pain. These drugs act on the central nervous system to alleviate pain and are highly effective in providing relief, especially for moderate to severe pain.

One of the primary advantages of opioids is their potency in providing rapid and significant pain relief. They can be administered through various routes, including oral tablets or liquid, suppositories, patches, injections, and intravenous infusions, offering flexibility in treatment options based on the patient’s needs and preferences.

Opioids are not without drawbacks. Concerns about tolerance, dependence, and the risk of addiction call for careful monitoring and continual reassessment of the risks versus benefits of use. Moreover, common side effects such as constipation, sedation, and respiratory depression can impact patients’ quality of life and require proactive management strategies.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for Bone Pain

NSAIDs, such as ibuprofen and naproxen, are commonly used as adjuvants to opioids in managing cancer-related bone pain. They work by inhibiting prostaglandin synthesis, thereby reducing inflammation and pain. NSAIDs are particularly useful for managing mild to moderate bone pain and can be taken orally or administered intravenously.

NSAIDs carry the risk of gastrointestinal bleeding, renal toxicity, and cardiovascular complications, especially in long-term use or in patients with preexisting conditions. Therefore, careful assessment of the patient’s medical history and regular monitoring of renal function and gastrointestinal symptoms are essential when using NSAIDs.

It is also critical to recognize that individual NSAIDs may carry greater risks for certain toxicities than others. For example, celecoxib has the lowest GI bleed risk while ketorolac or indomethacin carry a higher risk. Cardiovascular risks are also important to consider when selecting an NSAID. Here is a really important table that will help you differentiate which ones are higher versus lower risk. Note that this is also an important thing to remember for your board exams!

Bisphosphonates

Bisphosphonates, such as zoledronic acid and pamidronate, are drugs that inhibit bone resorption and are commonly used in cancer patients with bone metastases. By strengthening bone structure and reducing the risk of fractures, bisphosphonates can help alleviate bone pain and improve overall bone health.

In addition to their analgesic properties, bisphosphonates have been shown to reduce skeletal-related events, such as pathological fractures and spinal cord compression, thereby enhancing patients’ mobility and quality of life. Bisphosphonates are associated with adverse effects such as flu-like symptoms, renal toxicity, and osteonecrosis of the jaw, necessitating cautious monitoring and periodic assessments.

In conclusion, the management of bone pain in cancer patients requires a multimodal approach that addresses both the underlying disease process and the patient’s individual needs and preferences. While opioids remain the drug of choice for moderate to severe pain, alternatives such as NSAIDs, and bisphosphonates, offer valuable adjunctive options for enhancing pain control and improving overall quality of life. 

Refractory Patients

In patients who do not respond to NSAIDs and/or opioids in conjunction with bisphosphonates, glucocorticoids may be considered. Glucocorticoids are effective at reducing bone pain and also associated inflammation but carry significant risks such as HPA suppression (if used longer-term), GI toxicity, insomnia, and hyperglycemia. In addition, prolonged use may weaken bones which is the opposite of what the bisphosphonate is trying to accomplish. 

This article was written by Jack Mageto, PharmD Candidate in Collaboration with Eric Christianson, PharmD, BCPS, BCGP

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