Comparative Efficacy of Therapeutics for Chronic Cancer Pain: A Bayesian Network Meta-Analysis

Abstract

PURPOSE Opioids are the primary choice for managing chronic cancer pain. However, many nonopioid therapies are currently prescribed for chronic cancer pain with little published evidence comparing their efficacy. METHODS Electronic databases were searched for randomized controlled trials (RCTs) comparing any systemic pharmaceutical intervention and/or combination thereof in treating chronic cancer pain. The primary outcome was global efficacy reported as an odds ratio (OR). The secondary outcome was change in pain intensity reported as a standardized mean difference (SMD). RESULTS We included 81 RCTs consisting of 10,003 patients investigating 11 medication classes. Most RCTs (80%) displayed low risk of bias. The top-ranking classes for global efficacy were nonopioid analgesics (network OR, 0.30; 95% credibility interval [CrI], 0.13 to 0.67), nonsteroidal anti-inflammatory drugs (network OR, 0.44; 95% CrI, 0.22 to 0.90), and opioids (network OR, 0.49; 95% CrI, 0.27 to 0.86), whereas the top-ranked interventions were lidocaine (network OR, 0.04; 95% CrI, 0.01 to 0.18; surface under the cumulative ranking curve analysis [SUCRA] score, 98.1), codeine plus aspirin (network OR, 0.22; 95% CrI, 0.08 to 0.63; SUCRA score, 81.1), and pregabalin (network OR, 0.29; 95% CrI, 0.08 to 0.92; SUCRA score, 73.8). In terms of reducing pain intensity, we found that no class was superior to placebo, whereas the following top-ranked interventions were superior to placebo: ziconotide (network SMD, −24.98; 95% CrI, −32.62 to −17.35; SUCRA score, 99.8), dezocine (network SMD, −13.56; 95% CrI, −23.37 to −3.69; SUCRA score, 93.5), and diclofenac (network SMD, −11.22; 95% CrI, −15.91 to −5.80; SUCRA score, 92.9). CONCLUSION There are significant differences in efficacy among current regimens for chronic cancer pain. Our evidence suggests that certain nonopioid analgesics and nonsteroidal anti-inflammatory drugs can serve as effectively as opioids in managing chronic cancer pain.

Paracetamol: A Review of Guideline Recommendations

“…Therefore, the European Society of Medical Oncology stated that there is no reason to recommend or refute paracetamol for mild-to-moderate cancer pain [ 125 ]. Conversely, a 2019 network meta-analysis of analgesic drugs for chronic cancer pain concluded that the top-ranking drug classes for global efficacy were non-opioid analgesics, including paracetamol, as well as NSAIDs and opioids [ 126 ]. It is considered the first-choice drug for mild-to-moderate pain in older patients with cancer naïve to opioids [ 127 ].…”

Reviewing without a Clinical Background Is Detrimental for Cancer Pain Management

“…In a world in which reviews of previous reviews are increasingly published, looking for misleading evidence and leading scientists to rise up against statistical significance [5], a pragmatic approach may better select data reflecting the clinical reality, instead of indicating unlikely clinical evidence [6]. I was dismayed and shocked when reading the results of a recent review [7], in part because it was published in an authoritative journal. It is suggested that non-opioid analgesics and NSAIDs can be effective as opioid therapy, in contrast to the presumed superiority of opioids.…”

Medications Containing Low-Dose Codeine for the Treatment of Pain and Coughs

“…Of these 50 potentially relevant articles, 33 publications were excluded for various reasons and 17 publications met the inclusion criteria and were included in this report. These comprised 3 overviews of reviews 28-30 (i.e., systematic reviews of systematic reviews) and 13 systematic reviews [31][32][33][34][35][36][37][38][39][40][41][42][43][44] (5 with meta-analysis [31][32][33]37,42,44 and1 with network-meta analysis), 38 1 of which was reported in 2 publications. 32,33 Appendix 1 presents the PRISMA 45 flow chart of the study selection.…”