Daily subcutaneous parecoxib injection for cancer pain: an open label pilot study.

BACKGROUND: Nonsteroidal anti-inflammatory analgesics (NSAIDs) are useful in cancer pain but the specific use of subcutaneous parecoxib has not been previously reported. OBJECTIVE: This pilot study aimed to establish the efficacy and side effect profile of short-term sequential single daily dose subcutaneous parecoxib sodium in patients with severe cancer bone pain. METHODS: Nineteen hospitalized patients with advanced cancer and uncontrolled malignant bone pain (9 males, 10 females) received 24 courses of one, two, or three days sequential therapy with 'off-label' daily subcutaneous parecoxib. All patients were receiving opioid therapy; the median baseline daily oral equivalent dose (OED) of morphine was 180 mg. Pain was assessed at baseline, 24 hours, 48 hours, and 72 hours. Pain scores as assessed on an 11-point numeric pain rating scale (NPRS), any side effects including subcutaneous site reactions, as well as patient satisfaction rating with analgesia were recorded. A clinically significant decrease in pain scores was defined as a reduction of two or more points on the NPRS. RESULTS: Median pain score of all patient treatments decreased from 7 to 4.5 at 24 hours (p<0.001) and 4.0 at 48 hours. A response was seen in 17 (71%) of the 24 treatments at 24 hours. There was no difference between median negative change in pain scores in 19 (79%) treatments where pain was either strongly movement related, or in 22 (94%) treatments where local bone tenderness was more pronounced. No major side effects were observed during treatment. One patient died from pulmonary embolism after cessation of concurrent prophylactic low molecular weight heparin prior to staging liver biopsy. Subcutaneous site reactions occurred in 2 (8%) treatments and were mild and self limiting. CONCLUSIONS: Short-term daily subcutaneous parecoxib injection was effective for malignant bone pain when added to existing analgesic therapy and was well tolerated. Further research is warranted into the short-term use of parecoxib in hospitalized patients with intractable malignant bone pain.

Sedation and analgesia-prescribing patterns in terminally ill patients at the end of life.

The extensive use of sedative and analgesic medication at the end of life is often controversial due to the perception that death may be hastened as a result of progressive drug escalation. Physician attitudes toward prescribing medication in this setting vary, resulting in widely differing prescribing patterns for patients with advanced cancer. This investigation attempted to identify overall prescribing patterns and variation in the use of sedation and analgesia in an inpatient hospice setting at the end of life. A retrospective case review was undertaken of 102 consecutive patients who died in a palliative care hospice. A detailed review of medication prescription, with particular attention to sedation and analgesia in the last week of life, was performed. The review revealed that regular sedation was prescribed in 68 percent of the patients. Almost two-thirds of the patients began regular sedation on admission or within seven days of admission. Although survival was higher in patients who received regular sedation (mean, 36.5 days) versus those that did not (mean, 17 days), the difference was not significant (p = 0.1). Overall, regular sedation with moderate dose increases was observed. In patients prescribed morphine from the time of admission, morphine oral equivalents increased from a mean of 111 mg on admission to a mean of 346 mg at time of death for a mean escalation of 311 percent. The mean duration of admission was 26 days with an opioid-escalation index of 12 percent per day. Survival is a multifactorial phenomenon and was unrelated to the level of analgesia in this cohort. Findings showed that sedation dose increased modestly toward the end of life, and that the increase was not associated with a significant reduction in survival. Further there was no significant impact on survival related to an individual physician's prescribing pattern at the end of life. These results suggest that, in the institution where the review was conducted, neither sedation nor individual variation in physician prescribing habits in terminally ill patients was associated with hastening of death. Overall, the amount of sedative drugs required for adequate symptom control during terminal care was moderate.