Page 55 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
metastases, bisphosphonates appeared to reduce bone pain compared
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Meanwhile, a Cochrane network meta-analysis of patients with prostate
cancer and bone metastases receiving bisphosphonates or RANK-
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{ For the outcome of the proportion of patients with pain response,
zoledronate was ranked as the best treatment option followed
by etidronate, clodronate, and risedronate. However, only
zoledronate was found to be more effective than clodronate in
pair-wise comparison (RR=1.19, 95% CI 1.03 to 1.39). There was
no trial reported on denosumab in pair-wise comparison.
{ For the outcome of renal impairment, compared with no treatment/
placebo, zoledronate increased the risk (RR=1.63, 95% CI 1.08
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comparing the different bone targeting agents with each other, no
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{ For the outcome of osteonecrosis of the jaw (ONJ), compared
with no treatment/placebo, denosumab increased the occurrence
of ONJ (RR=3.45, 95% CI 1.06 to 11.24) while zoledronate and
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comparing the different bone targeting agents with each other, no
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nausea), compared with no treatment/placebo, only denosumab
increased the risk of the AEs (RR=1.46, 95% CI 1.06 to 1.99).
By comparing the different bone targeting agents with each other,
zoledronate had a lower risk of AEs compared with denosumab
(RR=0.92, 95% CI 0.87 to 0.98). The comparison between the
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WHO guidelines on cancer pain management: 11
{ recommends that bisphosphonate should be used to prevent and
treat bone pain in adults (including older persons) and adolescents
with bone metastases
{ has no recommendation for or against the use of monoclonal
antibodies to prevent and treat bone pain
{ also has no recommendation for or against the comparative
advantage of monoclonal antibodies over bisphosphonates to
prevent and treat bone pain

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Ketamine, an NMDA-receptor antagonist used for general anaesthesia
and sedation, can also be used in selected patients whose pain has
been inadequately relieved by opioids alone. However, a Cochrane
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37

e-cpg inside text-Cancer pain-25/5/24.indd 37 09/08/2024 12:09 AM