Use of NSAIDs vs opiates resulted in no significant difference in measures of pain but was associated with more rescue medication (additional medicine needed due to uncontrolled pain) among patients with malignant pleural effusions (excess fluid accumulates around the lungs that is a complication of cancer) undergoing pleurodesis (a treatment for this condition that closes up the pleural space), according to a study in the December 22/29 issue of JAMA.
The incidence of malignant pleural effusion is estimated to be 150,000 new cases in the United States each year. Nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided for treatment because they may reduce effectiveness of pleurodesis. Smaller chest tubes may be less painful than larger tubes during pleurodesis, but efficacy has not been proven.
Najib M. Rahman, D.Phil., of the University of Oxford, England and colleagues randomly assigned patients with malignant pleural effusion requiring pleurodesis undergoing thoracoscopy (endoscopic examination, therapy or surgery of the chest cavity) (n = 206) and who received a 24F (larger size) chest tube to receive opiates (n = 103) vs NSAIDs (n = 103). Those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28); 24F chest tube and NSAIDs [n = 29); 12F (smaller size) chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]). The study was conducted at 16 UK hospitals from 2007 to 2013.
The researchers found that the use of NSAIDs, compared with opiates, resulted in no significant difference in pain scores but was associated with more use of rescue medication while the chest tube was in place; however, NSAID use also resulted in noninferior (not worse than) rates of pleurodesis efficacy at 3 months. Among patients who did not undergo thoracoscopy, placement of 12F chest tubes compared with 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain scores and failed to meet noninferiority criteria for pleurodesis efficacy.
"These results challenge current guidelines that advocate avoidance of NSAIDs and use of small chest tubes," the authors write.
(doi:10.1001/jama.2015.16840; Available pre-embargo to the media at http://media.jamanetwork.com)
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