D. Add diclofenac – Explanation

Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in
managing bony pain but these are not first-line treatments
Palliative care prescribing: pain

NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed
below. Please see the link for more details.

Starting treatment

• when starting treatment, offer patients with advanced and progressive disease regular oral
  modifiedrelease (MR) or oral immediate-release morphine (depending on patient preference), with
  oral immediate-release morphine for breakthrough pain
• if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For
  example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as
  required
• oral modified-release morphine should be used in preference to transdermal patches
• laxatives should be prescribed for all patients initiating strong opioids
• patients should be advised that nausea is often transient. If it persists then an antiemetic should be
  offered

SIGN guidelines
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points

• the breakthrough dose of morphine is one-sixth the daily dose of morphine
• all patients who receive opioids should be prescribed a laxative
• opioids should be used with caution in patients with chronic kidney disease. Alfentanil,
  buprenorphine
  and fentanyl are preferred
• metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Other points
When increasing the dose of opioids the next dose should be increased by 30-50%.
Opioid side-effects

The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately equivalent to
one ’25 mcg/hour’ fentanyl patch, therefore product literature should be consulted. NICE give the
following advice on conversion:

• a transdermal fentanyl 12 microgram patch equates to approximately 45 mg oral morphine daily
• a transdermal buprenorphine 20 microgram patch equates to approximately 30 mg oral morphine
  daily.