Pain Management Options for a 90-Year-Old with Bladder Cancer

Primary Recommendation: Opioid Therapy

• The National Comprehensive Cancer Network (NCCN) guidelines recommend opioid analgesics as a safe and effective alternative to NSAIDs in patients with bleeding disorders, anemia, and hepatic dysfunction 1, 2
• Opioid analgesics should be the first-line choice for patients with absolute contraindications to NSAIDs, such as active bleeding, anemia, and thrombocytopenia risk 1, 2

Secondary Option: Acetaminophen

• The NCCN guidelines state that acetaminophen can be considered, but requires significant dose reduction, with a maximum dose of 650 mg every 6 hours (2.6 g/day maximum) if liver function has normalized 3, 4
• Acetaminophen should be avoided in combination with opioid-acetaminophen combinations to prevent accidental overdosing 3, 6

Contraindications

• All NSAIDs are absolutely contraindicated in patients with active bleeding, anemia, and age >60 years, due to the high risk of bleeding and hepatotoxicity 1, 2, 3, 5
• Even "safer" NSAIDs, such as nonacetylated salicylates and COX-2 inhibitors, should be avoided due to the risk of GI bleeding and hepatotoxicity 3, 5, 7

Additional Considerations

• The NCCN guidelines recommend considering interventional pain management consultation if pain is localized and likely to respond to nerve blocks, such as superior hypogastric plexus block for lower abdomen/bladder pain 3, 4, 8