{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T21:57:55Z","timestamp":1792101475791,"version":"4.4.0"},"reference-count":35,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2022,12,15]],"date-time":"2022-12-15T00:00:00Z","timestamp":1671062400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"L. Molteni &amp; C Dei Fratelli Alitti"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for cancer pain. We used the Delphi methodology to evaluate the opinions of clinicians on NSAIDs and paracetamol, with a specific focus on their safety profile. Consensus was reached on seven statements. A high level of consensus was reached regarding the use of NSAIDs and gastrointestinal, cardiovascular, and renal risk in patients taking low-dose aspirin and assessment of liver function during long-term treatment with paracetamol. Consensus was also reached that assessment and monitoring of eGFR are important in the elderly being administered NSAIDs. It was further agreed that NSAIDs can often play a key role in association with opioids in the treatment of cancer pain and that paracetamol is the analgesic of first choice for patients with mild chronic pain. When NSAIDs are administered in combination with steroids, it was agreed that the risk of gastrointestinal damage is increased since steroids delay the healing of ulcers and that paracetamol can be used during pregnancy and does not affect the health of the fetus. This Delphi study highlights that there is poor agreement on how these drugs are routinely prescribed. However, a consensus was reached for seven key statements and may represent a valid contribution to daily practice.<\/jats:p>","DOI":"10.3390\/jcm11247451","type":"journal-article","created":{"date-parts":[[2022,12,16]],"date-time":"2022-12-16T02:54:02Z","timestamp":1671159242000},"page":"7451","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["New Perspectives on the Adverse Effects of NSAIDs in Cancer Pain: An Italian Delphi Study from the Rational Use of Analgesics (RUA) Group"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3822-2923","authenticated-orcid":false,"given":"Giustino","family":"Varrassi","sequence":"first","affiliation":[{"name":"Giustino Varrassi, Paolo Procacci Foundation, Via Tacito 7, 00193 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7184-5519","authenticated-orcid":false,"given":"Flaminia","family":"Coluzzi","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04013 Latina, Italy"},{"name":"Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant\u2019Andrea University Hospital, 00189 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diego","family":"Fornasari","sequence":"additional","affiliation":[{"name":"Department of Medical Biotechnology and Molecular Medicine, Universit\u00e0 degli Studi di Milano, 20121 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Flavio","family":"Fusco","sequence":"additional","affiliation":[{"name":"Palliative Care Unit, Department of Primary and Community Care, ASL3, 16100 Liguria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Walter","family":"Gianni","sequence":"additional","affiliation":[{"name":"IRCCS Santa Lucia Foundation, 00179 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vittorio Andrea","family":"Guardamagna","sequence":"additional","affiliation":[{"name":"Pain Medicine Unit, Istituto Europeo Oncologico, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7274-6467","authenticated-orcid":false,"given":"Filomena","family":"Puntillo","sequence":"additional","affiliation":[{"name":"Department of Interdisciplinary Medicine (DIM), University of Bari, 70124 Bari, Italy"},{"name":"Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124 Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1600-4474","authenticated-orcid":false,"given":"Giovanni","family":"Sotgiu","sequence":"additional","affiliation":[{"name":"Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,12,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1420","DOI":"10.1093\/annonc\/mdp001","article-title":"Cancer-related pain: A pan-European survey of prevalence, treatment, and patient attitudes","volume":"20","author":"Breivik","year":"2009","journal-title":"Ann. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1985","DOI":"10.1093\/annonc\/mdn419","article-title":"Prevalence of undertreatment in cancer pain. A review of published literature","volume":"19","author":"Deandrea","year":"2008","journal-title":"Ann. Oncol."},{"key":"ref_3","unstructured":"WHO (1996). World Health Organization Cancer Pain Relief, with a Guide to Opioid Availability, World Health Organization. [2nd ed.]."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"iv166","DOI":"10.1093\/annonc\/mdy152","article-title":"Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines","volume":"29","author":"Fallon","year":"2018","journal-title":"Ann. Oncol."},{"key":"ref_5","first-page":"CD012637","article-title":"Oral paracetamol (acetaminophen) for cancer pain","volume":"7","author":"Wiffen","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"114147","DOI":"10.1016\/j.bcp.2020.114147","article-title":"Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective","volume":"180","author":"Bindu","year":"2020","journal-title":"Biochem. Pharmacol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1080\/14740338.2021.1965988","article-title":"Gastrointestinal and cardiovascular adverse events associated with NSAIDs","volume":"21","author":"Lanas","year":"2022","journal-title":"Expert Opin. Drug Saf."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1097\/SPC.0000000000000332","article-title":"Nonsteroidal anti-inflammatory drugs and cancer pain","volume":"12","author":"Strawson","year":"2018","journal-title":"Curr. Opin. Support. Palliat. Care"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"4676","DOI":"10.1111\/bcp.15478","article-title":"Protective effect of proton-pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: A systematic review and meta-analysis","volume":"88","author":"Ahn","year":"2022","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"637504","DOI":"10.3389\/fonc.2021.637504","article-title":"Cyclooxygenase-2 Inhibitor: A Potential Combination Strategy with Immunotherapy in Cancer","volume":"11","author":"Pu","year":"2021","journal-title":"Front. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1084","DOI":"10.1016\/S1474-4422(13)70193-5","article-title":"Combination pharmacotherapy for the management of chronic pain: From bench to bedside","volume":"12","author":"Gilron","year":"2013","journal-title":"Lancet Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e995","DOI":"10.1097\/PR9.0000000000000995","article-title":"Nonopioid drug combinations for cancer pain: A systematic review","volume":"7","author":"Sohi","year":"2021","journal-title":"Pain Rep."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"979","DOI":"10.2147\/JPR.S243222","article-title":"Cancer Pain Management: An Italian Delphi Survey from the Rational Use of Analgesics (RUA) Group","volume":"13","author":"Varrassi","year":"2020","journal-title":"J. Pain Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1007\/s40122-021-00248-x","article-title":"Personalizing Cancer Pain Therapy: Insights from the Rational Use of Analgesics (RUA) Group","volume":"10","author":"Varrassi","year":"2021","journal-title":"Pain Ther."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1080\/0142159X.2017.1245856","article-title":"Using consensus group methods such as Delphi and Nominal Group in medical education research","volume":"39","author":"Varpio","year":"2017","journal-title":"Med. Teach."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1136\/bmj.311.7001.376","article-title":"Qualitative Research: Consensus methods for medical and health services research","volume":"311","author":"Jones","year":"1995","journal-title":"BMJ"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1053\/j.ajkd.2020.03.023","article-title":"NSAIDs in CKD: Are They Safe?","volume":"76","author":"Baker","year":"2020","journal-title":"Am. J. Kidney Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"105","DOI":"10.2147\/JPR.S75160","article-title":"New insights into the use of currently available non-steroidal anti-inflammatory drugs","volume":"8","author":"Brune","year":"2015","journal-title":"J. Pain Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"898","DOI":"10.2215\/CJN.18501120","article-title":"Comparative Risks of Nonsteroidal Anti-Inflammatory Drugs on CKD","volume":"16","author":"Wan","year":"2021","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"617","DOI":"10.1136\/gutjnl-2019-319300","article-title":"Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: Joint APAGE\/APLAR\/APSDE\/APSH\/APSN\/PoA recommendations","volume":"69","author":"Szeto","year":"2020","journal-title":"Gut"},{"key":"ref_21","first-page":"11","article-title":"Paracetamol: Mechanism of action, applications and safety concern","volume":"71","author":"Nowak","year":"2014","journal-title":"Acta Pol. Pharm."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/j.amjopharm.2012.09.004","article-title":"Adverse Effects of Analgesics Commonly Used by Older Adults with Osteoarthritis: Focus on Non-Opioid and Opioid Analgesics","volume":"10","author":"Hanlon","year":"2012","journal-title":"Am. J. Geriatr. Pharmacother."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1007\/s40266-019-00658-9","article-title":"Safety of Paracetamol in Osteoarthritis: What Does the Literature Say?","volume":"36","author":"Conaghan","year":"2019","journal-title":"Drugs Aging"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"McNicol, E.D., Strassels, S., Goudas, L., Lau, J., and Carr, D.B. (2015). WITHDRAWN: NSAIDS or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database Syst. Rev., CD005180.","DOI":"10.1002\/14651858.CD005180.pub2"},{"key":"ref_25","first-page":"CD012638","article-title":"Oral nonsteroidal anti-inflammatory drugs (NSAIDs) for cancer pain in adults","volume":"7","author":"Derry","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1093\/oxfordjournals.aje.a010234","article-title":"Nonsteroidal Antiinflammatory Drugs and Acute Renal Failure in Elderly Persons","volume":"151","author":"Griffin","year":"2000","journal-title":"Am. J. Epidemiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"811","DOI":"10.1080\/03007995.2022.2049551","article-title":"Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older","volume":"38","author":"Alchin","year":"2022","journal-title":"Curr. Med. Res. Opin."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Freo, U., Ruocco, C., Valerio, A., Scagnol, I., and Nisoli, E. (2021). Paracetamol: A Review of Guideline Recommendations. J. Clin. Med., 10.","DOI":"10.3390\/jcm10153420"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1459","DOI":"10.1007\/s40265-018-0980-9","article-title":"Assessing and Treating Chronic Pain in Patients with End-Stage Renal Disease","volume":"78","author":"Coluzzi","year":"2018","journal-title":"Drugs"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1136\/gut.37.5.613","article-title":"Corticosteroids reduce regenerative repair of epithelium in experimental gastric ulcers","volume":"37","author":"Rentsch","year":"1995","journal-title":"Gut"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1111\/apt.13298","article-title":"Short-term use of glucocorticoids and risk of peptic ulcer bleeding: A nationwide population-based case-crossover study","volume":"42","author":"Tseng","year":"2015","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1089","DOI":"10.1093\/aje\/153.11.1089","article-title":"Steroids and risk of upper gastrointestinal complications","volume":"153","author":"Rodriguez","year":"2001","journal-title":"Am. J. Epidemiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1038\/s41574-021-00553-7","article-title":"Paracetamol use during pregnancy\u2014A call for precautionary action","volume":"17","author":"Bauer","year":"2021","journal-title":"Nat. Rev. Endocrinol."},{"key":"ref_34","first-page":"211","article-title":"Chronic pain management in pregnancy and lactation","volume":"80","author":"Coluzzi","year":"2013","journal-title":"Minerva Anestesiol."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Sznajder, K.K., Teti, D.M., and Kjerulff, K.H. (2022). Maternal use of acetaminophen during pregnancy and neurobehavioral problems in offspring at 3 years: A prospective cohort study. 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