Drugs used for the treatment of Simple Analgesics Weak Opioids Strong Opioids Oral Strong Opioids Transdermal Strong Opioids Subcutaneous Adjuvant analgesics Non Steroidal Anti-Inflammatory Drugs (NSAIDs) Topical treatments Nutraceuticals Anti-migraine drugs acute attack Anti-migraine drugs prophylaxis Skeletal Muscle Relaxants and Drugs for Nocturnal Cramps Updated: 18.08.2010
The current BNF contains a plethora of information with regards to the management of. Further information can also be found in the following guidelines: THPCT Persistent guidelines THPCT Palliative care guidelines WHO ladder The Long Term Neurological conditions National Service Framework outlines the commitment of the Department of Health to transform the way health and social care services support people living with long-term neurological conditions including persistent. For more information visit the Department of Health website: http://www.dh.gov.uk/en/healthcare/nationalserviceframeworks/index.htm Dental and orofacial Analgesics should only be used in dental care as a temporary measure until the cause of has been rectified. Analgesics provide temporary relief and the choice should be based on the suitability of the patient. Most dental is relieved by paracetamol, ibuprofen or aspirin and an opioid (relatively ineffective in dental ) is rarely required. Prescription requirements for controlled drugs Prescriptions for Controlled Drugs that are subject to prescription requirements must be indelible, and must be signed by the prescriber, be dated, and specify the prescriber's address. The prescription must always state: Name and address of the patient In the case of a preparation, the form and where appropriate the strength of the preparation; Either the total quantity (in both words and figures) of the preparation, or the number (in both words and figures) of dosage units, as appropriate, to be supplied; in any other case Total quantity (in both words and figures) of the Controlled Drug to be supplied Dose (and the words for dental treatment only' if issued by a dentist) Prescriptions for Controlled Drugs in Schedules 2, 3, and 4 should usually be limited to a supply of up to 30 days treatment. Further information is available at www.dh.gov.uk/controlleddrugs. Back Simple Analgesics
Paracetamol Mild to Moderate, soluble tablets, suspension, suppositories The effect of regular paracetamol (i.e. 1g 4 times a day) is greater than taking paracetamol on a PRN basis. Max daily dose of paracetamol is 4g/daily. Sugar free (SF) suspensions need to be requested. Care when prescribing soluble tablets sodium content of soluble tablets is 18mmol/tablet, this equates to 0.43g/tablet. A full daily dose (8 tablets) equates to 3.44g per day of sodium. Weak Opioids Codeine Mild to, moderate linctus Dihydrocodeine Moderate to severe, oral solution Max dose 240mg/day in divided doses long term use not advisable due to constipation. Max dose 240mg/day in divided doses higher doses cause more nausea & vomiting. Max dose 400mg/day. Not as effective in severe as other opioids. Tramadol Moderate to severe Capsules, dispersible tablets Care when prescribing with antidepressants several cases of serotonin syndrome reported. Caution should be exercised even though evidence of actual risk is small. Care when prescribing in the elderly as confusion and sedation are common with tramadol there is a high risk of falls. MR versions of tramadol are not recommended as there is no evidence of increased efficacy over normal release capsules. Compound analgesics, preparations that contain a simple analgesic such as paracetamol with an opioid component, reduce the scope for effective titration of the individual components in the management of of varying intensity.
Drug compound Indication Formulation Notes on prescribing The strength of co-codamol required (i.e. 8/500 or 30/500) should always be specified on prescriptions. Co-codamol (paracetamol + codeine) Co-dydramol (paracetamol + dihydrocodeine) Mild to moderate Moderate to severe, soluble tablets Note: For the co-codamol 30/500 preparation prescribing should be restricted to short term use only after a surgical procedure or accident as the codeine content at the maximum dose is high. Care when prescribing soluble tablets sodium content of soluble tablets is between 13.6-16.9mmol/tablet, depending on the brand. A full daily dose (8 tablets) equates to between 2.48 3.12g per day of sodium. The strength of co-dydramol required (i.e. 10/500 or 30/500) should always be specified on prescriptions. TNDG: Combined products of tramadol and paracetamol are NOT recommended as they do not contain effective doses of either analgesic. Back Strong Opioids Oral Morphine sulphate Severe Normal release tablets,oral solution MR tablets MR capsules MR sachets MXL capsules are a once a day preparation other preparations of morphine are 12 hourly. Please ensure the correct preparation and dose and frequency are prescribed. MXL and Zomorph capsules can be swallowed whole, opened and put in semisolid food or given via PEG tube.
Oxycodone and naloxone [Targinact] Oxycodone hydrochloride Severe and constipation Severe Film coated MR tablets Normal Release Capsules,oral solution MR TNDG: Targinact is not recommended for routine analgesic use. Targinact is recommended for patients unable to achieve adequate analgesia on an optimal opiate dose of morphine (1st line) and oxycodone (2 nd line) due to intolerable GI side effects which can not be alleviated by optimal laxatives and antiemetics. All patient selection to be undertaken by a Pain Consultant BLT to initiate and prescribe for the first month. Patients to be reviewed for analgesia and GI side-effects after 4-8 weeks after initiation. Targinact to be stopped if no significant improvement of analgesia/side effects is achieved. GPs could continue to prescribe maintenance Targinact and monitor patients. If the Pain Team proposes to expand these criteria for use, a case should come back to the Trust New Drugs Group Click here for algorithm for initiation and discontinuation advice TNDG: For those in whom morphine is either not effective enough or side effects are not tolerable - changing to a different opioid may result in a lessening or elimination of the side effect and/or improved analgesia. Multiple medication errors have been reported with oxycodone preparations. It is essential that the correct formulation is prescribed and its use explained to the patient. OxyNorm is NORMal release preparation OxytContin is a CONTINuous (MR) preparation The starting dose of opioid depends on previous analgesia use, age and medical condition. Immediate release preparations have a rapid onset and short duration of action, allowing steady state to be achieved quickly. It is important to review the daily dose of opioid regularly. 12 hourly modified release preparations (MR) are intended for maintenance when the dose is stable. These are NOT suitable for acute relief because of its slow onset. Patients on MR preparations must also be written up for treatment of breakthrough. Prescribe MR preparations by both brand and approved name to avoid confusion. To convert to 12 hourly MR preparations from immediate release:
Total oral morphine dose over previous 24 hours 2 = 12 hourly MR Morphine every 12 hours To calculate breakthrough Total oral MR morphine dose over 24 hours 6 = breakthrough dose that can be taken 4 hourly (normal release only) Strong Opioids Oromucosal Fentanyl Back Severe breakthrough Strong Opioids Transdermal Lozenge (with oromucosal applicator) TNDG: Fentanyl lozenges should be initiated at the recommendation of a Palliative Care Specialist. Approved for patients with chronic stabilised on a strong opioid and meeting one or more of the following criteria: Breakthrough of short duration and who have intolerable adverse effects from their normal release opioid and where dextromoramide is not appropriate/or effective. The onset of action of oral preparations is too slow requiring parenteral analgesia to be administered. Patient has severe dysphagia and is unable to swallow (e.g. oesophageal cancer) and where there is no alternative access such as a PEG tube, or where absorption from the oral route is incomplete (e.g. short bowel syndrome).
Fentanyl Buprenorphine 96 hour patches Buprenorphine 7 day patches Severe Severe Severe 72 hour transdermal patches [Transtec ] 96 hour transdermal patches [Butrans ] 7 day transdermal patches TNDG: For those who cannot swallow tablets and for those in whom morphine is either not effective or side effects are intolerable - changing to a different opioid may result in a lessening or elimination of the side effect and/or improved analgesia. Administration: Avoid using the same area for several days. These should be prescribed by brand name as different brands are not necessarily equivalent. Administration: Avoid using the same area for at least 6 days. These should be prescribed by brand name as different brands are not necessarily equivalent. These are second line patches and should be prescribed upon recommendation from the clinic or by experienced clinicians only. Administration: Avoid using the same area for at least 3 weeks These should be prescribed by brand name as different brands are not necessarily equivalent. Patches: Administration: Apply to dry, non-irritated, non-irradiated, non-hairy skin on torso or upper arm. The replacement patch should be sited on a different area. Fever or external heat may cause increased absorption; monitor for increased side-effects. Buprenorphine and fentanyl are drugs with very long duration of action. For advice on dose titration see current BNF. Side effects may persist for over 24 hours after patch removal. Strong Opioids Subcutaneous For information on controlled drugs and drug dependence and prescribing in palliative care please refer to the Guidance on Prescribing section in the current BNF.
Diamorphine Severe Injection, powder for reconstitution Morphine Severe Injection / infusion, Not suitable for oedematous patients. solution Oxycodone Severe Injection / infusion, solution The Scottish Medicines Consortium has advised (October 2004) that OxyNorm injection is used only in patients with cancer who have difficulty in tolerating morphine or diamorphine. Back Adjuvant analgesics
Unlicensed but Amitriptyline has established efficacy in neuropathic, migraine Oral solution prophylaxis According to local expert opinion (BLT Pain Clinic) max dose for neuropathic recommended is 50mg at night. The dose could be increased as tolerated up to the BNF maximum of 200mg per day to treat depression. It is especially important to exercise caution when using such doses in combination with serotonergic drugs like SSRIs and tramadol as there is a greater risk of serotonin syndrome. Trigeminal neuralgia max dose up to 1.6 g daily in some patients. Dose-related sideeffects of carbamazepine may be reduced by using the modified-release formulation. CSM: See current BNF for symptoms of blood, hepatic or skin effects that the patient needs to be aware of and report. Carbamazepine Trigeminal neuralgia only Normal release tablets Oral Solution Suppositories MR tablets Carbamazepine is a potent CYP450 enzyme inducer, as well as an auto inducer care should be exercised when prescribing concomitantly with other drugs especially those with narrow therapeutic indices (e.g. theophylline). The risk of hyponatraemia may be increased when prescribing with other drugs that deplete sodium (e.g. diuretics). TDM: Levels only required if toxicity or non-concordance is suspected. Target serum concentration: 4-12 mg / L Sample time: Trough i.e. pre-dose Notes: Time to steady state is 2-4 weeks while therapy is initiated, 4 days with chronic therapy. If levels are outside the therapeutic range, please assess patient concordance and contact the specialist for advice. Gabapentin Neuropathic Pain when amitriptyline is inappropriate Capsules M/R preparations Different preparations may vary in bioavailability; to avoid reduced effect or excessive side effects, it may be prudent to avoid changing the formulation. (The use of M/R tablets significantly lessens the incidence of dose-related side effects). Should be increased to maximum tolerated dose. Dose should be titrated according to BNF Patient should be warned about drowsiness and blurred vision which is usually transient. are very expensive
Nortriptyline Pregabalin [Lyrica ] (unlicensed in trigeminal neuralgia) Neuropathic (unlicensed) Neuropathic Capsules Maximum licensed dose for neuropathic is 3.6g/day. Initially 10-25mg Usual max dose = 75 mg daily; higher doses under specialist supervision only. Care when prescribing with antidepressants several cases of serotonin syndrome reported. Caution should be exercised even though evidence of actual risk is small. Useful for patients intolerant to the side effects of amitriptyline. TNDG: Approved for initiation by the specialist team and continuation by GPs. Non Steroidal Anti-Inflammatory Drugs (NSAIDs) CSM: NSAIDs may be associated with an increased risk of thrombotic events particularly when used at high doses for long term treatment. NSAIDs are associated with serious gastro-intestinal (GI) toxicity with a higher risk in the elderly. All non-selective NSAIDs are contraindicated in patients with a history of peptic ulceration. NSAIDs are contraindicated in heart failure. Combination of an NSAID and low dose aspirin or anti-coagulant can increase the risk of GI bleeding. Worsening of asthma or hypersensitivity reactions may be due to treatment with NSAIDs. The risk of bleeding is increased by the concurrent use of SSRIs and NSAIDs.
Ibuprofen Diclofenac Naproxen Mefenamic acid Selective COXII inhibitors Back Topical treatments Mild to moderate ; and inflammation in rheumatic disease and other musculoskeletal disorders; postoperative analgesia; migraine Pain and inflammation in rheumatic disease and other musculoskeletal disorders Pain and inflammation in rheumatic disease and other musculoskeletal disorders; dysmenorrhoea; acute gout Mild to moderate in rheumatoid and osteoarthritis;dysmenorrhoea and menorrhagia Pain and inflammation in osteo and rheumatoid arthritis Oral suspension EC tablets MR tablets suppositories EC tablets, capsules, paediatric oral suspension Ibuprofen is the traditional NSAID associated with the lowest level of gastro-intestinal risk. Increased thrombotic risk is very unlikely for shortterm low dose treatment. At high doses (>1200mg) there is an increased risk. Ibuprofen may reduce the cardioprotective effect of low-dose aspirin in people with cardiovascular disease. Studies looking at concomitant use of various NSAIDs with aspirin suggest that the risk of an interaction between ibuprofen and aspirin may be more likely when ibuprofen is taken regularly. MHRA: Diclofenac (particularly 150mg daily) may have a thrombotic risk similar to that of etoricoxib and possibly other coxibs. MHRA: Naproxen is associated with a lower thrombotic risk than coxibs, and epidemiological data do not suggest an increased risk of MI, however, some risk can not be excluded. It has occasionally been associated with diarrhoea and haemolytic anaemia which require discontinuation of treatment. Initiation by specialist advice recommended.
Drug Indication Formulation How prescribed Diclofenac Osteoarthritis Gel 1.16% Topical non-steroidal anti inflammatory drugs are considered to be of limited clinical value, hence generally deemed unsuitable for prescribing, however their use can be justified in certain circumstances: Short term use (<2 weeks) for acute musculoskeletal Treatment for osteoarthritis of the knee and hand for up to 12 weeks Based on the available evidence from clinical trials (NICE), for the treatment of osteoarthritis, topical NSAIDs could be prescribed for a maximum of 12 weeks after which treatment should be reviewed on a monthly basis. Lidocaine Post herpetic neuralgia Topical 5% plaster The patches are associated with a high frequency of adverse reactions, particularly dermatological. Each patch must be worn for only 12 hours per day and a maximum of three patches can be applied at any time. The plasters can be cut. TNDG: Approved for post herpetic neuralgia only. Post herpetic neuralgia. Transient burning sensation may occur during initial treatment, Capsaicin Cream 0.075% particularly if too much cream is used, or if the frequency of Painful diabetic neuropathy administration is less than 3 times daily, or if applied after a hot under supervision of hospital bath/shower. consultant Nutraceuticals Glucosamine sulphate Glucosamine hydrochloride Glucosamine + NICE: The use of other glucosamine and / or chondroitin products is not recommended for the treatment of osteo-arthritis.
chondroitin Anti-migraine drugs acute attack Initial treatment of migraine should be with simple analgesics like paracetamol and aspirin or an NSAID (preferably soluble formulation) with an anti-emetic if required. A 5HT agonist (triptans) should only be used if initial treatment has been tried and failed. Excessive use of treatments may be associated with Medication Overuse Headache (MOH) For acute migraine, triptans should only be used as monotherapy. Paracetamol Aspirin Sumatriptan Zolmitriptan Back See above dispersible preparations preferred. Treatment of acute migraine Treatment of acute migraine Treatment of acute migraine Dispersible tablets, tablets, nasal spray, injection Orodispersible tablets To be taken with or after food contraindicated in patients with active peptic/duodenal ulcers. Max Dose = 4g/day Nasal spray and s/c injection are very expensive. Discontinue if any tingling, heat heaviness, pressure or tightness of any part of the body becomes intense. CSM: Avoid in patients with ischaemic heart disease or Prinzmetal s angina as there have been reports of chest and tightness (coronary vasoconstriction). Orodispersible tablets are useful for those unable to swallow sumatriptan tablets due to vomiting. Discontinue if any tingling, heat heaviness, pressure or tightness of any part of the body becomes intense. Anti-migraine drugs prophylaxis When migraine attacks are frequent possible provoking factors such as stress, irregular lifestyles, chemical triggers (e.g. alcohol, cheese, caffeine chocolates and combined oral contraceptives) should be sought.
Pizotifen Propranolol Amitriptyline Topiramate Sodium valproate Migraine prophylaxis Migraine prophylaxis Commence low dose and titrate as necessary to reduce drowsiness. Can cause weight gain. CSM: beta blockers should not be given to people with a history of asthma or bronchospasm. (unlicensed) See above Treatment should be supervised by a specialist. Migraine prophylaxis (unlicensed), sprinkle capsules MR tablets, EC tablets, solution Treatment should be supervised by a specialist. Avoid abrupt withdrawal. CSM: Topiramate has been associated with acute myopia with secondary angle-closure glaucoma. Displacement of the lens and iris has also been reported. Seek specialist opthalmalogical advice. Treatment should be supervised by a specialist. CSM: inform patients how to recognise symptoms of blood, hepatic or pancreatitis effects and to seek medical attention. M/R preparations Different preparations may vary in bioavailability; to avoid reduced effect or excessive side effects, it may be prudent to avoid changing the formulation. (The use of M/R tablets significantly lessens the incidence of dose-related side effects).
Back References: Joint Formulary Committee. British National Formulary. 54 th ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain. 2007. Schnitzer TJ. Non-NSAID pharmacologic treatment options for the management of chronic. Am J Med. 1998; 105(Suppl 1B): 45S-52S. Ivon Stockley. Stockley's Drug Interactions. Pharmaceutical Press. Available from: http://www.medicinescomplete.com/mc/stockley/current/x23-2330.htm?i=%22ssris%22#_hit. Accessed on 30 th January 2008. Quang-Cantagrel et al. Regional Anaesthesia and Pain Medicine. Opioid Rotation in Chronic NonCancer Pain. Anesth. Anal.G. 2000;90:933 7 Summary of Product Characteristics. Versatis, Butrans, Transtec, Durogesic, Oxycontin, Oxynorm, MST Continus. Available from: http://emc.medicines.org.uk.last accessed 30th January 2008. Twycross R, Wilcock A. PCF Palliative Care Formulary online. Available from: http://www.palliativedrugs.com. Accessed 30 th January 2008. Clinical Knowledge Summaries. NSAIDs. SCHIN Ltd. Centre for Health Informatics at Newcastle. Available from: http://cks.library.nhs.uk/nsaids/view_whole_guidance Accessed 30 th January 2008. MHRA. NSAIDs and coxibs: balancing of cardiovascular and gastrointestinal risks. Drug Safety Update. Volume 1, Issue 5 December 2007 Cannon CP, Curtis SP, FitzGerald GA, et al. Cardiovascular outcomes with etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomised comparison. Lancet 2006; 368: (9549): 1771-1781. National Institute for Clinical Excellence. Osteoarthritis: the care and management of osteoarthritis in adults. Clinical Guidance 59. February 2008. Available from: www.nice.org.uk. Accessed 17/03/08 Armstrong A, Bishop S, Radhamanohar M. Medication and Risk of Falls in the Older Person. Approved: March 2006. http://10.148.22.36:8080/thpct/prescribing/practice%20tools%20documents/medication%20and%20the%20risk%20of%20falls%20in%20the%20older%20person. pdf Updated 16 th September 2008. Ameet Gordhan