Specific dosage instructions should be written on the prescription, i.e. "X to be taken x hourly when required for pain", rather than simply "PRN". This ensures a maximum dose is stated and will prevent dose escalation without prescriber approval.

See also section 10.1 Drugs used in rheumatic diseases and gout

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These include mild fever and minor conditions associated with pain such as (but not limited to) headache, coughs and colds, acute sore throat, period pain, mild toothache, mild back pain etc.

Many analgesic containing products to treat these conditions are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Soluble tablets: Taking 8 tablets per day of soluble paracetamol or co-codamol will increase intake of sodium chloride by 8g daily. The Department of Health recommended daily intake of sodium chloride is 6g. This may be a significant risk in patients with heart failure or hypertension. Dispersible preparations should be reserved only for patients who cannot swallow solid forms. They are also more expensive.

Paracetamol

• Tablets 500mg (£1.94 = 100 tablets)
• Soluble tablets 500mg (contains Na+ 18.6mmol/tablet) (£21.87 = 100 tablets)
• Oral suspension sugar free 120mg/5ml, 250mg/5ml (£3.04 = 120mg/5ml x 100ml)
• Suppository 60mg, 120mg, 125mg, 240mg, 250mg, 500mg, 1g (£27.60 = 250mg x 10 suppositories)
• Solution for infusion 1000mg/100ml, 500mg/50ml
• Oral suspension 500mg/5ml (unlicensed preparation)

Indications

• Mild to moderate pain
• Pyrexia (pyrexia with discomfort in children)

Dose

• Adult, 0.5–1g every 4–6 hours to a maximum of 4g daily
• The daily dose of paracetamol should not exceed 60mg/kg when prescribed for adults weighing less than 50kg. The maximum daily dose should be reduced to 3g for adult patients with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition, or dehydration
• Child – please see BNFc

Notes

1. Shortage of paracetamol suppositories (April 2024):
   1. A Medicine Supply Notification (MSN/2023/062) for paracetamol suppositories was issued on 29 June 2023 with resupply dates expected in 2024. Anticipated resupply dates have been amended to 31 January 2025 for the following:
      1. Paracetamol 60mg suppositories
      2. Paracetamol 125mg suppositories
      3. Paracetamol 250mg suppositories.
   2. Please refer to the SPS for advice on prescribing.
2. Paracetamol should be used as a first line analgesic unless contra-indicated.
3. Community Nurse Practitioners are able to prescribe oral paracetamol tablets in quantities up to 100 tablets on each occasion.
4. Paracetamol suppositories are very expensive and other forms should be substituted as soon as possible.
5. Hospital inpatients who need paracetamol but who cannot be given it by mouth or by enteral feeding tube and who have IV access must be given intravenous paracetamol. Patients without IV access should be switched from suppositories as soon as they can take it by mouth or by enteral feeding tube.

Oral Sucrose

• Sterile 24% solution, single use container

Notes

1. Used as a pacifier in neonates prior to procedures such as heel stick or taking blood if needed.

Nefopam

The routine commissioning of nefopam is not accepted in Devon for the management of chronic pain (see Commissioning Policy for more information).

Compound analgesic preparations

There may be advantages to prescribing an opioid and non-opioid separately; consideration should be given to the increased tablet burden on an individual patient basis. Prescribing medication separately gives flexibility in both the adjustment of the doses and in the selection of the most appropriate combination.

Prescribers are reminded that tramadol/paracetamol combination preparations are not included in the formulary and should not be prescribed.

Co-codamol

(combination of codeine and paracetamol)

• Tablets 8mg/500mg, 15mg/500mg, 30mg/500mg (£3.53 = 30mg/500mg x 100 tablets)
• Capsules 30mg/500mg (£5.56 = 100 capsules)
• Effervescent tablets 8mg/500mg, 15mg/500mg^SF, 30mg/500mg (£7.47 = 30mg/500mg x 100 tablets)

Indications

• Moderate pain

Dose

• 1–2 tablets every 4–6 hours when necessary; maximum 8 tablets daily

Notes

1. Compound preparations containing 8mg codeine phosphate may not provide significant additional relief of pain but is enough to cause opioid side effects.

Co-dydramol

(combination of dihydrocodeine and paracetamol)

• Tablets 10mg/500mg (£5.63 = 100 tablets)

Indications

• Mild to moderate pain

Dose

• 1–2 tablets every 4–6 hours when necessary; maximum 8 tablets daily

Co-proxamol

Not recommended for use due to significant safety concerns. Click here for more information. Prescribers should not initiate co-proxamol for any new patient. Click the following link for a patient information leaflet to support deprescribing.

Paracetamol and tramadol combination products (e.g. Tramacet)

Not recommended for use due to significant extra costs and no evidence of increased efficacy or safety over the individual products. Click here for more information. Prescribers should not initiate paracetamol and tramadol combination products for any new patient. Click the following link for a patient information leaflet to support deprescribing.