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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.
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.
(combination of codeine and paracetamol)
(Combination of dihydrocodeine and paracetamol)
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.
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.