4.7.1 Non-opioid analgesics and compound analgesic preparations

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

Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information 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 (£1.56 = 100 tablets)
  • Soluble tablets 500mg (contains Na+ 18.6mmol/tablet) (£8.13 = 100 tablets)
  • Oral suspensionSF 120mg/5ml, 250mg/5ml (£1.19 = 100ml 120mg/5ml)
  • Suppository 60mg, 120mg, 125mg, 240mg, 250mg, 500mg, 1g (£27.60 = 10 x 250mg)
  • Intravenous 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. Paracetamol should be used as a first line analgesic unless contra-indicated
  2. Community Nurse Practitioners are able to prescribe oral paracetamol tablets in quantities up to 100 tablets on each occasion.
  3. Paracetamol suppositories are very expensive and other forms should be substituted as soon as possible.
  4. 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.

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.

Metoclopramide plus paracetamol
  • Sachets, paracetamol 500mg plus metoclopramide 5mg (Paramax®) (£12.52 = 42 sachets)

Indications

  • Acute migraine

Dose

  • 2 sachets dissolved in a quarter tumblerful of water at onset of attack then repeat every 4 hours when necessary to maximum 6 sachets in 24 hours

Notes

  1. Antimigraine preparations containing metoclopramide are not suitable for patients under the age of 20 years.
Co-codamol

(combination of codeine and paracetamol)

  • Tablets 8mg/500mg, 15/500, 30/500 (£3.57 = 100 tablets 30/500)
  • Capsules 30mg/500mg (£4.68 = 100 capsules)
  • Effervescent tablets 8mg/500mg, 15/500, 30/500 (£8.22 = 100 tablets 30/500)

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 (£2.50 = 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.

 

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