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Clinical Knowledge

Summaries
CKS
Analgesia mild to
moderate pain
Prescribing analgesics for mild to
moderate pain in adults and
children.
Educational slides based on the CKS topic Analgesia mild to moderate pain (August 2010).

Key learning points and


objectives
To be able to:
o Outline key points to consider before
prescribing analgesics.
o Outline the stepwise strategy for pain
management in adults and children.
o Describe the factors that should be
considered when choosing an NSAID or
a weak opioid for adults and children.

Educational slides based on the CKS topic Analgesia mild to moderate pain (August 2010).

Analgesia for mild to


moderate pain in adults

Educational slides based on the CKS topic Analgesia mild to moderate pain (August 2010).

Points to consider before


prescribing analgesics
Treat the underlying cause of the pain
(where possible).
For people who have continuous pain:
o Perform a full clinical assessment and
o Give regular analgesia.

Before switching to a different analgesic


ensure a full therapeutic dose is used.
Avoid prescribing effervescent
preparations especially in people with
hypertension (high salt content).
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Choosing an analgesic
adults
A stepwise strategy is recommended:
o Step 1 prescribe paracetamol.

o Suitable first-line choice for most people with mild-tomoderate pain.


o Increase to the maximum dose of 1gram four times a
day, before switching to (or combining with) another
analgesic.

o Step2substitute the paracetamol with lowdoseibuprofen (400 mg three times a day).


o Increase to a maximum of2.4grams daily.
o If the person is unable to take an NSAID, titrate up to
a full therapeutic dose of aweak opioid(such as
codeine 60mg every 46hours; maximum 240mg
daily).
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Choosing an analgesic adults


Step3add paracetamol (1gram
four times a day) to low-dose
ibuprofen (400mg three times a
day):
o If necessary, increase the dose of
ibuprofen to a maximum of 2.4grams
daily).
o If the person is unable to tolerate an
NSAID, add paracetamol to a weak
opioid.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Choosing an analgesic adults


Step4continue with paracetamol 1gram
four times a day. Replace ibuprofen with an
alternativeNSAID, such as naproxen 250mg
to 500mg twice a day.
Step5start a full therapeutic dose of a
weak opioid such as:
o Codeine 60mg up to four times a day (maximum
240mg daily) in addition to full-dose paracetamol
(1gram four times a day) and/or an NSAID.
Note: tolerance and dependence can occur,
and elderly people are more prone to adverse
effects.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Choosing an NSAID
Low-dose ibuprofen (400mg three
times a day) or naproxen up to
500mg twice a day are preferred.
NSAIDs are associated with:
o Cardiovascular and renal complicationse.g.
cardiac failure, hypertension, and renal failure;
diclofenac, coxibs and some others increase
the risk of myocardial infarction and stroke.
o Dyspepsia and other upper GI complications
e.g. ulcer, perforation, or bleeding.

Based on the CKS topic Analgesia mild to moderate pain (August 2010), MHRA - NSAIDs and coxibs:
balancing of cardiovascular and gastrointestinal risks (2007), and a Drug Safety Update; Non-steroidal antiinflammatory drugs: cardiovascular risk (2009).

Choosing an NSAID
Ibuprofen (<1200 mg per day) and
naproxen (1000 mg per day) are not
associated with an increased
cardiovascular risk.
Ibuprofen is associated with the
lowest risk of GI adverse effects.
When prescribing use the lowest
effective dose for the shortest
Based on
the CKS topic Analgesia
mild to moderate pain (August 2010), MHRA - NSAIDs and coxibs:
possible
time.
balancing of cardiovascular and gastrointestinal risks (2007), and a Drug safety update; Non-steroidal antiinflammatory drugs: cardiovascular risk (2009).

Cardiovascular adverse
effects

Some NSAIDs are associated with


a small absolute increased risk of
thrombotic adverse effects.
o Coxibs increase the risk of
atherothrombosis by about 3events per
1000people per year (compared with
placebo).
o Diclofenac has a similar risk profile to
coxibs.
Based on the CKS topic Analgesia mild to moderate pain (August 2010), MHRA - NSAIDs and coxibs:
balancing of cardiovascular and gastrointestinal risks (2007), and a Drug Safety Update; Non-steroidal antiinflammatory drugs: cardiovascular risk (2009).

Cardiovascular adverse
effects
Naproxen 1000mg daily has a lower
thrombotic risk than coxibs.

o Overall data do not suggest an increased risk


of myocardial infarction.

For Ibuprofen at high doses (e.g.


2400 mg daily) there may be a small
thrombotic risk, but
For ibuprofen at lower doses (< 1200
mg daily) data do not suggest an
increased risk of myocardial
infarction.
Based on the CKS topic Analgesia mild to moderate pain (August 2010), MHRA - NSAIDs and coxibs:
balancing of cardiovascular and gastrointestinal risks (2007), and a Drug safety update; Non-steroidal antiinflammatory drugs: cardiovascular risk (2009).

GI adverse effects
Of the traditional NSAIDs low dose
ibuprofen offers the lowest risk.
Naproxen is thought to have an
intermediate risk.
For people who are at an increased
risk of GI adverse effects:
o Consider prescribing paracetamol.
o If an NSAID is necessary, prescribe lowdose ibuprofen or naproxen with a proton
pump inhibitor (PPI).
Based on the CKS topic Analgesia mild to moderate pain (August 2010), and MHRA - NSAIDs and coxibs:
balancing of cardiovascular and gastrointestinal risks (2007).

GI adverse effects
A coxib plus a PPI may also be
considered, but:
o Although coxibs are associated with a
lower GI risk than standard NSAIDs, their
benefits are equivocal.
o Coxibs are significantly more expensive
than ibuprofen or naproxen.
o There is a lack of evidence that adding a
PPI to a coxib is more beneficial than
adding a PPI to a standard NSAID.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Weak opioids
Tolerance and dependence can occur in
people taking long-term opioids.
o For elderly people always start with a lower dose
and titrate up slowly. They are more susceptible to
opioid adverse effects.

Codeine, dihydrocodeine, or tramadol


are possible options.
Codeine and dihydrocodeine are
recommended by:
o The British Pain Society and
o The Medicines and Healthcare products
Regulatory Agency (MHRA).
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Weak opioids
Tramadol is effective for treating
pain, however
There has been a recent significant
increase in tramadol related deaths
(when not obtained on prescription)*:
o 83 deaths in 2008.
o 175 deaths in 2012.

Tramadol is being reclassified as a


schedule 3 controlled drug later in
2014.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).
* Office for National Statistics; Deaths related to drug poisoning in England and Wales 2012.

When to use fixed dose


combinations
Prescribe single-constituent
analgesics where possible, to
allow independent titration of
each drug.
Consider fixed-dose combination
analgesics:
o For people with chronic stable pain.
o To reduce the number of tablets taken.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Fixed dose combinations


Avoid fixed-dose combination
analgesics containing low doses of
opioids such as:
o Codeine 8mg plus paracetamol 500mg, or
o Dihydrocodeine 10mg plus paracetamol
500mg.

Little evidence that they are more


effective than paracetamol alone,
and
They can cause opioid adverse
Based on the CKS topic Analgesia mild to moderate pain (August 2010) and Merec Bulletin Volume 16,
numbereffects
4 (2006).
(e.g. constipation).

Summary - adults

Use a stepwise approach to pain management paracetamol is the


preferred step 1 analgesic.
Before switching analgesics ensure a full therapeutic dose is
being prescribed.
If using an NSAID:
o Low dose ibuprofen (400 mg three times a day) or naproxen is generally
preferred.
o Consider the need for gastroprotection.
o Prescribe the lowest possible dose for the shortest possible time.

If using a weak opioid:


o
o
o
o

Consider codeine or dihydrocodeine .


Tramadol is being reclassified as a schedule 3 controlled drug later in 2014.
Be aware of tolerance and dependence.
Start with lower doses and titrate slowly in older people.

Avoid effervescent preparations (high salt content).


Avoid fixed dose combinations, consider if the person has chronic
stable pain or there is a need to reduce the number of tablets.

Analgesia for mild to


moderate pain in
children

Educational slides based on the CKS topic Analgesia mild to moderate pain (August 2010).

Choosing an analgesic
children

For children under 16 years:

o Prescribe either paracetamol or ibuprofen alone.


Both are suitable first-line choices for treating mild-to-moderate
pain in children.

If the child does not respond to the first


analgesic:
o Check their concordance, and that an appropriate dose
is being taken.
o If paracetamol has been used, switch to ibuprofen
alone.
o If ibuprofen has been used, switch to paracetamol
alone.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Choosing an analgesic
children
If switching has been unsuccessful, or
distress persists or recurs before the
next dose is due consider alternating
paracetamol and ibuprofen:
o Add a dose of the second drug (e.g. after 2 or
3hours), if the parents are confident to do this.
o Take care not to exceed the maximum daily dose.
o A treatment diary may be useful to avoid
administration errors.

If the child is still in pain consider


referral to a paediatrician.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Treatments not
recommended for
Administering paracetamol and ibuprofen
children
in of
primary
care
at the same time
the day.
o Taking both drugs together is complicated and there
is an increased risk of exceeding the maximum daily
dose.

Aspirin.
o Unless specifically indicated by a specialist, for
example for Kawasaki disease.
o Risk of Reyes syndrome.

Naproxen.
o Only licensed for use in children with juvenile rheumatoid
arthritis.
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Treatments not
recommended for
Diclofenac.
children
inof primary
care
o Most preparations
diclofenac are only licensed for
juvenile rheumatoid arthritis.
o A liquid formulation is not available in primary care
(which would allow for dose adjustment against the
child's age).

Weak opioids.
o Children have a lower threshold for theadverse
effectsof weak opioids (e.g. respiratory depression).
o Codeine use is restricted in children following reports
of serious adverse effects and children who died after
taking codeine for pain relief (post surgical).
Based on the CKS topic Analgesia mild to moderate pain (August 2010).

Summary - children
Prescribe either paracetamol or ibuprofen
alone.
If the first analgesic is unsuccessful, switch to
either paracetamol or ibuprofen (whichever has
not been used).
Consider alternating between paracetamol or
ibuprofen.
Weak opioids are not recommended increased
reports of serious adverse effects and deaths in
children given codeine post surgery.
Consider referral if pain continues despite
optimal drug management.