ADJUVANT ANALGESIA

These medications are usually used in conjunction with classical analgesics.

Bone pain

Options include:

  • Non steroidal anti-inflammatories: See NSAID section
  • Steroids: See Steroid pages
  • Radiotherapy
  • Bisphosphonates/Denosumab

In all cases seek specialist advice if needed.

Enlarging tumours

Consider radiotherapy

Seek specialist advice

Muscle spasm

Diazepam

Oral: 2mg–10mg daily increase if necessary

Preparations:

Tablets: 2mg, 5mg and 10mg
Oral solution: – 2mg/5ml

Contraindicated in:

  • Severe or acute respiratory insufficiency/depression
  • Sleep apnoea syndrome
  • Severe hepatic insufficiency

Baclofen

Oral: 5mg TDS after food (gradually increase to a max total daily dose of 100mg if necessary)

Preparations:

Tablets: 10mg

Sugar free oral solution: 5mg/5ml

Cautioned use in epilepsy and psychotic disorders, schizophrenia depressive or manic disorders, confusional states or Parkinson’s disease may be exacerbated by treatment with baclofen.

Smooth muscle spasm / colic

Hyoscine butylbromide

Dose SC: 20mg stat, or SC infusion 60mg up to 120mg in 24 hours

Tablets are poorly absorbed

Preparations:

Tablets: 10mg
Injection: 20mg/ml

Contraindicated in patients with myasthenia gravis, megacolon, narrow angle glaucoma, tachycardia, prostatic enlargement with urinary retention, mechanical stenoses in the region of the gastrointestinal tract or paralytic ileus.

Glycopyrronium

Dose SC: 200 micrograms stat and SC infusion 600 mcg up to 1200 mcg in 24hours

Contraindicated in patients with myasthenia gravis, megacolon, narrow angle glaucoma, tachycardia, prostatic enlargement with urinary retention, mechanical stenoses in the region of the gastrointestinal tract or paralytic ileus.

NB: Glycopyrronium is more sedating than hyoscine butylbromide

Tenesmus

Treat initially as for Neuropathic pain (see separate section below). Additional option is Nifedipine. 

Nifedipine

Oral: 5mg–20mg BD

Preparations:

  • Capsules 5mg, 10mg
  • Tablets SR 10mg, 20mg

There is a risk of rapid onset hypotension with immediate release preparations and reflex tachycardia therefore immediate release preparation should not be used in patient with angina.
Should be brand prescribed due to non-bioequivalence.

Also consider nerve block

Neuropathic pain

Step 1
Antidepressant (tricyclic) e.g. Amitriptyline OR  anticonvulsant

Step 2
Antidepressant (tricyclic) PLUS anticonvulsant

For nerve compression pain consider steroids also consider Transcutaneous Nerve Stimulation (TENS) or nerve block

Neuropathic agents

Amitriptyline

Oral: 10mg–25mg at night increasing slowly up to 75mg nocte

Preparations:

  • Tablets 10mg, 25mg, 50mg
  • Solution 10mg/5ml, 25mg/5ml and 50mg/5ml

Gabapentin

Oral: 100mg–300mg nocte increasing gradually to maximum daily dose of 900mg–1800mg in divided doses.

Preparations:

  • Capsules 100mg, 300mg, 400mg (Can  be opened and sprinkled on food  or administered via PEG tube for  patients with impaired swallow)
  • Tablets 600mg, 800mg

Pregabalin

Oral: 150mg daily in divided  doses (25mg–50mg bd in frail patients) increasing gradually to maximum daily dose of 600mg in divided doses.

Preparations:

  • Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 300mg

Sodium Valproate

Oral Starting Dose: 200mg m/r PO, increase as per BNF

Preparations:

  • Tablet EC 200mg and 500mg
  • Crushable tablets 100mg
  • MR tablets 200mg, 300mg, 500mg
  • Oral Solution 200mg/5ml

Caution: Not for use in women and girls of childbearing potential.

Carbamazepine

Oral: 100mg BD increasing gradually if tolerated up to 1200mg daily in divided doses if necessary.

Preparations:

  • Tablets 100mg, 200mg, 400mg
  • Chewable tablets 100mg and 200mg
  • MR Tablets 200mg, 400mg
  • Oral liquid ‘sugar free’ 10mg/5ml
  • Suppositories 125mg (equivalent to 100mg tablets)

Monitoring:

Check LFT’s and FBC once started.

Caution:

Potent inducer of CYP3A4 therefore, can reduce the levels of buprenorphine, methadone, paracetamol (long term administration of carbamazepine and paracetamol (acetaminophen) may be associated with hepatotoxicity), tramadol.

Please see the current BNF for all other drug interactions.

Clonazepam

Oral: 500 micrograms nocte; increasing gradually to 2mg nocte

Preparations:

  • Tablets 500 micrograms & 2mg

Use with caution in patients with chronic pulmonary insufficiency, or with renal or hepatic function impairment, and in the elderly or debilitated. In these cases dosage should generally be reduced.

Advice: to start small and titrate up.

Duloxetine

Oral: 60mg OD (consider 30mg OD orally in frail patients) increasing gradually up to maximum daily dose of 120mg in divided doses.

Preparations:

  • Cymbalta® 30mg capsules and 60mg capsules

Contraindicated in Severe renal impairment (creatinine clearance <30 ml/min) and severe hypertension.

Monitor blood pressure and heart rate.

Lidocaine plaster

Consider in localised neuropathic pain 5% plaster; use up to three plasters over 12hrs per 24hrs

Preparations:
Versatis® 5% medicated plaster

Capsaicin

Consider in localised neuropathic pain

Preparations:

  • Cream: Topical: 0.025% and 0.075% cream. Apply using gloves 2 to 4 times daily.
  • Patch: 8%. Qutenza® Apply for one hour only.

Advice to patients: Burning sensation can occur during initial treatment.

Mirtazapine

Benefit reported in neuropathic pain but not tested in RCT.

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.