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Step 1: Paracetamol & NSAIDS

Paracetamol

Therapeutic effects

  • analgesic
  • anti-pyretic

Dose: 500mg – 1g, 4–6 hourly. Max dose 4g in 24 hours
Preparations: Tablets/caplets/capsules: 500mg, 1g
Dispersible tablets: 500mg
Oral suspension: 120mg/5ml, 250mg/5ml, 500mg/5ml
Suppositories: 60mg, 125mg, 250mg, 500mg
Injection for IV infusion: 10mg/ml, 50ml (500mg) and 100ml (1g) vials

Reduce dose if severe liver disease, alcohol dependence, malnutrition, low weight (<50kg), frail elderly.
Dose interval should be ≥ 6h if severe renal impairment.

Non-steroidal anti-inflammatories - NSAIDs

Therapeutic effects

  • Anti-inflammatory
  • Anti-pyretic
  • Analgesic

Indications: for analgesia in palliative care, including action as adjuvant analgesic

  1. Bone pain
  2. Soft tissue pain due to malignant infiltration
  3. Arthritis
  4. Possible role in early management of neuropathic pain

Assess analgesic response after regular use for one week

Patients considered to be at risk of NSAID induced gastroduodenal ulceration (age over 65 years, past history of peptic ulcer disease, concomitant oral steroids or anticoagulants, serious
comorbidity) should receive a gastro-protective drug such as a proton pump inhibitor.

Use with extreme caution in renal failure. Fluid retention and renal function may all be worsened by NSAIDs. There is little evidence to suggest that any particular NSAID is safer than another in respect of renal toxicity.

NSAIDs may be considered for asthmatic patients unless they have a history of sensitivity.

Non-steroidal anti-inflammatory drugs

Ibuprofen

Usually first line NSAID

Adult Dose
Oral: 200-400mg TDS

Dosage Forms
Tablet: 200mg, 400mg, 600mg
MR tablet: 800mg OD
MR capsule: 300mg BD
Suspension: 100mg/5ml
Granules: 600mg sachet
Gel for topical use 5% and 10%

Additional Information
Current evidence suggests an increased risk of cardiovascular thrombotic events with NSAIDs.
For those at risk consider naproxen or low dose ibuprofen (1200mg or less/24h)

Nabumetone

Adult Dose
Oral: 500mg – 1g BD

Dosage Forms
Tablet: 500mg
Suspension: 500mg/ml

Additional Information
It appears to be associated with a lower incidence of GI side effects

Naproxen

Adult Dose
Oral: 250-500mg BD

Dosage Forms
Tablet: 250mg, 500mg

Additional Information
It appears to be associated with a lower risk of cardiovascular thrombotic events

Celecoxib

Adult Dose
100mg BD

Dosage Forms
Capsules: 100mg, 200mg

Additional Information
It appears to be associated with a lower incidence of GI side effects.

Diclofenac

Adult Dose
Up to 150mg in 24 hours
Can be given via CSCI but not compatible with other drugs
Injection can cause skin necrosis

Dosage Forms
Tablet: 25mg, 50mg
Modified Release tablets and capsules: 75mg, 100mg
Dispersible tablets: 50mg
Suppositories: 12.5mg, 25mg, 50mg, 100mg
Injection: 25mg/ml
Gel: For topical use

Additional Information
Low GI Risk
Higher cardiac risk

MR = Modified release
EC = enteric coated

In patients who are terminally ill the increased risk of renal, cardiovascular and GI toxicity associated with NSAIDs must be weighed against the potential for improved pain control.

For further guidance on the use of NSAIDs (including alternative parenteral agents) consult your local Specialist Palliative Care Team.

Use the links below for more steps:

STEP 1: Paracetamol & NSAIDS
STEP 2: Weak Opioids
STEP 3: Strong Opioids
Morphine Preparations
Next: Weak Opioids

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.
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