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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).
Educational slides based on the CKS topic Analgesia mild to moderate pain (August 2010).
Educational slides 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.
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
Cardiovascular adverse
effects
Naproxen 1000mg daily has a lower
thrombotic risk than coxibs.
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.
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.
Summary - adults
Educational slides based on the CKS topic Analgesia mild to moderate pain (August 2010).
Choosing an analgesic
children
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.
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.