For mild to moderate pain relief. Suitable for pain in musculoskeletal conditions.
|
| |
GREEN Paracetamol [Consider OTC/Self care]
|
| tablets 500mg, soluble tablets 500mg |
| suspension 120mg/5mL, 250mg/5mL |
| suspension SF 500mg/5mL (Rosemont) |
| suppositories 125mg, 250mg, 500mg |
| |
For short term use as advised by acute pain team or anaesthetists only
|
RED Paracetamol intravenous infusion 10mg/mL 100mL vial
|
| |
Non-steroidal Anti-inflammatory Drugs
|
Ibuprofen, Naproxen, Diclofenac
|
| for preparations see section 10.1.1 |
| |
Compound analgesic preparations (containing opioids)
|
These preparations should not be used routinely.
|
Patients should be given the individual components where possible to allow titration of dose.
|
Where these preparations are used, they should be for short term use only, for relief of moderate pain.
|
| |
GREEN Co-codamol 8/500 (codeine 8mg + paracetamol 500mg) [Consider OTC/Self care]
|
| tablets 8/500, tablets dispersible 8/500 |
| GREEN Co-codamol 30/500 (codeine 30mg + paracetamol 500mg) | |
| tablets 30/500, tablets effervescent 30/500 |
GREEN Co-dydramol (dihydrocodeine 10mg + paracetamol 500mg)
|
| tablets 10/500 |
BLACK Nefopam tablets - link to ELHE Position Statement
|
|
|
| |
Used for relief of moderate to severe pain. Suitable for pain of visceral origin.
|
GREEN Codeine phosphate
|
| tablets 15mg, 30mg, 60mg |
| syrup 25mg/5mL |
| |
GREEN Dihydrocodeine
|
| tablets 30mg |
| elixir 10mg/5mL |
GREEN Tramadol
|
| capsules 50mg |
| tablets prolonged release* 100mg, 150mg, 200mg |
| *prescribe as Marol® MR tablets - more cost effective than capsules MR |
| capsules m/r 100mg, 150mg, 200mg (prescribe as Marol® Tablets MR as above) |
(M/R preparations should be prescribed in favour of standard release if there is a risk of abuse or diversion)
|
| |
| RED Tramadol injection 100mg/2mL (Theatre Recovery only) |
|
GREEN Morphine sulfate
|
| capsules m/r 10mg, 30mg, 60mg, 100mg, 200mg {Zomorph®] |
| tablets 10mg, 20mg, 50mg [Sevredol®] |
| oral solution 10mg/5mL, 100mg/5mL [Oramorph®] |
| injection 10mg/mL, 15mg/mL, 30mg/mL |
| tablets m/r 5mg, 10mg, 15mg, 30mg, 60mg, 200mg [MST®] |
| (Modified release tablets and capsules should be prescribed by brand) |
| |
| The onus is on the prescriber to take adequate steps to assure safe and cost effective choices. |
| |
RED Morphine syringe 100mg/50mL
|
GREEN Diamorphine (ongoing supply problems contact pharmacist for advice)
|
| injection 5mg, 10mg, 30mg, 100mg, 500mg |
GREEN Pethidine
|
| injection 50mg/mL, 100mg/2mL |
GREEN Fentanyl matrix patches 12, 25, 50, 75,100 micrograms/hr
|
| Matrifen®, Mezolar®, Fencino®, Opiodur® |
(Fentanyl matrix patches should be prescribed by brand name to minimise the risk of reservoir patches being accidentally supplied)
|
| |
| N.B. This formulary does not specify which brand to prescribe because procurement costs are frequently changing. |
| The onus is on the prescriber to take adequate steps to assure safe and cost effective choices. |
| |
For guidance on the use of fentanyl patches in care homes - click here
|
| |
AMBER Oxycodone Hcl
|
| capsules 5mg, 10mg, 20mg (Lynlor®, Shortec®) |
| AMBER Oxycodone Hcl modified-release tablets* |
| tablets m/r 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg (Oxypro®MR tablets, Longtec®) |
| * Oxypro®MR tablets is the cost-effective branded generic to options for prolonged-release oxycodone. |
| [East Lancashire Hospital Trust use 'Oxylan®'' MR - please note this is similar in name to Oxypro®MR |
AMBER Oxycodone Liquid 5mg/5mL - 2nd line to capsules
|
AMBER Oxycodone Concentrated oral solution 10mg/mL - Palliative Care Use Only
|
AMBER Oxycodone Injection 10mg/mL - Palliative Care Use Only when morphine is unsuitable
|
RED Methadone (see section 4.10 for use in opiate addiction)
|
| mixture 1mg/mL (some brands are unlicensed for use in analgesia) |
| tablets 5mg |
| injection 10mg/mL |
GREEN Buprenorphine
|
| sublingual tablets 200microgram, 400microgram |
Please note: Buprenorphine oral lyophilisate (Espranor®) is RED traffic Light and should only be prescribed by The
|
| Specialist Substance Misuse Service .(see section 4.10 for use in opiate addiction) |
AMBER Buprenorphine transdermal weekly patches
|
| (Butec®) 5, 10, 15, 20 micrograms/hour / (Sevodyne®) 5,10, 20micrograms/hr |
| Preferred brands for all patients |
AMBER Buprenorphine transdermal 96 hourly patches
|
| (Bupeaze®) 35, 52.5, 70 micrograms/hour - preferred brand for all patients |
| |
Please note the difference in duration of action between the patches. Butec® and Sevodyne® require changing every seven
|
days whilst Transtec® and Bupeaze® are a 96 hour patch which will require changing twice weekly. Ensure that the dosage
|
interval prescribed is appropriate for the product prescribed in order to prevent either unnecessary changing of patches or
|
potentially leaving patients unmedicated.
|
| |
Strong Opioids: Treatments of choice
|
Chronic Pain
|
Morphine is the first line strong opioid in management of severe chronic pain, in combination with non-opioid and adjuvant
|
therapies. Oxycodone and topical agents (Fentanyl / Buprenorphine patches) should be considered as second line agents, for
|
patients intolerant or contraindicated of morphine.
|
| |
Post Operative Pain
|
Various agents and regimens are used according to treatment pathway and prescribing is restricted to secondary care, although
|
patients may be discharged on limited course of high potency opioid. Choices are in accordance with the Acute Post Operative
|
Analgesic Prescribing Guidelines and Oxycodone Guideline for Orthopaedic Patients. For prescribing after discharge from hospital,
|
patients should be stepped down to lower potency analgesics or pre admission regimens should be reinstated after careful
|
consideration of the new analgesic requirement.
|
| |
Palliative Care
|
Morphine is the first line strong opioid in palliative care, by oral or parenteral route.
|
Oxycodone and topical agents (Fentanyl / Buprenorphine patches) should be considered as second line agents, for patients
|
intolerant or contraindicated of morphine.
|
| |
| Use of Alfentanil |
| Pain in patients with renal failure or intolerable side effects from other opioids. It is an alternative to other opioids such as morphine, oxycodone and diamorphine, particularly in patients with renal failure. It should only be used as a continuous subcutaneous infusion and on the advice of Specialist Palliative Care. |
| AMBER Alfentanil solution for injection 1mg/2mL |
| solution for injection 5mg/1mL |
| See Syringe Pump Policy ELHT |
| |
Actions recommended in NPSA/2008/RRR05
|
Reducing Dosing Errors with Opioid Medicines
|
This guidance applies when the following opioid medicines are prescribed, dispensed or administered: buprenorphine,
|
diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum and pethidine.
|
| |
When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare
|
practitioner concerned, or their clinical supervisor, should:
|
| > Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines |
| prescribed for the patient. This may be done for example through discussion with the patient or their representative |
| (although not in the case of treatment for addiction), the prescriber or through medication records. |
| > Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or |
| oxycodone in adult patients, not normally more than 50% higher than the previous dose). |
| > Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose, |
| frequency of administration, standard dosing increments, symptoms of overdose, common side effects. |
| |
| Healthcare organisations should ensure local medicines and prescribing policies, including Standard Operating Procedures, are |
| reviewed to reflect this guidance. |
| |
Prescribing Fentanyl Patches
|
Fentanyl patches may differ between brands depending on the type of patch used (matrix or reservoir) and it may not be suitable
|
to switch patients from one type to the other.
|
For this reason we recommend that only matrix patches are used across the health economy for all patients. Matrix transdermal
|
patches consist of a protective film (to be removed prior to application of the patch) and two functional layers: one self-adhesive
|
matrix layer containing fentanyl and a carrier film impermeable to water.
|
Matrix patches differ from reservoir patches by the way that the drug is carried. Reservoir patches have a reservoir filled with the
|
fentanyl in a gel or solution form which is released into the body through a membrane. Matrix patches hold the drug in an
|
adhesive layer which is distributed evenly throughout the patch and so are considered to be a more safe delivery method as there
|
is no chance of the fentanyl leaking.
|
| |
Method of administration
|
The patches should be applied to non-irritated and non-irradiated skin on a flat surface of the torso or upper arm (in young
|
children, the upper back is the preferred location to apply the patch, this is to minimize the potential of the child removing the
|
patch). Hair at the application site (hairless area is preferred) should be clipped (not shaved) prior to system application.
|
If the site requires cleansing prior to application of the patch, this should be done with water. Soaps, oils, lotions, alcohol or any
|
other agent that might irritate the skin or alter its characteristics should not be used. The skin should be completely dry before
|
application of the patch. Since the transdermal patch is protected outwardly by a waterproof covering foil, it may also be worn
|
when taking a shower. The patch should be attached as soon as the pack has been opened. Following removal of the protective
|
layer, the transdermal patch should be pressed firmly in place with the palm of the hand for approximately 30 seconds, making
|
sure that the contact is complete, especially around the edges. The patches should be worn continuously for 72 hours after which
|
it should be replaced with a new patch. A new transdermal patch should always be applied to a different site from the previous
|
one. The same application site may be re-used only after an interval of at least 7 days. If residues remain on the skin after removal
|
of the patch, these can be cleaned off with soap and plenty of water. In no case should alcohol or other solvents be used for
|
cleansing as these could penetrate the skin due o the effect of the patch. The transdermal patch should not be divided, as no data
|
| are available with regard to this. |
| |
Safe use and disposal of used patches
|
Patients with fever should be regularly monitored for increased side effects as increased absorption is possible.
|
Patients should be advised to avoid exposing application site to external heat, for example a hot bath or a sauna.
|
The manufacturers recommend use only in opioid tolerant patients due to risk of respiratory depression in strong opioid naive
|
patients.
|
Patients should be counselled on safe use, correct administration, disposal, strict adherence to dosage instructions, and the
|
symptoms and signs of opioid over dosage.
|
| |
| |
| See Neuropathic Pain Treatment Pathway |
Duloxetine (Cymbalta®) – see section 4.3.4
|
Gabapentin – see section 4.8.1
|
| |
Pregabalin
|
Pregabalin should only be used in patients who are unresponsive, unsuitable or intolerant of therapy with tricyclic anti-
|
depressants, gabapentin and first line analgesics. Pregabalin should always be prescribed as a twice daily dose as this is the most
|
cost effective regimen. Response to therapy should be regularly assessed, and therapy stopped in patients who are unresponsive.
|
[For prescribing in Generalised Anxiety Disorder, AMBER specialist initiation with criteria, see section 4.3]
|
GREEN Pregabalin
|
| capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg |
BLACK Pregabalin Liquid
|
GREEN Alzain® (cost effective option)
|
| capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg |
GREEN Axalid ® (cost effective option)
|
| capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg |
Note: Licensed indications may vary. Check SPCs to inform decisions made with individual patients.
|
|
| |
| Capsaicin * [currently out of stock - advise to purchase alternative product from pharmacy |
| |
Avoid contact with eyes, and inflamed or broken skin. Hands should be washed immediately after use. Not for use under tight
|
bandages. Avoid taking a hot shower or bath just before or after applying capsaicin - burning sensation enhanced.
|
Side-effects
|
administration is less than 3–4 times daily.
|
GREEN *Capsaicin cream 0.025% [Zacin®] (for osteoarthritis of the hand and knee only- NOT for back pain)
|
| For general musculoskeletal pain advise to purchase a rubefacient product] [Consider OTC/Self care] |
| AMBER Capsaicin cream 0.075% [Axsain®] (for post herpetic neuralgia & painful diabetic neuropathy) |
| |
Lidocaine Plasters
|
Lidocaine patches should only be initiated by specialists in the management of postherpetic neuralgia. These are chronic pain
|
consultants and consultant neurologists. They should only be used for the management of post herpetic neuralgia where other
|
available treatments (e.g. TCA’s, gabapentin/pregabalin, capsaicin cream) have been used, are inappropriate or not tolerated.
|
Lidocaine patches have not demonstrated sufficient benefits in terms of efficacy or comparative effectiveness to warrant wider
|
use at this stage. If no benefit has been seen after 2-4 weeks, treatment should be stopped. Assess possibility of reducing
|
number of plasters, or increasing time between plasters on a regular basis.
|
| |
| AMBER Lidocaine patches 5% for postherpetic neuralgia |
(2nd line only after other options have been used.)
|
| |
| AMBER Lidocaine patches 5% as a final option in palliative care. |
RED Lidocaine patches 5% for all indications other than postherpetic neuralgia.
|
| |
Lidocaine plasters for Allondynia and/or hyperalgesia and dysesthesia
|
Lidocaine patches are recommended only if unresponsive to or intolerant of other neuropathic agents in NICE/ELMMB
|
guidelines , and treatment is prescribed by clinicians who specialise in control of pain. Prescribing should not be transferred to
|
Primary Care
|
| |
RED Lidocaine patches 5% for Allondynia and/or hyperalgesia and dysesthia (unlicensed use)
|
| |
| |
4.7.4 Antimigraine drugs |
Guidelines for the management of migraine - see Appendix 1.
|
| |
| |
Analgesics - for preparations see section 4.7.1
|
Nausea - domperidone (section 4.6) may be helpful.
|
| |
First Line Options
|
GREEN Sumatriptan
|
| tablets 50mg |
| nasal spray10mg/ 0.1mL unit dose |
| nasal spray 20mg/0.1mL unit dose |
| GREEN Sumatriptan 3 mg/0.5 ml solution for injection in pre-filled pen |
| Sumatriptan injection (subcutaneous) 6mg/0.5mL syringe |
GREEN Zolmitriptan
|
| Orodispersable tablets 2.5mg |
| |
Second Line options
|
Patients often warrant a trial of different oral triptans due to individual variability in response, and prescribers should choose a
|
second line product with their patient based on efficacy, tolerability, formulation and cost.
|
| |
4.7.4.2 Prophylaxis of migraine |
Factors which trigger attacks should be sought. Therapy should be reviewed at 6 monthly intervals as long term prophylaxis
|
with these drugs is undesirable.
|
Amitriptyline is unlicensed for migraine but may be usefully prescribed at a dose of 10mg at night, increasing to a maintenance
|
dose of 50-150mg at night.
|
Sodium valproate (unlicensed) is no longer recommended. This is due to the availability of licensed anti-convulsants (e.g.
|
topiramate) and also the teratogenic risk associated with its use in pregnancy (e.g. unplanned pregnancy).
|
GREEN Amitriptyline (unlicensed) tablets 10mg, 25mg, 50mg
|
| |
| tablets 500 micrograms, 1.5mg |
| elixir 250 micrograms/5mL |
GREEN Propranolol capsules m/r 80mg
|
GREEN Topiramate capsules NICE CG150 (see section 4.8 for use in epilepsy [AMBER])
|
| RED Flunarizine tablets 5mg, 10mg (Sibelium®) Specialist use only |
| |
| RED Galcanezumab [Emgality 120mg/1mL solution for injection p/f pens] |
| NICE TA659 Galcanezumab is recommended as an option for preventing migraine in adults, only if: |
| > they have 4 or more migraine days a month |
| > at least 3 preventive drug treatments have failed and |
| > the company provides it according to the commercial arrangement |
| CCG Commissioned Blueteq form required |
| RED Erenumab [Aimovig] |
| NICE TA682 Erenumab is recommended as an option for preventing migraine in adults, only if: |
| > they have 4 or more migraine days a month |
| > at least 3 preventive drug treatments have failed |
| > the 140mg dose of erenumab is used and |
| > the company provides it according to the commercial arrangement |
| Stop erenumab after 12 weeks of treatment if: |
| > in episodic migraine [less than 15 headache days a month] the frequency does not reduce by at least 50% |
| > in chronic migraine [15 headache days a month or more with at least 8 of those having features of migraine] the frequency |
| does not reduce by at least 30% |
| |
Treatment of chronic migraine
|
RED Botulinum Toxin A (use of brand with lowest acquisition cost) injection CCG Commissioned
|
| NICE TA260 Recommended as an option for the prophylaxis of headaches in adults with chronic migraine )defined as headaches |
| on at least 15 days per month of which at least 8 days are with migraine): |
| ° that has not responded to at least three prior pharmacological prophylaxis therapies and |
| ° whose condition is appropriately managed for medication overuse. |
| |
| RED Fremanezumab solution for injection [Ajovy® 225mg/1.5ml] CCG Commissioned BlueTeq form required |
NICE TA631 Recommended as an option for preventing migraine in adults, only if:
|
| º the migraine is chronic, that is, 15 or more headache days a month for more than 3 months with at least of those |
| having features of migraine |
| ° at least 3 preventative drug treatments have failed and |
| ° the company provides it according to the commercial arrangement |
| |
| |
| |
| |
| |
| |
All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the |
public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service
|
| Email: info.elmmb@nhs.net |
| |
| Copyright© 2016 - 2020 East Lancashire Medicines Management Board |
