NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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4 Central nervous system

4.7 Analgesics

4.7.1 Non-opioid analgesics and compound analgesic preparations

Preferred list
CO-CODAMOL

Restrictions: Strengths other than 8/500 or 30/ 500 are non-Formulary. Dispersible and effervescent formulations are considerably more expensive and should be restricted to patients with swallowing difficulties. Their high sodium content (up to 8g daily) exceeds the WHO daily salt intake recommendation of 6g daily and may compromise the treatment of hypertension, heart failure and renal disease.

Prescribing Notes:

There is no evidence that the 8/500 strength is any more effective than paracetamol alone.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/201058.htm

IBUPROFEN

Restrictions: Use of MR preparations is restricted (see notes below).

Prescribing Notes:

Modified-release preparations of any NSAID should be restricted to patients with early morning stiffness or compliance problems as they encourage regular/higher doses of NSAIDs and do not afford flexibility in reducing the dose.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5192.htm

PARACETAMOL

Restrictions: Dispersible and effervescent formulations are considerably more expensive and should be restricted to patients with swallowing difficulties. Their high sodium content (up to 8g daily) exceeds the WHO daily salt intake recommendation of 6g daily and may compromise the treatment of hypertension, heart failure and renal disease.

Prescribing Notes:

Paracetamol 500mg tablet is the preferred formulation for use in adults.

Consider dose reduction in patients with low body weight (< 50kg), renal/hepatic impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15 mg/kg/dose up to four times daily (max 60mg/kg/day) An example is: paracetamol oral 500 mg four times daily.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3469.htm

Total Formulary
CO-DYDRAMOL

Restrictions: Only the 10/500 (10mg dihydrocodeine, 500mg paracetamol) strength of tablets are included in the Formulary.

Prescribing Notes:

Remedeine® and Remedeine Forte® remain non-formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/208638.htm

4.7.2 Opioid analgesics

Preferred list
DIHYDROCODEINE

Restrictions: Excludes DF118 Forte®, Remedeine®, and Remedeine Forte®.

Prescribing Notes:

Dihydrocodeine is generally not an effective analgesic for post-operative pain except in neurosurgical procedures where NSAIDs are contraindicated when it avoids undue sedation and confusion which might interfere with neurological appraisal.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3524.htm

MORPHINE

Prescribing Notes:

Modified-release preparations should be prescribed by brand name.  The preferred choice of solid morphine sulphate MR across primary and secondary care in NHSGGC is Zomorph®

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3492.htm

OXYCODONE HYDROCHLORIDE (oral formulations)

Restrictions:

Use is restricted to patients in whom morphine is ineffective or not tolerated. The injection is restricted to initiation by specialists in palliative care and oncology for use in patients for whom morphine/diamorphine is ineffective or not tolerated. Oxycodone injection is non-Formulary for post-operative use. The combination product of oxycodone and naloxone (Targinact®) is not recommended for use in NHS Scotland by the SMC and is non-Formulary.

Prescribing Notes:

Oral oxycodone preparations should be prescribed by brand name and the current brands of choice for modified-release and immediate release preparations respectively are Longtec® and Shortec®.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/85406.htm

Total Formulary
FENTANYL (TRANSDERMAL PATCHES)

Restrictions: Restricted to use on specialist advice in palliative care and to second line use in patients with intractable, non-malignant pain which is relatively stable and has been controlled by oral therapy. It should be reserved for patients with swallowing difficulties or who have problems with opiate constipation.

Prescribing Notes:

Ionsys® transdermal system is not recommended by SMC and remains non-formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129814.htm#_129814

METHADONE

Restrictions: Restricted to specialist initiation only.

Prescribing Notes:

Eptadone® remains non-formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3533.htm

TRAMADOL (CAPSULES)

Restrictions: Restricted to use when simple analgesia has failed or is not tolerated. Excludes modified-release and combination preparations.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/17872.htm

TRAMADOL (INJECTION)

Restrictions: Restricted to specialist initiation only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/38808.htm#_38808

FENTANYL (EFFENTORA) (BUCCAL TABLETS)

Restrictions: Restricted to patients who are unsuitable for other short-acting opioids

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/202699.htm#_202699

FENTANYL (ABSTRAL) (SUBLINGUAL TABLETS)

Restrictions: Restricted to patients who are unsuitable for other short-acting opioids

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/201311.htm#_201311

HYDROMORPHONE (Palladone) (CAPSULES)

Restrictions: Restricted to use in palliative care patients who are unable to tolerate other opioids in accordance with local protocol. Excludes the parenteral preparation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/63578.htm#_63578

HYDROMORPHONE (Palladone SR) (MR CAPSULES)

Restrictions: Restricted to use in palliative care patients who are unable to tolerate other opioids in accordance with local protocol. Excludes the parenteral preparation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/63579.htm#_63579

TAPENTADOL (PALEXIA SR)

Restrictions: Use in the management of severe chronic pain in adults is restricted to initiation by, or on the advice of pain specialists only in patients who have failed to respond or tolerate both morphine and oxycodone. Tapentadol immediate release tablets are not recommended by SMC and remain non-Formulary.

Prescribing Notes:

For the relevant SMC advice click here

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/215627.htm#_215627

OXYCODONE HYDROCHLORIDE (INJECTION)

Restrictions:

Oxycodone 10mg/ml injection is restricted to use in the treatment of moderate to severe pain in cancer in those patients who have difficulty in tolerating morphine or diamorphine therapy.

The 50mg/ml injection is further restricted to those patients who require either a high dose bolus injection (>2ml of the 10mg/1ml injection) of oxycodone, or oxycodone delivered via a continuous subcutaneous infusion where the use of the 10mg/ml injection would result in a total volume of all medicines which necessitates the use of an additional syringe pump.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/85406.htm

BUPRENORPHINE (7-day transdermal patch)

Restrictions:

Treatment of chronic non-malignant pain of moderate intensity when an opioid is necessary for obtaining adequate analgesia is restricted to use only in elderly patients (over 65 years) where standard analgesic options are ineffective or not tolerated.

Prescribing Notes:

  • There are several brands of buprenorphine transdermal patches. They are not all interchangeable and can vary in relation to the frequency of application. To avoid confusion and the potential for dosing errors, buprenorphine transdermal patches should be prescribed by brand name.
  • In NHSGGC Butec® is the preferred brand of 7-day patch

4.7.3 Neuropathic pain

Preferred list
AMITRIPTYLINE

Prescribing Notes:

Use in the treatment of neuropathic pain is an unlicensed indication of amitriptyline.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3548.htm

Total Formulary
PREGABALIN

Restrictions: Restricted to use for peripheral neuropathic pain in adults who have not responded to or tolerated conventional first and second line treatments. Treatment should be discontinued if the patient has not shown sufficient benefit within 8  weeks of reaching the maximally tolerated therapeutic dose. The oral solution is further restricted to those patients who find it difficult to or are unable to swallow tablets.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/89413.htm

DULOXETINE

Restrictions: Use in peripheral diabetic neuropathic pain in adults is restricted to specialist initiation as second or third line therapy.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129245.htm

IMIPRAMINE (tablets)

Restrictions: Restricted to use in the management of neuropathic pain where amitriptyline is not appropriate because of issues with sedation or hypotension.

Prescribing Notes:

Use in the treatment  of neuropathic pain is an unlicensed indication for imipramine.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP2380-imipramine-non-proprietary.htm?q=imipramine&t=search&ss=text&p=2#PHP2380-imipramine-non-proprietary

NORTRIPTYLINE

Restrictions: Restricted to use in the management of neuropathic pain where amitriptyline is not appropriate because of issues with sedation or hypotension.

Prescribing Notes:

Use in the treatment  of neuropathic pain is an unlicensed indication for nortriptyline.

PHENYTOIN

Restrictions: Restricted to specialist initiation only.

4.7.4 Antimigraine drugs

4.7.4.1 Treatment of acute migraine

First-line treatment consists of analgesia (paracetamol, aspirin, or a nonsteroidal anti-inflammatory drug e.g. ibuprofen) and (especially if nausea is present) anti-emetics (prochlorperazine, domperidone, or metoclopramide). Second-line treatment with a triptan may be required if first-line treatment is inadequate. All people receiving treatment with a triptan should be followed up where possible

Preferred list
MIGRALEVE PINK

Restrictions: Migraleve yellow® is excluded as it is equivalent to co-codamol 8/500, but much more expensive.

Prescribing Notes:

Contains buclizine hydrochloride 6.25mg, paracetamol 500mg and codeine phosphate 8mg

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3553.htm#_3553

Total Formulary
PARAMAX

Prescribing Notes:

Contains metoclopramide. Not indicated in patients less than 20 years of age except for limited indications when the dose should be determined by body weight.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3555.htm#_3555

RIZATRIPTAN

Prescribing Notes:

Plasma concentrations may be increased by concomitant use of propranolol, therefore the 5mg dose of rizatriptan should be used.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/73593.htm

ZOLMITRIPTAN

Prescribing Notes:

Excluding nasal spray.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/61033.htm

SUMATRIPTAN (injection)

Restrictions: Sumatriptan injection is restricted to use in patients for whom other formulations are not suitable or effective.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP2857-imigran.htm#PHP2857-imigran

SUMATRIPTAN (NASAL SPRAY)

Restrictions: Sumatriptan nasal spray is restricted to use in patients for whom other formulations are not suitable or effective.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP2857-imigran.htm#PHP2857-imigran

SUMATRIPTAN (ORODISPERSIBLE TABLETS)

Restrictions: The oro-dispersible tablets are restricted to second line treatment for patients for whom standard tablets are not appropriate.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP2858-imigran-radis.htm#PHP2858-imigran-radis

4.7.4.2 Prophylaxis of migraine

Preferred list
PIZOTIFEN

Prescribing Notes:

Also consider propranolol (section 2.4) for prophylaxis of migraine.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3572.htm

Total Formulary
BOTULINUM TOXIN A (Botox)

Restrictions: Restricted to specialist use only in adults with chronic migraine in accordance with local protocol (in development).

Prescribing Notes:

Botulinum toxin A (Botox) for chronic migraine should only be used in patients who have failed to respond to ≥6 previous oral prophylactic treatments and where medication overuse has been appropriately managed.

TOPIRAMATE

Restrictions: Use in the prophylaxis of migraine is restricted to initiation by specialists and treatment should be managed under specialist supervision or shared care arrangements in patients who have not responded to prophylactic treatment with at least one other agent.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/36514.htm

4.7.4.3 Cluster headache and the trigeminal autonomic cephalalgias