N.B. If the patient's pain remains unresolved despite using the treatment guidance below, or local guidelines, refer to the appropriate team for further advice.
Use oral paracetamol (not IV) or NSAID (if not contraindicated) +/- other adjuvant (see below).
Paracetamol oral: 1g four times daily (max dose). Consider dose reduction in patients with low body weight (<50kg), renal impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: paracetamol oral 500mg four times daily.
In patients with hepatocellular insufficiency, a dose reduction of the oral preparation should be determined on a case by case basis with senior medical input. N.B. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).
Weak opioid + paracetamol (dose as above) or NSAID +/- other adjuvant
Co-codamol* oral 30/500mg 1 - 2 tablets four times daily (max 8 tablets in 24 hours) or
Codeine oral 30 - 60mg four times daily (max 240mg/day) or
Dihydrocodeine oral 30mg four times daily (max 120mg/day).
Note: dihydrocodeine 60mg will provide little additional analgesia but more pronounced side effects.
Opioid (morphine first-line) + paracetamol (dose as above) or NSAID +/- other adjuvant. N.B. If renal impairment (eGFR <60ml/minute/1.73m2) seek palliative care advice or refer to www.palliativecareguidelines.scot.nhs.uk, pain section then select 'Choosing and Changing Opioids'
Morphine and oxycodone must be used with caution in patients with eGFR <60ml/minute/1.73m2. See www.palliativecareguidelines.scot.nhs.uk, pain section then select 'Choosing and Changing Opioids' for further information. Contact local Palliative Care team for advice on alternative opioids. With NSAIDs, avoid if possible in renal impairment. For further cautions / contraindications with NSAIDs see Prescribing Notes for Acute Pain for detail.
Treat by reducing opioid dose by 1/3, ensure patient is well hydrated, review and re-titrate the analgesia. Consider adjuvant therapies and/or alternative opioids. For naloxone dosing guidance in other circumstances, see Reversal of Opioid-induced Respiratory Depression. If patient is in renal or hepatic impairment seek dosing advice from your clinical pharmacist or senior member of medical staff or local palliative care team.
Consider NSAIDs for bone pain, liver pain, soft tissue infiltration or inflammatory conditions. If topical NSAID is required then consider piroxicam 0.5% gel applied 3 - 4 times daily. For systemic NSAID options, see Prescribing Notes for Acute Pain.
Note: diclofenac may be used subcutaneously in palliative care patients. Please contact Palliative Care team for advice on dosing and administration.
See Prescribing Notes for Acute Pain for full details of cautions and contraindications. Within the palliative care population concerns over the cardiovascular risk associated with NSAIDS should be weighted against the fact the patient may have a limited prognosis. The benefits of NSAIDs in promoting good symptom control and quality of life for a limited time may outweigh the risk of cardiovascular complications. If this is the case seek advice from an experienced clinician.
Specialists may recommend higher doses. Reduce dose in patients with renal impairment and seek specialist advice. For further information refer to neuropathic pain section at www.palliativecareguidelines.scot.nhs.uk.
Consider gastroprotection and monitor blood glucose.
For all adjuvants reduce to the lowest effective dose.
If patients struggle to swallow analgesics in tablet form, consider switching to liquid preparations or parenteral alternatives. Seek advice from a pharmacist. Do not crush tablets before discussing with a pharmacist.
If patients are advised to take "nil by mouth", consider switching to parenteral alternatives. Note that IV paracetamol can only be given on a named patient basis by consultant request when oral or rectal administration is not possible.
Consider switching to liquid preparations or parenteral alternatives. Seek advice from a pharmacist. Some medications should not be given via PEG tubes even if crushed or in liquid form.