| Formulary Chapter 4: Central nervous system - Full Chapter
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| 04.07.01 |
Non-opioid analgesics and compound analgesic preparations |
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| 04.07.01 |
Compound analgesic preparations |
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Avoid using compound analgesic preparations wherever possible |
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Paracetamol
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First Choice
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Tablet, Soluble tablet, Injection, Liquid, Suppositories
- Recent updates to the dosing of paracetamol and the use of intravenous preparations mean that the usual 1g four times a day may not be suitable for all. Care should be taken when dosing paracetamol for patients weighing less than 50kg, and particularly in the frail, elderly population. Patients weighing more than 50kg may also have conditions which mean a dose reduction would also be appropriate e.g. chronic alcoholism, liver dysfunction, malnutrition. [BMJ article (2010)] [NUH paracetamol podcast].
- Suppositories - note that lower strength suppositories (less than 60mg) are unlicensed.
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 SFH: Paracetamol dose chart for children
One side guide to analgesia (SFH)
Oral Analgesia Guideline (Notts Childrens Hospital)
Relative strengths graph of analgesics
Analgesic prices
 Breastfeeding and paracetamol. (UKMI Q+A)
COVID19: Notts CCG - Managing Symptoms of Covid-19 (End of Life) in Community and Non-acute Hospital Settings
COVID19: Should I prescribe paracetamol during COVID19?
IV vs oral paracetamol information
MHRA safety information on use of IV paracetamol in children
Paracetamol Self-Care Position Statements (Greater and Mid Notts CCGs)
SFH: Paracetamol in low body weight patients
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Aspirin
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Formulary
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Tablet, Tablet e/c, Tablet dispersible, Suppository
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Aspirin in RECOVERY trial
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Nefopam
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 Restricted
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Tablet.
- On pain team/ renal consultant advice only. Only to be considered if paracetamol, NSAIDs and opioids are unsuitable. Unknown efficacy (see Cochrane review) and has many side effects eg nausea, nervousness, anticholinergic side effects (dry mouth, constipation, blurred vision urinary retention, light headedness, reduced cognition, hypotension etc.). Such effects are particularly bad in the elderly - who are prone to falls [See Prescqipp].
- Manufacturers advise not to crush or disperse the tablets for patients with swallowing difficulties as drug has a local anaesthetic effect. For patients with enteral tubes use tablets dispersed in water immediately prior to administration. See here for general advice on dispersing tablets.
- Cost of common analgesics.
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Analgesic prices
See unexpectedly expensive medicines list
SFH one side guide to analgesia
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Paracetamol and codeine (Co-codamol® 30/500)
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Restricted
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Tablet, Effervescent tablet
- Not recommended. Causes all the usual opioid side effects (constipation, drowsiness, nausea etc).
- Usually better to use separate paracetamol, with codeine, dihydrocodeine or tramadol added only when required.
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Analgesic prices
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Paracetamol and codeine (Co-codamol® 8/500)
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Restricted
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Tablet, Soluble tablet.
- Not recommended. Not enough codeine to have any effect other than cause constipation.
- Usually better to use separate paracetamol, with codeine, dihydrocodeine or tramadol added only when required.
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| Non Formulary Items |
Co-proxamol
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Non Formulary
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MHRA safety warning: Co-proxamol
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Paracetamol and codeine (Co-codamol ®15/500)
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Non Formulary
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Paracetamol and dihydrocodeine (Co-dydramol®)
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Non Formulary
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Tablet
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MHRA: Prescribe co-dydramol by strength
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
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Description |
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Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
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Medicines which should normally be prescribed by specialists only. eg hospital only.
For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
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Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
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Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
*Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
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Primary care/ non specialist may initiate as per APC guideline.
The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
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Medicines suitable for routine use within primary care.
Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing. |
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