15. Analgesic contraindications and cautions Flashcards
What are 6 types of analgesic combinations?
- Paracetamol (up to 4x 1g daily)
- Ibuprofen (up to 4x400mg daily)
- Ibuprofen (up to 4x600mg daily)
- Ibuprofen (up too 4x400mg daily) + Paracetamol (up to 4x 1g daily)
- Ibuprofen (up to 4x600mg daily) + Paracetamol (up to 4x 1g daily)
- Diclofenac (up to 3x50 mg daily) + Paracetamol (up to 4x 1g daily)
If someone has no medical conditions, what analgesic preparations can they have?
All!
Paracetamol +/- Ibuprofen +/- Diclofenac
–> all 6 combinations
If some has existing non-dental NSAID use (excluding low dose aspirin) what analgesics can they be prescribed?
Paracetamol (up to 4x 1g daily)
Caution for all other analgesic combinations involving ibuprofen and diclofenac:
–> Patients already taking an NSAID (prescribed or not) regularly for a non-dental condition should not take an additional NSAID to control dental pain.
If someone takes low dose aspirin, which analgesics can they take?
- Paracetamol (up to 4x 1g daily).
Caution:
> Ibuprofen 400mg or 600mg +/- Paracetamol.
–> up to 1200mg daily
Avoid:
> Diclofenac + paracetamol combination.
–> Prescribe ibuprofen with caution for patients taking low dose aspirin. Addition of an NSAID may reduce the cardioprotective benefit of low dose aspirin and increases the risk of GI bleeds.
–> In pts taking low dose aspirin, if an NSAID is necessary to control pain, consider the use of ibuprofen up to 1200mg maximum daily with a PPI or contact the patient’s GMP for advice.
–> Diclofenac is not recommended in this guide for pts taking low dose aspirin because some will have a condition for which diclofenac is contraindicated.
What analgesics can be prescribed in elderly patients >65 years old?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen (up 4x400mg daily) +/- paracetamol (up to 1g daily).
–> Don’t exceed 1200mg per day!!
Avoid:
- Ibuprofen (up to 600mg daily) +/- paracetamol (up to 1g daily)
- Diclofenac (up to 3x50mg daily) + paracetamol (up to 4x 1g daily)
–> Elderly patients are at increased risk of cardiovascular, renal and serious GI adverse effects (including GI bleeding and perforation, which may be fatal). Prescribe ibuprofen with caution.
–> Do not exceed 1200mg ibuprofen per day. A PPI should be co-prescribed - liaise with the patient’s GMP if a PPI is not currently prescribed.
–> Monitoring blood pressure, renal function, and features of heart failure may be required 1-2 weeks after starting or increasing the dose of an NSAID. Liaise with the pt’s GMP to discuss.
–> Diclofenac is not recommended in this guide due to increased cardiovascular risk in the elderly.
What analgesics can be prescribed for a pt with low body weight, alcohol dependence, chronic alcoholism, chronic malnutrition, or dehydration?
Caution with all 6 analgesic preparations!!
Prescribe paracetamol with caution for people who weigh under 50kg, using clinical judgement to adjust the dose. Prescribe paracetamol with caution if there is alcohol dependence, chronic alcoholism, chronic malnutrition or dehydration.
NSAIDs should be avoided in people with dehydration, due to risk of acut kidney injury. For pts with chronic alcoholism and alcohol dependence the GI risk is increased with NSAIDs. Avoid NSAIDs if possible or prescribe with a PPI.
What analgesics can be prescribed in a pregnant patient?
Paracetamol (up to 4x 1g daily)
Avoid:
- all ibuprofen and diclofenac
–> Paracetamol is the analgesic of choice during pregnancy.
–> All NSAIDs should be avoided in pregnant patients unless the benefits outweigh the risks, they are not recommended in this guide. If necessary, a GMP may prescribe an NSAID using the lowest effective dose for the shortest time possible. NSAIDs must not be used for 30 weeks of pregnancy without specialist advice and regular foetal monitoring.
What analgesics can be used in breastfeeding patients?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen 400mg or 600mg +/- paracetamol
Avoid:
Diclofenac + paracetamol
–> Paracetamol is the analgesic of choice for women who are breastfeeding. Seek expert advice if the infant is preterm, or low birthweight.
–> Absorption, distribution, metabolism, or excretion of paracetamol may be affected by an underlying medical condition.
–> Use NSAIDs with caution. If an NSAID is necessary, ibuprofen is preferred using the lowest effective dose for the shortest time possible.
What analgesics do you prescribe in pts with a history or hypersensitivity/severe allergic reaction to an NSAID (including aspirin) e.g asthma, rhinitis, angioedema, urticaria.
- Paracetamol (up to 4x1g daily)
Avoid:
- Ibuprofen 400mg or 600mg
- Diclofenac
What analgesics can you prescribe to someone with a history of hypersensitivity to paracetamol?
- Ibuprofen (up to 4x400mg daily)
- Ibuprofen (up to 4x600mg daily)
Avoid:
- paracetamol
- paracetamol + ibuprofen
- paracetamol + diclofenac
What analgesics can you prescribe to pts with allergic disorders (e.g. allergy to other medicines, foods, latex or pollens)?
- Paracetamol (up to 4x1g daily)
Caution:
- Ibuprofen 400mg or 600mg +/- paracetamol
- Diclofenac + paracetamol
–> Prescribe NSAIDs with caution to people with allergic disorders as they may be at increased risk of NSAID induced allergy.
–> Advise the patient to look out for allergic symptoms and to stop taking the NSAID if these occur.
What analgesics can be prescribed to pts with asthma?
- Paracetamol (up to 4x1g daily)
Caution:
- Ibuprofen 400mg/600mg +/- paracetamol
- Diclofenac + paracetamol
–> Prescribe NSAIDs with caution to people with asthma. All NSAIDs have the potential to exacerbate asthma, either acutely or as a gradual worsening of symptoms.
–> Warn the patient of the potential for development of NSAID induced asthma, particularly late in life.
–> Advise the pt to look out for symptoms, follow their usual plan for worsening of symptoms and to stop taking NSAID if these occur.
What analgesics can you prescribe to someone with severe heart failure?
- Paracetamol (up to 4x1g daily)
Avoid:
- Ibuprofen 400mg or 600mg
- Diclofenac
- Avoid all NSAIDs
Do not prescribe NSAIDs in severe heart failure.
What analgesics can you prescribe for mild to moderate heart failure?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen (up to 4x400mg daily) +/- Paracetamol
–> up to 1200mg daily!
Avoid
- Ibuprofen (up to 4x600mg daily) +/- paracetamol
- Diclofenac + paracetamol
–> Prescribe ibuprofen with caution to people with cardiac impairment or mild to moderate heart failure (NSAIDs may impair renal function). Do not prescribe NSAIDs in severe heart failure.
–> Prescribe ibuprofen up to 1200 mg per day as a first-line option (note that this is a lower dose than the 4 x 400 mg per day regimen recommended in the BNF for dental pain). For higher doses liaise with the patient’s GMP.
–> Monitoring of blood pressure, renal function, and features of heart failure may be required 1–2 weeks after starting or increasing the dose of an NSAID. Liaise with the patient’s GMP to discuss. If in doubt about the severity of the patient’s heart failure or appropriate analgesics, consult with their GMP.
What analgesics can you prescribe for Ischaemic heart disease, cerebrovascular disease, peripheral arterial disease?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen (up to 4x400mg daily) +/- Paracetamol
–> up to 1200mg daily!!
Avoid
- Ibuprofen (up to 4x600mg daily) +/- paracetamol
- Diclofenac + paracetamol
–> Prescribe ibuprofen with caution to people with cerebrovascular disease, ischaemic heart disease, peripheral arterial disease, or risk factors for cardiovascular events (for example, hypertension, hyperlipidaemia, diabetes mellitus, smoking).
–> Prescribe ibuprofen up to 1200 mg per day as a first-line option (note that this is a lower dose than the 4 x 400 mg per day regimen recommended in the BNF for dental pain).
–> For higher doses liaise with the patient’s GMP. Monitoring of blood pressure, renal function, and features of heart failure may be required 1–2 weeks after starting or increasing the dose of an NSAID. Liaise with the patient’s GMP to discuss.
What analgesics can you prescribe for hypertension?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen (up to 4x400mg daily) +/- Paracetamol
–> up to 1200mg!!
Avoid
- Ibuprofen (up to 4x600mg daily) +/- paracetamol
- Diclofenac + paracetamol
–> Prescribe NSAIDs with caution to people with hypertension (NSAIDs may impair renal function).
–> Prescribe ibuprofen up to 1200 mg per day as a first-line option (note that this is a lower dose than the 4 x 400 mg per day regimen recommended in the BNF for dental pain).
–> For higher doses liaise with the patient’s GMP. Monitoring of blood pressure may be required 1–4 weeks after starting long-term treatment or increasing the dose of an NSAID. Liaise with the patient’s GMP to discuss. Diclofenac is not recommended in this guide for patients with hypertension due to cardiovascular risk.
What analgesics can be prescribed in pt with:
Active GI bleeding or GI ulcer
or
History of GI bleeding or ulcer related to previous NSAID use
or
History of two or more GI bleeds or ulcers?
- Paracetamol (up to 4x1g daily)
Avoid:
- Ibuprofen 400mg or 600mg
- Diclofenac
What analgesics can be prescribed for pts with a history of one previous GI bled or ulcer not associated with NSAID use?
- Paracetamol (up to 4x1g daily)
Caution:
- Ibuprofen 400mg/600mg +/- paracetamol
- Diclofenac (up to 3x50mg daily) + paracetamol
–> Prescribe NSAIDs with caution to people with a history of GI ulceration or bleed or people at high risk of GI adverse effects.
–> A PPI should be co-prescribed with an NSAID – liaise with the patient’s GMP if a PPI is not currently prescribed. If in doubt about the patient’s level of GI risk or appropriate analgesics, consult with their GMP.
What are risk factors for NSAID-induced GI adverse effects?
− Aged over 65 years
− A high dose of an NSAID
− A history of gastroduodenal ulcer, GI bleeding, or gastroduodenal perforation
− Concomitant use of medications that are known to increase the likelihood of upper GI adverse events (for example, anticoagulants, corticosteroids, selective serotonin reuptake inhibitors)
− A serious comorbidity, such as cardiovascular disease, hepatic or renal impairment (including dehydration), diabetes, or hypertension
− Heavy smoking
− Excessive alcohol consumption
− Previous adverse reaction to NSAIDs
− Prolonged requirement for NSAIDs
What analgesics can be prescribed for pts with inflammatory bowel disease?
- Paracetamol (up to 4x1g daily)
Caution:
- Ibuprofen 400mg/600mg +/- paracetamol
- Diclofenac (up to 3x50mg daily) + paracetamol
–> Prescribe NSAIDs with caution to people with inflammatory bowel disease (NSAIDs may increase the risk of developing or cause exacerbations of ulcerative colitis or Crohn’s disease).
What analgesics can you prescribe for someone with severe hepatic impairment (serum albumin <25 g/l or Child-Pugh score of 10 or more)?
Caution:
Paracetamol (up to 4x1g daily)
Avoid:
- All NSAID
- Ibuprofen 400mg/600mg
- Diclofenac (up to 3x 50mg daily)
–> Paracetamol is considered to be a suitable analgesic option in most people with liver disease. However, the manufacturer advises caution. Dose reduction might be required for some patients, for example those with moderate or severe acute hepatitis.
What analgesic can be prescribed in people with hepatic impairment (mild to moderate)?
Caution:
- Paracetamol (up to 4x1g daily)
- Ibuprofen (up to 4x400mg daily)/(up to 4x600mg daily) +/- paracetamol
- Diclofenac (up to 3x50mg daily) + paracetamol
–> Prescribe NSAIDs with caution to people with mild to moderate hepatic impairment (do not prescribe in severe hepatic impairment). Dose reductions and monitoring of liver function may be necessary.
What analgesics can be prescribed for pts with severe renal impairment (eGFR <30 mL/minute/1.73 m^2)?
Caution:
Paracetamol (up to 4x1g daily)
Avoid:
- All NSAID
- Ibuprofen 400mg/600mg
- Diclofenac (up to 3x 50mg daily)
–> Prescribe paracetamol with caution to people with severe renal impairment. Dose reduction might be required; liaise with the patient/s GMP to discuss.
What analgesics can you prescribe to pts with renal impairment (mild to moderate)?
- Paracetamol (up to 4x 1g daily)
Caution:
- ibuprofen 400mg/600mg +/- paracetamol
- Diclofenac + paracetamol
–> Prescribe NSAIDs with caution to people with mild to moderate renal impairment; avoid if possible (do not prescribe in severe renal impairment). Sodium and water retention may occur leading to a deterioration in renal function and, possibly renal failure. If the patient cannot avoid using an NSAID and has impaired renal function, monitoring of renal function is required 1–2 weeks after starting or increasing the dose of an NSAID. Liaise with the patient’s GMP to discuss.
What analgesics can pts with anticoagulant use use?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen 400mg/600mg +/- paracetamol
- Diclofenac (up to 3x 50mg) + paracetamol.
–> For pts taking anticoagulants, paracetamol is considered safer than aspirin or NSAIDs because it does not affect platelets or cause gastric bleeding. Pts should have their usual INR check planned and inform their clinician if they have been using paracetamol regularly.
–> Avoid concomitant use of NSAIDs with anticoagulants (e.g. warfarin, dabigatran) if possible. All NSAIDs cause GI irritation and reduce platelet aggregation, which can worsen any bleeding event. If concurrent use is necessary be aware of the potential risks of bleeding.
–> Consider giving gastroprotection. Liaise with the patient’s GMP if a PPI is required but is not currently prescribed.
What effect do NSAIDs have on the
- GI tract?
- platelets?
All NSAIDs can cause GI irritation.
NSAIDs reduce platelet aggregation, which can worsen any bleeding event.
*risk of bleeding / GI bleeding
What analgesics can pts with bleeding disorders use?
- Paracetamol (up to 4x 1g daily)
Caution:
- Ibuprofen 400mg/600mg +/- paracetamol
- Diclofenac (up to 3x 50mg) + paracetamol.
–> Prescribe NSAIDs with caution for patients with bleeding disorders (e.g. Haemophilia, Von Willebrand disease and clotting factor deficiencies). Consult with the patient’s GMP or haematologist.
