PAIN

Question 1

Avoid in sickle-cell disease

Answer 1

Pethidine

Question 2

Dental pain

Answer 2

• Paracetamol, NSAIDs, aspirin
• Opioids rarely used due to SEs

Question 3

Anti-pyretic and anti-inflammatory

Answer 3

NSAIDs
Aspirin

Question 4

Only anti-pyretic

Answer 4

Paracetamol

Question 5

Aspirin CI

Answer 5

• Under 16
• Peptic ulcer/ history of ulceration

Question 6

Aspirin main SE

Answer 6

• Gastric irritation
• After food
• E/C or GR preps

Question 7

Disadvantage of EC asirin

Answer 7

• Slow onset of action
• Unsuitable for single dose
• May be suitable for night pain

Question 8

Paracetamol risks

Answer 8

• Overdose
• May not be apparent until 4-6 days later

Question 9

Which is preferred in elderly? Paracetamol or ibuprofen?

Answer 9

Paracetamol

Question 10

Paracetamol - minimum age

Answer 10

2 months

Question 11

Can paracetamol be sold over the counter for fever prophylaxis following
immunisation for 2 months old?

Answer 11

yes

Question 12

REMEMBER: What are the doses of paracetamol in children?
Paracetamol infant (120mg/ 5ml)

Answer 12

Child 1-2 months (NOT OTC)
30-60mg
* 2 to 6 months: 2.5ml
* 6 months - 24months: 5ml
* 2-4yrs: 7.5ml
* 4-6yrs: 10ml

Question 13

Paracetamol six plus susp (250mg/5ml)

Answer 13

• 6-8yrs: 5ml
• 8-10yrs: 7.5ml
• 10-12yrs: 10ml
• 12-16 years: 10-15ml
  Above 16yrs you can give up to 1g (10-20ml)
  All (apart from first one) every 4-6 hours

Question 14

When is Paracetamol
OTC licensed for 2 month old babies?

Answer 14

ONLY for relief/prophylaxis of tever post-vaccination
i.e. do not give for general pain

Question 15

Which paracetamol oral suspension is not licensed for use in children under 16
years old?

Answer 15

500mg/5ml (POM)

Question 16

What is the dose of paracetamol in adults?

Answer 16

0.5 - 1g every 4-6 hours
MAX 4g a day (8 500mg
tablets)

Question 17

Which patients may be at risk of experiencing toxicity from paracetamol at a therapeutic dose?

Answer 17

• <50kg
• hepatoxicity
• taking liver enzyme-inducing drugs (e.g. carbamazepine, phenytoin, rifampicin)

Question 18

What can be a sign of a paracetamol overdose?

Answer 18

• N&V (usually settles within 24 hours
• Right subcostal pain and tenderness usually indicates development of hepatic necrosis

Question 19

If someone who is obese has a
paracetamol overdose, which weight do you use to calculate the dose of paracetamol they took?

Answer 19

If they weigh more than 110kg, use their actual weight per mg to not underestimate the toxic effects of paracetamol

Question 20

What do you give for paracetamol overdose and when is it the most effective?

Answer 20

• Acetylcysteine (IV)
• Most effective within 8 hours of ingestion, after which effectiveness declines

Question 21

Nefopam

Answer 21

It is a non-opioid, centrally-acting analgesic
It is used for the relief of persistent pain unresponsive to other non-opioid analgesics

Question 22

What are the side-effects of Nefopam?

Answer 22

• Sympathomimetic and anti-muscarinic (dry mouth, drowsiness, urinary incontinence, etc.)
• IT DOES NOT CAUSE
  RESPIRATORY DEPRESSION

Question 23

What is the World
Health Organization
(WHO) pain ladder?

Answer 23

Step 1:
- NON-opioid
- e.g. Paracetamol, NSAID, Aspirin
Step 2:
- Weak opioid + non-opioid
- e.g. Codeine and
paracetamol
Step 3:
- Strong opioid + non-opioid
- E.g. Morphine and paracetamol

Each step you can either add adjuvants or not
Examples of adjuvants e.g.
Amitriptyline, Gapapentin, Pregabalin, Antiepileptics e.g. carbamazepine

Question 24

How often are opioids administered in chronic pain?

Answer 24

Either as:
* IR preps every 4 hours
OR
* MR preps every 12 hours
* Rescue doses (for breakthrough pain) may be given in addition

Question 25

Breakthrough pain

Answer 25

* This is when patients experience symptoms of pain despite taking their correct dose of regular opioid * They would be given rescue doses in between their main doses of opioids (i.e. Morning and evening)

Question 26

How do you calculate the rescue dose for breakthrough pain?

Answer 26

1/10th to 1/6th of the regular 24 hour dose This dose is given every 2-4 hours when required!!

Question 27

When would you need to review pain management at a regular opioid dose?

Answer 27

- If rescue dose is needed frequently, e.g. twice a day or more

Question 28

Let's say morphine was used to control pain, how would you titrate up morphine?

Answer 28

Increments of morphine should not exceed 1/3 to a HALF of the total daily dose every 24 hours The titration would stop once the pain is controlled or unacceptable adverse effects occur

Question 29

How do you treat low back pain?

Answer 29

1. Oral NSAID OR 2. Weak opioids with or without paracetamol - ONLY if NSAID is not tolerated, Cl or ineffective Benzodiazepines are sometimes used (evidence is weak)