4.7. Analgesics
4.7.1. Non-opioid analgesics and compound analgesic preparations
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.
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.
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.
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.
Restrictions:
Restricted to specialist use only for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain.
4.7.2. Opioid analgesics
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.
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®
- Immediate release Actimorph® is available on advice of the palliative care team when administration of low doses with oral morphine liquid is deemed unsuitable
Restrictions:
Use is restricted to patients in whom morphine is ineffective or not tolerated. 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:
- Tablets and capsules should be prescribed by brand name and the current brands of choice for modified-release and immediate release preparations respectively are Oxypro® and Shortec®.
- Oral liquid is no longer available as the Shortec® brand. Please prescribe generically to allow timely supply of other available brands.
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 Sevodyne® is the preferred brand of 7-day patch
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.
Restrictions:
Restricted to use in palliative care patients who are unable to tolerate other opioids in accordance with local protocol. Excludes the parenteral preparation.
Restrictions:
Restricted to use in palliative care patients who are unable to tolerate other opioids in accordance with local protocol. Excludes the parenteral preparation.
Restrictions:
Restricted to specialist initiation only.
Prescribing Notes:
Eptadone® remains non-formulary.
Restrictions:
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.
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.
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
Restrictions:
Restricted to use when simple analgesia has failed or is not tolerated. Excludes modified-release and combination preparations.
4.7.3. Neuropathic pain
Prescribing Notes:
Use in the treatment of neuropathic pain is an unlicensed indication of amitriptyline.
Restrictions:
Use in peripheral diabetic neuropathic pain in adults is restricted to specialist initiation as second or third line therapy.
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.
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.
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.
4.7.4. Antimigraine drugs
National guidance on the pharmacological management of migraine can be found in SIGN 155 (Sept 2022).
4.7.4.1. Treatment of acute migraine
National guidance on the pharmacological management of migraine can be found in SIGN 155 (Sept 2022).
First-line treatment consists of analgesia and (especially if nausea is present) anti-emetics. 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.
Restrictions:
Treatment for acute migraine, with or without aura is restricted to use in patients who have had inadequate symptom relief after trials of at least two triptans or in whom triptans are contraindicated or not tolerated; and have inadequate pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol.
Prescribing Notes:
Rimegepant has been approved for the preventative management of episodic migraine - see section 4.7.4.2 for full details.
Prescribing Notes:
- Plasma concentrations may be increased by concomitant use of propranolol, therefore the 5mg dose of rizatriptan should be used.
- Tablets are the preferred oral formulation.
- National guidance on the pharmacological management of migraine can be found in SIGN 155 (Sept 2022).
- Local guidance and referral pathway for migraine is also available here (2021 booklet)
Restrictions:
The oro-dispersible tablets are restricted to second line treatment for patients for whom standard tablets are not appropriate.
Prescribing Notes:
Restrictions:
Sumatriptan nasal spray is restricted to use in patients for whom other formulations are not suitable or effective.
Prescribing Notes:
Restrictions:
Sumatriptan injection is restricted to use in patients for whom other formulations are not suitable or effective.
Prescribing Notes:
4.7.4.2. Prophylaxis of migraine
National guidance on the pharmacological management of migraine can be found in SIGN 155 (Sept 2022).
Restrictions:
Restricted to use as a second-line prophylatic treatment for migraine.
Prescribing Notes:
Restrictions:
Restricted for use in patients with chronic and episodic migraine who have at least 4 migraine days per month, and who have had prior failure on three or more migraine preventative treatments (local protocol under review).
Restrictions:
Restricted to specialist use only in adults with chronic migraine in accordance with local protocol.
Prescribing Notes:
- Botulinum toxin A (Botox) for chronic migraine should only be used in patients who have failed to respond to ≥4 previous oral prophylactic treatments and where medication overuse has been appropriately managed.
- National guidance on the pharmacological management of migraine can be found in SIGN 155 (Sept 2022).
Restrictions:
Restricted to use as a second-line prophylatic treatment for migraine.
Prescribing Notes:
Restrictions:
Restricted to specialist use in patients with chronic and episodic migraine who have at least 4 migraine days per month, and who have had prior failure on three or more migraine preventative treatments.
Restrictions:
Restricted to specialist use in accordance with local protocol in patients with chronic migraine for whom at least four prior prophylactics have failed and the patient has failed to respond to, or not tolerated, an adequate trial of botulinum toxin A (Botox®). Erenumab may be considered if Botox® is contraindicated.
Restrictions:
Restricted to specialist use in accordance with local protocol for use in patients with chronic migraine for whom at least four prior prophylactic treatment options have failed and the patient has failed to respond to, or has not tolerated an adequate trial of botulinum toxin A or where this is contraindicated.
Restrictions:
Prophylaxis of migraine in adults who have at least 4 migraine days per month is restricted to specialist use for the treatment of patients with chronic and episodic migraine who have had prior failure on three or more migraine preventive treatments. Click here for local protocol.
Restrictions:
For the preventive treatment of episodic migraine in adults who have at least 4 migraine attacks per month, but fewer than 15 headache days per month and who have had prior failure on three or more migraine preventive treatments (local guidance under review).
Prescribing Notes:
Rimegepant is also approved for the treatment for acute migraine - see section 4.7.4.1 for full details.
Prescribing Notes:
- In June 2024, the MHRA advised that topiramate is contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled.
- National guidance on the pharmacological management of migraine can be found in SIGN 155 (Sept 2022).
- Local guidance and referral pathway for migraine is also available here (2021 booklet)