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MSK Practitioner formulary

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Opiates - pain relief

Codeine phosphate

 

Opioid analgesic (Moderate)

5-HT stimulation

Mild to moderate pain

Painful cough

Acute diarrhea

Tablet by mouth

Adult

 

30–60 mg every 4 hours if required; maximum 240 mg per day.

 

Dependency rating:

Medium

Caution if prescribing to drug abusers

Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus

 

Adrenocortical insufficiency (reduced dose is recommended); asthma (avoid during an acute attack);

convulsive disorders; debilitated patients (reduced dose is recommended) (in adults);

diseases of the biliary tract; elderly (reduced dose is recommended) (in adults);

hypotension; hypothyroidism (reduced dose is recommended); impaired respiratory function (avoid in chronic obstructive pulmonary disease);

inflammatory bowel disorders; myasthenia gravis; obstructive bowel disorders;

prostatic hypertrophy (in adults);

shock; urethral stenosis (in adults)

 

Codeine is contra-indicated in patients of any age who are known to be ultra-rapid metabolisers of codeine (CYP2D6 ultra-rapid metabolisers)

Acute ulcerative colitis; antibiotic-associated colitis;

children under 18 years who undergo the removal of tonsils or adenoids for the treatment of obstructive sleep apnoea;

conditions where abdominal distension develops;

conditions where inhibition of peristalsis should be avoided.

 

Codeine should not be used in breast-feeding mothers because it can pass to the baby through breast milk.

 

Alcoholism; chronic dehydration; chronic malnutrition; hepatocellular insufficiency; pancreatitis; severe cor pulmonale (BNF.NICE.ORG.UK)

Constipation

Nausea

Vomiting

Drowsiness

Cocodamol

Codeine + paracetamol (acetaminophen)

 

Opioid analgesic (mild to moderate)

5-HT stimulation

Brands:

Solpadeine plus

Solpadeine Max

Solpadol

Kapake

Tylenol (US)

Emtec (Canada)

Prontalgine (Europe)

Mild to moderate pain

 

Tablet by mouth

Adult

8/500mg

15/500mg

 

 

30/500mg

2 every 4 hours if required; maximum 8 per day max.

 

Dependency rating:

Medium

Caution if prescribing to drug abusers

Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus

 

Adrenocortical insufficiency (reduced dose is recommended); asthma (avoid during an acute attack);

convulsive disorders; debilitated patients (reduced dose is recommended) (in adults);

diseases of the biliary tract; elderly (reduced dose is recommended) (in adults);

hypotension; hypothyroidism (reduced dose is recommended); impaired respiratory function (avoid in chronic obstructive pulmonary disease);

inflammatory bowel disorders; myasthenia gravis; obstructive bowel disorders;

prostatic hypertrophy (in adults);

shock; urethral stenosis (in adults)

 

Codeine is contra-indicated in patients of any age who are known to be ultra-rapid metabolisers of codeine (CYP2D6 ultra-rapid metabolisers)

Acute ulcerative colitis; antibiotic-associated colitis;

children under 18 years who undergo the removal of tonsils or adenoids for the treatment of obstructive sleep apnoea;

conditions where abdominal distension develops;

conditions where inhibition of peristalsis should be avoided.

 

Codeine should not be used in breast-feeding mothers because it can pass to the baby through breast milk.

 

Alcoholism; chronic dehydration; chronic malnutrition; hepatocellular insufficiency; pancreatitis; severe cor pulmonale (BNF.NICE.ORG.UK)

Constipation

Nausea

Vomiting

Drowsiness

Dihydrocodeine tartrate

 

Opioid analgesic (mild to moderate)

5-HT stimulation

CYP450 system

 

Brands:

DF118 Forte

DH Plus (US)

Panlor (US)

Moderate to severe pain

  

Chronic severe pain

 

 

TTablet by mouth

 

Adult

30–60 mg every 4 hours if required; maximum 240 mg per day.

 

60–120 mg every 12 hours; Modified release

 

40–80 mg 3 times a day; maximum 240 mg per day

 

Dependency rating:   Medium

 

Caution if prescribing to drug abusers

Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus

 

Adrenocortical insufficiency (reduced dose is recommended); asthma (avoid during an acute attack);

convulsive disorders; debilitated patients (reduced dose is recommended) (in adults);

diseases of the biliary tract; elderly (reduced dose is recommended) (in adults);

hypotension; hypothyroidism (reduced dose is recommended); impaired respiratory function (avoid in chronic obstructive pulmonary disease);

inflammatory bowel disorders; myasthenia gravis; obstructive bowel disorders;

prostatic hypertrophy (in adults);

shock; urethral stenosis (in adults)

 

Codeine is contra-indicated in patients of any age who are known to be ultra-rapid metabolisers of codeine (CYP2D6 ultra-rapid metabolisers)

Acute ulcerative colitis; antibiotic-associated colitis;

children under 18 years who undergo the removal of tonsils or adenoids for the treatment of obstructive sleep apnoea;

conditions where abdominal distension develops;

conditions where inhibition of peristalsis should be avoided.

 

Codeine should not be used in breast-feeding mothers because it can pass to the baby through breast milk.

 

Alcoholism; chronic dehydration; chronic malnutrition; hepatocellular insufficiency; pancreatitis; severe cor pulmonale (BNF.NICE.ORG.UK)

Constipation

Nausea

Vomiting

Drowsiness

Codydramol

Dihydrocodeine tartrate + Paracetamol

 

Opioid analgesic (mild to moderate)

5-HT stimulation

 

CYP450 system

Mild to moderate pain

Tablet by mouth

Adult

10/500mg x 8 tablets daily

 

 

20/500

 

30/500mg x 8 tablets per day max.

 

Dependency rating:

Medium

 

Caution if prescribing to drug abusers

Acute respiratory depression; comatose patients; head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment); raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment); risk of paralytic ileus

 

Adrenocortical insufficiency (reduced dose is recommended); asthma (avoid during an acute attack);

convulsive disorders; debilitated patients (reduced dose is recommended) (in adults);

diseases of the biliary tract; elderly (reduced dose is recommended) (in adults);

hypotension; hypothyroidism (reduced dose is recommended); impaired respiratory function (avoid in chronic obstructive pulmonary disease);

inflammatory bowel disorders; myasthenia gravis; obstructive bowel disorders;

prostatic hypertrophy (in adults);

shock; urethral stenosis (in adults)

 

Codeine is contra-indicated in patients of any age who are known to be ultra-rapid metabolisers of codeine (CYP2D6 ultra-rapid metabolisers)

Acute ulcerative colitis; antibiotic-associated colitis;

children under 18 years who undergo the removal of tonsils or adenoids for the treatment of obstructive sleep apnoea;

conditions where abdominal distension develops;

conditions where inhibition of peristalsis should be avoided.

 

Codeine should not be used in breast-feeding mothers because it can pass to the baby through breast milk.

 

Alcoholism; chronic dehydration; chronic malnutrition; hepatocellular insufficiency; pancreatitis; severe cor pulmonale (BNF.NICE.ORG.UK)

Constipation

Nausea

Vomiting

Drowsiness

NSAIDs - non steroidal anti-inflammatory drugs

Naproxen

COX-1 + COX-2

Enzyme pathway

 

 

 

Brands:

Naprosyn

Feminax Ultra

Stirlescent (dissolve)

MSK pain and inflammation

 

Rheumatic disease

Tablet by mouth

Adult

0.5–1 g daily in 1–2 divided doses.

 

Take with or after food

Contraindicated in patients with a history of hypersensitivity to aspirin or any other NSAID—which includes those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID.

Active gastro-intestinal bleeding; active gastro-intestinal ulceration; history of gastro-intestinal bleeding related to previous NSAID therapy; history of gastro-intestinal perforation related to previous NSAID therapy; history of recurrent gastro-intestinal haemorrhage (two or more distinct episodes); history of recurrent gastro-intestinal ulceration (two or more distinct episodes); severe heart failure

 

Avoid in third trimester or caution breast feeding

Side effects; Alveolitis; aseptic meningitis (patients with connective-tissue disorders such as systemic lupus erythematosus may be especially susceptible); hepatic damage; interstitial fibrosis associated with NSAIDs can lead to renal failure; pancreatitis; papillary necrosis associated with NSAIDs can lead to renal failure; pulmonary eosinophilia; Stevens-Johnson syndrome; toxic epidermal necrolysis; visual disturbances. (BNF.NICE.org.uk)

Gastro/Ulcer

 

Bowel

Nausea

Ibuprofen

 

COX-1 + COX-2

Enzyme pathway

 

Brands:

Brufen (MR 800mg)

Cuprofen

Nurofen

Ibucalm

Calprofen (suspn)

MSK pain and inflammation

 

Rheumatic disease

Tablet by mouth

Adult

400mg three times a day typical therapeutic dose

600mg x 4 daily max

 

 

 

Take with or after food

Contraindicated in patients with a history of hypersensitivity to aspirin or any other NSAID—which includes those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID.

Active gastro-intestinal bleeding; active gastro-intestinal ulceration; history of gastro-intestinal bleeding related to previous NSAID therapy; history of gastro-intestinal perforation related to previous NSAID therapy; history of recurrent gastro-intestinal haemorrhage (two or more distinct episodes); history of recurrent gastro-intestinal ulceration (two or more distinct episodes); severe heart failure

 

Avoid in third trimester or caution breast feeding

Side effects; Alveolitis; aseptic meningitis (patients with connective-tissue disorders such as systemic lupus erythematosus may be especially susceptible); hepatic damage; interstitial fibrosis associated with NSAIDs can lead to renal failure; pancreatitis; papillary necrosis associated with NSAIDs can lead to renal failure; pulmonary eosinophilia; Stevens-Johnson syndrome; toxic epidermal necrolysis; visual disturbances. (BNF.NICE.org.uk)

Gastro/Ulcer

 

Bowel

Nausea

Proton pump inhibitor PPI - stomach protection drug

Lansoprazole

ATP enzyme and gastric ion channel blocker

 

 

 

Brands:

Zoton

Anti-ulcer

 

 

Gastro reflux

Tablet by mouth

Adult

30mg 1 daily

 

15-30mg daily

 

 

28 capsules/pack

Can increase the risk of fractures (particularly when usedat high doses for over a year in the elderly) (in adults); may increase the risk of gastro-intestinal infections

(including Clostridium difficile infection);may mask the symptoms of gastric cancer (in adults); patients at risk of osteoporosis

 

Interactions:

Antacids reduce absorption

Digoxin, increased blood levels

Atazanavir avoid

Abdo pain

Headache

Indigestion

Diarrhoea

Omeprazole

ATP enzyme and gastric ion channel blocker

 

 

 

Anti-ulcer

 

 

Gastro reflux

TTablet by mouth

 

Adult

20mg 1 daily

 

1-2 daily

 

28 capsules/pack

Can increase the risk of fractures (particularly when usedat high doses for over a year in the elderly) (in adults); may increase the risk of gastro-intestinal infections

(including Clostridium difficile infection);may mask the symptoms of gastric cancer (in adults); patients at risk of osteoporosis

 

Interactions:

Antacids reduce absorption

Digoxin, increased blood levels

Atazanavir avoid

Abdo pain

Headache

Indigestion

Diarrhoea

Neuropathic pain medication

Amitriptyline

Tricyclic antidepressant

 

Serotonin nor adrenaline reuptake inhibitor

 

 

CYP2D6 and CYP2D19

 

Metabolise intestine and liver

Neuropathic pain, sciatica, acute or chronic low back pain, neuropathy, depression

Tablets by mouth

10mg, 25mg, 50mg

 

Max dose 75mg daily for pain

 

Max dose 200mg for depression

 

 

28 capsules per pack

Cautions

Epilepsy, closed angle glaucoma, liver disease, cardiac disease, thyrotoxosis, psychoses, prostatic hypertrophy or urinary retention, porphyria.

 Contra-indications

 

Hypersensitivity to amitriptyline, nortriptyline or imipramine, recent myocardial infarction and arrhythmias, pregnancy and breastfeeding. Acute porphyrias, during manic phase of bipolar disorder, heart block. (BNF, 2016)

 Interactions

 

Barbituates, anaesthetics, CNS depressants i.e. alcohol, phenothiazines. Anticholinergic drugs,

Monoamine oxidase inhibitors (MAOIs); enhanced sedative effect, hypertensive crisis.

 

Sympothomimetic drugs i.e. adrenaline noradrenaline, potential the cardiovascular event

 

Drugs that utilise the hepatic cytochrome P45011D6 isoenzyme system may compete for metabolism by this system, drug interaction. (Fluoxetine, phenothiazines, carbamazepine, proafenone and flecainide.

 

Precaution

 

CYP2D6 and CYP2D19 enzyme liver deficiency, can cause raise blood plasma levels (BNF.NICE.org.uk)

drowsiness, dizziness, postural hypotension, nausea, constipation, blurred vision, dry mouth, difficulty with micturition, sinus tachycardia, agitation, hyponatraemia, lower seizure threshold

Steroid injection

Triamcinolone Acetonide

 

CYP3A4

Metabolised in liver

 

Brands:

 

Kenalog

 

 

Joint pain, swelling and stiffness associated with rheumatoid arthritis and osteoarthrosis, with an inflammatory component; also for bursitis, epicondylitis, and tenosynovitis.

(EMC)

Intra-articular use

 

5–40 mg per ml, (1 ampoule) with a recommended maximum dose of 80 mg in 2ml (BNF, 2016)

 

mixed with of 1% lidocaine hydrochloride (ampoule)

 

 

Total volume delivered dependent on joint size

Systemic or local infection, skin lesion at injection site, prosthetic joint at injection site, live vaccine in last 2 weeks, taking oral anticoagulants INR<2.5.

Hypersensitivity or previous reaction to injection materials including chlorhexidine and plasters.

Pregnant or breastfeeding, uncontrolled diabetes, major surgery in the last 6 weeks, planned surgery in the next 2 weeks.

Relevant history of cancer.

Had 3 previous injections into target area in last 12 months.

 

Interactions

Antagonize hypoglycaemic agents

Antagonize hypertensive agents and diuretics

Enhance or reduce the effects of anticoagulants

Enhances the potassium lowering effects of acetazolamide (Diamox), Loop Diuretics and Thiazides.

 

Anticonvulsants can reduce the effects of corticosteroids 

(BNF.NICE.org.uk)

Infection, allergy and anaphylaxis, steroid flare, facial flushing, skin pigmentation and/or atrophy, soft tissue weakening, raised blood sugars in diabetics.

 

Lidocaine Hydrochloride

 

Metabolised in liver

 

Local, regional anaesthetic

1% w/v = 10mg/ml lidocaine hydrochloride solution (ampoule)

 10, 20, 50, 100, 200 mg preparations

 

 

 

Total volume delivered dependent on target

 

 Dependency rating:   Low

 

Contra-indications

 

Known hypersensitivity to anaesthetics of the amide type

Complete heart block

Hypovolaemia

Hepatic failure

 

Cautions

patients with epilepsy, myasthenia gravis, impaired cardiac conduction, congestive cardiac failure, bradycardia or impaired respiratory function, Hypokalaemia, hypoxia

Small amounts of lidocaine are secreted into breast milk

Lidocaine readily crosses the placental barrier

 

Interactions

Cimetidine and propranolol depress microsomal enzyme activity, thus enhancing lidocaine toxicity.

Ranitidine produces a small reduction in Lidocaine clearance

Increase in serum levels of lidocaine may also occur with anti-viral agents (e.g. amprenavir, atazanavir, darunavir, lopinavir).

Hypokalaemia caused by diuretics may antagonize the action of lidocaine agents structurally related to amide-type local anaesthetics (e.g. anti-arrhythmics, such as mexiletine), risk of ventricular arrhythmia in patients treated concurrently with antipsychotics which prolong or may prolong the QT interval (e.g. pimozide, sertindole, olanzapine, quetiapine, zotepine), prenylamine, adrenaline (if accidently injected intravenously)) or 5HT3 antagonists (e.g. tropisetron, dolasetron).

Concomitant use of quinupristin/dalfopristin may increase lidocaine levels

While adrenaline (epinephrine) when used in conjunction with lidocaine might decrease vascular absorption, it greatly increases the danger of ventricular tachycardia and fibrillation if accidentally injected intravenously.

(BNF.NICE.org.uk)

Raised plasma concentration due to accidental intravascular injection:

Hypersensitivity

Methaemoglobinaemia

 

dizziness or light-headedness, nervousness, tremor, circumoral paraesthesia, tongue numbness, drowsiness, convulsions, coma.

Comments

One comment

    Charlie Seefeld

    31 August 2020

    Yes, this is a Good one

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