MSK Practitioner formulary
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
COX-1 + COX-2
Enzyme pathway
Brands:
Brufen (MR 800mg)
Cuprofen
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
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.
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.