▶ Child 10–17 years: 25 mg, dose to be taken at onset of
motion sickness, then 25 mg once daily for 2 days, dose
▶ Adult: 25 mg, dose to be taken at onset of motion
sickness, then 25 mg once daily for 2 days, dose to be
MHRA/CHM ADVICE (MARCH 2008 AND FEBRUARY 2009) OVERTHE-COUNTER COUGH AND COLD MEDICINES FOR CHILDREN
Children under 6 years should not be given over-thecounter cough and cold medicines containing
obstruction . Reye’s syndrome . severe coronary artery
disease . susceptibility to angle-closure glaucoma . urinary
l INTERACTIONS → Appendix 1: antihistamines, sedating
SIDE-EFFECTS, FURTHER INFORMATION Elderly patients are
more susceptible to anticholinergic side-effects. In
children paradoxical stimulation may occur, especially
l PREGNANCY Most manufacturers of antihistamines advise
avoiding their use during pregnancy; however, there is no
evidence of teratogenicity. Use in the latter part of the
third trimester may cause adverse effects in neonates such
as irritability, paradoxical excitability, and tremor.
l BREAST FEEDING Most antihistamines are present in
breast milk in varying amounts; although not known to be
harmful, most manufacturers advise avoiding their use in
mothers who are breast-feeding.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
l RENAL IMPAIRMENT Use with caution.
Driving and skilled tasks Drowsiness may affect
performance of skilled tasks (e.g. cycling or driving);
sedating effects enhanced by alcohol.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2
▶ Avomine (Manx Healthcare Ltd)
Promethazine teoclate 25 mg Avomine 25mg tablets | 10 tablet p £1.13 | 28 tablet p £3.13 DT = £3.13
▶ Vertigon (Manx Healthcare Ltd)
Promethazine teoclate 25 mg Vertigon 25mg tablets | 28 tablet p s DT = £3.13
Hyoscine hydrobromide 30-Mar-2017
▶ Child 4–9 years: 75–150 micrograms, dose to be taken
up to 30 minutes before the start of journey, then
75–150 micrograms every 6 hours if required;
maximum 450 micrograms per day
▶ Child 10–17 years: 150–300 micrograms, dose to be
taken up to 30 minutes before the start of journey, then
150–300 micrograms every 6 hours if required;
maximum 900 micrograms per day
▶ Adult: 150–300 micrograms, dose to be taken up to
30 minutes before the start of journey, then
150–300 micrograms every 6 hours if required;
maximum 900 micrograms per day
▶ Child 10–17 years: Apply 1 patch, apply behind ear
5–6 hours before journey, then apply 1 patch after
72 hours if required, remove old patch and site
replacement patch behind the other ear
▶ Adult: Apply 1 patch, apply behind ear 5–6 hours
before journey, then apply 1 patch after 72 hours if
required, remove old patch and site replacement patch
Hypersalivation associated with clozapine therapy
▶ Adult: 300 micrograms up to 3 times a day; maximum
Excessive respiratory secretion in palliative care
▶ Adult: 400 micrograms every 4 hours as required,
hourly use is occasionally necessary, particularly in
excessive respiratory secretions
▶ BY CONTINUOUS SUBCUTANEOUS INFUSION
Bowel colic in palliative care
▶ Adult: 400 micrograms every 4 hours as required,
hourly use is occasionally necessary
Bowel colic pain in palliative care
▶ BY MOUTH USING SUBLINGUAL TABLETS
▶ Adult: 300 micrograms 3 times a day, as Kwells ®.
▶ BY SUBCUTANEOUS INJECTION, OR BY INTRAMUSCULAR
▶ Adult: 200–600 micrograms, to be administered
30–60 minutes before induction of anaesthesia
l UNLICENSED USE Not licensed for hypersalivation
associated with clozapine therapy.
Antimuscarininc drugs used for premedication to
general anaesthesia should only be administered by, or
under the direct supervision of, personnel experienced
▶ In adults In some patients, especially the elderly, hyoscine
may cause the central anticholinergic syndrome
(excitement, ataxia, hallucinations, behavioural
abnormalities, and drowsiness).
▶ In children In some children hyoscine may cause the central
anticholinergic syndrome (excitement, ataxia,
hallucinations, behavioural abnormalities, and
l INTERACTIONS → Appendix 1: hyoscine
▶ With transdermal use Eye disorders . eyelid irritation
BNF 78 Nausea and labyrinth disorders 439
▶ With oral use Asthma . cardiovascular disorders . central
reaction .restlessness . seizure
▶ With transdermal use Balance impaired
l PREGNANCY Use only if potential benefit outweighs risk.
Injection may depress neonatal respiration.
l BREAST FEEDING Amount too small to be harmful.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
l RENAL IMPAIRMENT Use with caution.
l DIRECTIONS FOR ADMINISTRATION
▶ With transdermal use in children Patch applied to hairless area
of skin behind ear; if less than whole patch required either
cut with scissors along full thickness ensuring membrane
is not peeled away or cover portion to prevent contact with
▶ With oral use in children For administration by mouth,
injection solution may be given orally.
l PRESCRIBING AND DISPENSING INFORMATION Flavours of
chewable tablet formulations may include raspberry.
Palliative care For further information on the use of
hyoscine hydrobromide in palliative care, see
www.medicinescomplete.com/#/content/palliative/hyoscinehydrobromide.
▶ With transdermal use Explain accompanying instructions to
patient and in particular emphasise advice to wash hands
after handling and to wash application site after removing,
and to use one patch at a time.
Driving and skilled tasks Drowsiness may persist for up to
24 hours or longer after removal of patch; effects of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
Hyoscine hydrobromide 150 microgram Kwells Kids 150microgram
tablets | 12 tablet p £1.84 DT = £1.84
Hyoscine hydrobromide 300 microgram Kwells 300microgram
tablets | 12 tablet p £1.84 DT = £1.84
▶ Travel Calm (The Boots Company Plc)
Hyoscine hydrobromide 300 microgram Travel Calm
300microgram tablets | 12 tablet p s DT = £1.84
▶ Hyoscine hydrobromide (Non-proprietary)
Hyoscine hydrobromide 400 microgram per 1 ml Hyoscine
Hyoscine hydrobromide 600 microgram per 1 ml Hyoscine
hydrobromide 600micrograms/1ml solution for injection ampoules |
10 ampoule P £53.93 DT = £53.93
CAUTIONARY AND ADVISORY LABELS 19
▶ Scopoderm (GlaxoSmithKline Consumer Healthcare)
Hyoscine 1 mg per 72 hour Scopoderm 1.5mg patches | 2 patch p
CAUTIONARY AND ADVISORY LABELS 2, 24
Hyoscine hydrobromide 150 microgram Joy-rides 150microgram
chewable tablets sugar-free | 12 tablet p £1.55 DT = £1.55
ANTIPSYCHOTICS › FIRST-GENERATION
l DRUG ACTION Droperidol is a butyrophenone, structurally
related to haloperidol, which blocks dopamine receptors in
the chemoreceptor trigger zone.
Prevention and treatment of postoperative nausea and
▶ Adult: 0.625–1.25 mg, dose to be given 30 minutes
before end of surgery, then 0.625–1.25 mg every
▶ Elderly: 625 micrograms, dose to be given 30 minutes
before end of surgery, then 625 micrograms every
Prevention of nausea and vomiting caused by opioid
analgesics in postoperative patient-controlled analgesia
▶ Adult: 15–50 micrograms of droperidol for every 1 mg
of morphine in PCA, reduce dose in elderly; maximum
l INTERACTIONS → Appendix 1: droperidol
▶ Uncommon Anxiety . oculogyration
▶ Rare or very rare Blood disorder. cardiac arrest. confusion . dysphoria
l BREAST FEEDING Limited information available—avoid
l HEPATIC IMPAIRMENT Manufacturer advises caution.
▶ When used for Prevention and treatment of postoperative
nausea and vomiting Manufacturer advises maximum
625 micrograms repeated every 6 hours as required.
▶ When used for Prevention of nausea and vomiting caused by
opioid analgesics in postoperative patient-controlled
analgesia Manufacturer advises dose reduction (no
Dose adjustments In postoperative nausea and vomiting,
max. 625 micrograms repeated every 6 hours as required.
For nausea and vomiting caused by opioid analgesics in
postoperative patient-controlled analgesia, reduce dose.
l MONITORING REQUIREMENTS Continuous pulse oximetry
required if risk of ventricular arrhythmia—continue for
30 minutes following administration.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Droperidol (Non-proprietary)
Droperidol 2.5 mg per 1 ml Droperidol 2.5mg/1ml solution for
injection ampoules | 10 ampoule P s
440 Nausea and labyrinth disorders BNF 78
Droperidol 2.5 mg per 1 ml Xomolix 2.5mg/1ml solution for injection
ampoules | 10 ampoule P £39.40
Pain in palliative care (reserved for distressed patients
with severe pain unresponsive to other measures)
▶ BY CONTINUOUS SUBCUTANEOUS INFUSION, OR BY
INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS INJECTION
▶ Adult: Seek specialist advice
Restlessness and confusion in palliative care
▶ BY CONTINUOUS SUBCUTANEOUS INFUSION
▶ Child 1–11 years: 0.35–3 mg/kg, to be administered over
▶ Child 12–17 years: 12.5–200 mg, to be administered over
▶ Adult: 6 mg every 2 hours as required
▶ Adult: 6.25 mg every 2 hours as required
▶ Adult: Initially 12.5–50 mg/24 hours, titrated according
to response (doses greater than 100 mg/24 hours
should be given under specialist supervision)
Nausea and vomiting in palliative care
▶ BY CONTINUOUS INTRAVENOUS INFUSION, OR BY
▶ Child 1 month–11 years: 100–400 micrograms/kg, to be
▶ Child 12–17 years: 5–25 mg, to be administered over
▶ Adult: 6 mg once daily, dose to be taken at bedtime,
increased if necessary to 12.5–25 mg twice daily
▶ Adult: 6.25 mg once daily, dose to be given at bedtime,
increased if necessary to 12.5–25 mg twice daily
▶ Adult: 5–25 mg/24 hours, sedation can limit the dose
▶ Adult: Initially 100–200 mg daily in 3 divided doses,
increased if necessary to 1 g daily
▶ Adult: Initially 25–50 mg daily in divided doses, dose
l CONTRA-INDICATIONS CNS depression . comatose states . phaeochromocytoma
l CAUTIONS Patients receiving large initial doses should
▶ In adults Risk of postural hypotension; not recommended
for ambulant patients over 50 years unless risk of
hypotensive reaction assessed.
l INTERACTIONS → Appendix 1: phenothiazines
▶ Common or very common Asthenia . heat stroke
▶ Rare or very rare Cardiac arrest. hepatic disorders
impaired . hyperglycaemia . hyponatraemia . photosensitivity reaction . priapism . SIADH
l HEPATIC IMPAIRMENT Manufacturer advises consider
Dose adjustments Start with small doses in severe renal
impairment because of increased cerebral sensitivity.
l DIRECTIONS FOR ADMINISTRATION
▶ With subcutaneous use in children For administration by
subcutaneous infusion dilute with a suitable volume of
l PRESCRIBING AND DISPENSING INFORMATION
Palliative care For further information on the use of
levomepromazine in palliative care, see
www.medicinescomplete.com/#/content/palliative/
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, oral
CAUTIONARY AND ADVISORY LABELS 2
Levomepromazine maleate 6 mg Levinan 6mg tablets | 28 tablet P s
Levomepromazine maleate 25 mg Nozinan 25mg tablets | 84 tablet P £20.26 DT = £20.26
▶ Levomepromazine (Non-proprietary)
Levomepromazine hydrochloride 25 mg per
1 ml Levomepromazine 25mg/1ml solution for injection ampoules | 10 ampoule P £20.13 DT = £20.13
Levomepromazine hydrochloride 25 mg per 1 ml Nozinan
25mg/1ml solution for injection ampoules | 10 ampoule P £20.13
Vertigo, tinnitus and hearing loss associated with
▶ Adult: Initially 16 mg 3 times a day, dose preferably
taken with food; maintenance 24–48 mg daily
l CONTRA-INDICATIONS Phaeochromocytoma
l CAUTIONS Asthma . history of peptic ulcer
l INTERACTIONS → Appendix 1: betahistine
▶ Common or very common Gastrointestinal discomfort. headache . nausea
▶ Frequency not known Allergic dermatitis . vomiting
l PREGNANCY Avoid unless clearly necessary—no
l BREAST FEEDING Use only if potential benefit outweighs
risk—no information available.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 21
▶ Betahistine dihydrochloride (Non-proprietary)
Betahistine dihydrochloride 16 mg Betahistine 16mg tablets |
Betahistine dihydrochloride 8 mg Serc 8mg tablets | 120 tablet P £9.04
Betahistine dihydrochloride 16 mg Serc 16mg tablets | 84 tablet P £12.65 DT = £1.64
The non-opioid drugs, paracetamol p. 444 and aspirin p. 121
(and other NSAIDs), are particularly suitable for pain in
musculoskeletal conditions, whereas the opioid analgesics
are more suitable for moderate to severe pain, particularly of
The pain of mild sickle-cell crises is managed with
paracetamol, a NSAID, codeine phosphate p. 454, or
dihydrocodeine tartrate p. 456. Severe crises may require the
use of morphine p. 463 or diamorphine hydrochloride p. 456;
concomitant use of a NSAID may potentiate analgesia and
allow lower doses of the opioid to be used. Pethidine
hydrochloride p. 470 should be avoided if possible because
accumulation of a neurotoxic metabolite can precipitate
seizures; the relatively short half-life of pethidine
hydrochloride necessitates frequent injections.
Analgesics should be used judiciously in dental care as a
temporary measure until the cause of the pain has been
Dental pain of inflammatory origin, such as that associated
with pulpitis, apical infection, localised osteitis or
pericoronitis is usually best managed by treating the
infection, providing drainage, restorative procedures, and
other local measures. Analgesics provide temporary relief of
pain (usually for about 1 to 7 days) until the causative factors
have been brought under control. In the case of pulpitis,
intra-osseous infection or abscess, reliance on analgesics
alone is usually inappropriate.
Similarly the pain and discomfort associated with acute
problems of the oral mucosa (e.g. acute herpetic
gingivostomatitis, erythema multiforme) may be relieved by
benzydamine hydrochloride mouthwash or spray p. 1215
until the cause of the mucosal disorder has been dealt with.
However, where a patient is febrile, the antipyretic action of
paracetamol or ibuprofen p. 1141 is often helpful.
The choice of an analgesic for dental purposes should be
based on its suitability for the patient. Most dental pain is
relieved effectively by non-steroidal anti-inflammatory
drugs (NSAIDs). NSAIDs that are used for dental pain include
ibuprofen, diclofenac sodium p. 1135, and aspirin.
Paracetamol has analgesic and antipyretic effects but no
Opioid analgesics such as dihydrocodeine tartrate act on
the central nervous system and are traditionally used for
moderate to severe pain. However, opioid analgesics are
relatively ineffective in dental pain and their side-effects can
be unpleasant. Paracetamol, ibuprofen, or aspirin are
adequate for most cases of dental pain and an opioid is rarely
Combining a non-opioid with an opioid analgesic can
provide greater relief of pain than either analgesic given
alone. However, this applies only when an adequate dose of
each analgesic is used. Most combination analgesic
preparations have not been shown to provide greater relief
of pain than an adequate dose of the non-opioid component
given alone. Moreover, combination preparations have the
disadvantage of an increased number of side-effects.
Any analgesic given before a dental procedure should have a
low risk of increasing postoperative bleeding. In the case of
pain after the dental procedure, taking an analgesic before
the effect of the local anaesthetic has worn off can improve
control. Postoperative analgesia with ibuprofen or aspirin is
usually continued for about 24 to 72 hours.
Temporomandibular dysfunction can be related to anxiety in
some patients who may clench or grind their teeth (bruxism)
during the day or night. The muscle spasm (which appears to
be the main source of pain) may be treated empirically with
an overlay appliance which provides a free sliding occlusion
and may also interfere with grinding. In addition, diazepam
p. 343, which has muscle relaxant as well as anxiolytic
properties, may be helpful but it should only be prescribed
on a short-term basis during the acute phase. Analgesics
such as aspirin or ibuprofen may also be required.
Use of an oral contraceptive prevents the pain of
dysmenorrhoea which is generally associated with ovulatory
cycles. If treatment is necessary paracetamol or a NSAID will
generally provide adequate relief of pain. The vomiting and
severe pain associated with dysmenorrhoea in women with
endometriosis may call for an antiemetic (in addition to an
analgesic). Antispasmodics (such as alverine citrate p. 86)
have been advocated for dysmenorrhoea but the
antispasmodic action does not generally provide significant
Non-opioid analgesics and compound analgesic
Aspirin is indicated for headache, transient musculoskeletal
pain, dysmenorrhoea, and pyrexia. In inflammatory
conditions, most physicians prefer anti-inflammatory
treatment with another NSAID which may be better
tolerated and more convenient for the patient. Aspirin is
used increasingly for its antiplatelet properties. Aspirin
tablets or dispersible aspirin tablets are adequate for most
Gastric irritation may be a problem; it is minimised by
taking the dose after food. Enteric-coated preparations are
available, but have a slow onset of action and are therefore
unsuitable for single-dose analgesic use (though their
prolonged action may be useful for night pain).
Aspirin interacts significantly with a number of other
drugs and its interaction with warfarin sodium p. 140 is a
Paracetamol is similar in efficacy to aspirin, but has no
demonstrable anti-inflammatory activity; it is less irritant to
the stomach and for that reason is now generally preferred to
aspirin, particularly in the elderly. Overdosage with
paracetamol is particularly dangerous as it may cause
hepatic damage which is sometimes not apparent for 4 to
Nefopam hydrochloride p. 446 may have a place in the
relief of persistent pain unresponsive to other non-opioid
analgesics. It causes little or no respiratory depression, but
sympathomimetic and antimuscarinic side-effects may be
Non-steroidal anti-inflammatory analgesics (NSAIDs)
are particularly useful for the treatment of patients with
chronic disease accompanied by pain and inflammation.
Some of them are also used in the short-term treatment of
mild to moderate pain including transient musculoskeletal
pain but paracetamol is now often preferred, particularly in
the elderly. They are also suitable for the relief of pain in
dysmenorrhoea and to treat pain caused by secondary bone
tumours, many of which produce lysis of bone and release
prostaglandins. Selective inhibitors of cyclo-oxygenase-2
may be used in preference to non-selective NSAIDs for
patients at high risk of developing serious gastro-intestinal
side-effects. Several NSAIDs are also used for postoperative
A non-opioid analgesic administered by intrathecal infusion
(ziconotide (Prialt ®), available from Eisai) is licensed for the
treatment of chronic severe pain; ziconotide can be used by a
hospital specialist as an adjunct to opioid analgesics.
Compound analgesic preparations
Compound analgesic preparations that contain a simple
analgesic (such as aspirin or paracetamol p. 444) with an
opioid component reduce the scope for effective titration of
the individual components in the management of pain of
Compound analgesic preparations containing paracetamol
or aspirin p. 121 with a low dose of an opioid analgesic (e.g.
8 mg of codeine phosphate p. 454 per compound tablet) are
commonly used, but the advantages have not been
substantiated. The low dose of the opioid may be enough to
cause opioid side-effects (in particular, constipation) and
can complicate the treatment of overdosage yet may not
provide significant additional relief of pain.
A full dose of the opioid component (e.g. 60 mg codeine
phosphate) in compound analgesic preparations effectively
augments the analgesic activity but is associated with the
full range of opioid side-effects (including nausea, vomiting,
severe constipation, drowsiness, respiratory depression, and
risk of dependence on long-term administration).
Important: the elderly are particularly susceptible to opioid
side-effects and should receive lower doses.
In general, when assessing pain, it is necessary to weigh up
carefully whether there is a need for a non-opioid and an
opioid analgesic to be taken simultaneously.
Caffeine is a weak stimulant that is often included, in
small doses, in analgesic preparations. It is claimed that the
addition of caffeine may enhance the analgesic effect, but
the alerting effect, mild habit-forming effect and possible
provocation of headache may not always be desirable.
Moreover, in excessive dosage or on withdrawal caffeine may
Co-proxamol tablets (dextropropoxyphene in
combination with paracetamol) are no longer licensed
because of safety concerns, particularly toxicity in overdose.
Co-proxamol tablets [unlicensed] may still be prescribed for
patients who find it difficult to change, because alternatives
are not effective or suitable.
Opioid analgesics and dependence
Opioid analgesics are usually used to relieve moderate to
severe pain particularly of visceral origin. Repeated
administration may cause dependence and tolerance, but
this is no deterrent in the control of pain in terminal illness.
Regular use of a potent opioid may be appropriate for certain
cases of chronic non-malignant pain; treatment should be
supervised by a specialist and the patient should be assessed
Morphine p. 463 remains the most valuable opioid analgesic
for severe pain although it frequently causes nausea and
vomiting. It is the standard against which other opioid
analgesics are compared. In addition to relief of pain,
morphine also confers a state of euphoria and mental
Morphine is the opioid of choice for the oral treatment of
severe pain in palliative care. It is given regularly every
4 hours (or every 12 or 24 hours as modified-release
Buprenorphine p. 447 has both opioid agonist and
antagonist properties and may precipitate withdrawal
symptoms, including pain, in patients dependent on other
opioids. It has abuse potential and may itself cause
dependence. It has a much longer duration of action than
morphine and sublingually is an effective analgesic for 6 to
8 hours. Unlike most opioid analgesics, the effects of
buprenorphine are only partially reversed by naloxone
Dipipanone hydrochloride used alone is less sedating than
morphine but the only preparation available contains an
antiemetic and is therefore not suitable for regular regimens
Diamorphine hydrochloride p. 456 (heroin) is a powerful
opioid analgesic. It may cause less nausea and hypotension
than morphine. In palliative care the greater solubility of
diamorphine hydrochloride allows effective doses to be
injected in smaller volumes and this is important in the
Alfentanil p. 1343, fentanyl p. 458 and remifentanil
p. 1344 are used by injection for intra-operative analgesia;
fentanyl is available in a transdermal drug delivery system as
a self-adhesive patch which is changed every 72 hours.
Methadone hydrochloride p. 502 is less sedating than
morphine and acts for longer periods. In prolonged use,
methadone hydrochloride should not be administered more
often than twice daily to avoid the risk of accumulation and
opioid overdosage. Methadone hydrochloride may be used
instead of morphine in the occasional patient who
experiences excitation (or exacerbation of pain) with
used as a second-line drug if morphine is not tolerated or
Papaveretum p. 469 is rarely used; morphine is easier to
prescribe and less prone to error with regard to the strength
Pentazocine p. 469 has both agonist and antagonist
properties and precipitates withdrawal symptoms, including
pain in patients dependent on other opioids. By injection it
is more potent than dihydrocodeine tartrate p. 456 or
codeine phosphate, but hallucinations and thought
disturbances may occur. It is not recommended and, in
particular, should be avoided after myocardial infarction as it
may increase pulmonary and aortic blood pressure as well as
Pethidine hydrochloride p. 470 produces prompt but
short-lasting analgesia; it is less constipating than
morphine, but even in high doses is a less potent analgesic.
It is not suitable for severe continuing pain. It is used for
analgesia in labour; however, other opioids, such as
morphine or diamorphine hydrochloride, are often preferred
Tapentadol p. 471 produces analgesia by two mechanisms.
It is an opioid-receptor agonist and it also inhibits
noradrenaline reuptake. Nausea, vomiting, and constipation
are less likely to occur with tapentadol than with other
Tramadol hydrochloride p. 471 produces analgesia by two
mechanisms: an opioid effect and an enhancement of
serotonergic and adrenergic pathways. It has fewer of the
typical opioid side-effects (notably, less respiratory
depression, less constipation and less addiction potential);
psychiatric reactions have been reported.
Codeine phosphate can be used for the relief of mild to
moderate pain where other painkillers such as paracetamol
or ibuprofen p. 1141 have proved ineffective.
Dihydrocodeine tartrate has an analgesic efficacy similar
to that of codeine phosphate. Higher doses may provide
some additional pain relief but this may be at the cost of
Meptazinol p. 463 is claimed to have a low incidence of
repiratory depression. It has a reported length of action of
2 to 7 hours with onset within 15 minutes.
A combination of opioid and non-opioid analgesics is used to
treat postoperative pain. The use of intra-operative opioids
affects the prescribing of postoperative analgesics. A
postoperative opioid analgesic should be given with care
since it may potentiate any residual respiratory depression.
Morphine is used most widely. Tramadol hydrochloride is
not as effective in severe pain as other opioid analgesics.
Buprenorphine may antagonise the analgesic effect of
previously administered opioids and is generally not
recommended. Pethidine hydrochloride is generally not
recommended for postoperative pain because it is
metabolised to norpethidine which may accumulate,
particularly in renal impairment; norpethidine stimulates
the central nervous system and may cause convulsions.
Opioids are also given epidurally [unlicensed route] in the
postoperative period but are associated with side-effects
such as pruritus, urinary retention, nausea and vomiting;
respiratory depression can be delayed, particularly with
Patient-controlled analgesia (PCA) can be used to relieve
postoperative pain—consult individual hospital protocols.
Pain management and opioid dependence
Although caution is necessary, patients who are dependent
on opioids or have a history of drug dependence may be
treated with opioid analgesics when there is a clinical need.
Treatment with opioid analgesics in this patient group
should normally be carried out with the advice of specialists.
However, doctors do not require a special licence to
prescribe opioid analgesics to patients with opioid
dependence for relief of pain due to organic disease or injury.
ANAESTHETICS, GENERAL › VOLATILE LIQUID
Moderate-to-severe pain associated with trauma (under
▶ Adult: 3–6 mL as required, avoid administration on
consecutive days; administer using inhaler device;
Manufacturer advises methoxyflurane should only be
self-administered under the supervision of personnel
experienced in its use, using a hand-held Penthrox ®
l CONTRA-INDICATIONS Cardiovascular disease . history of
liver damage associated with use of methoxyflurane or
increased risk of hepatic injury .risk factors for hepatic
impairment.risk factors for renal impairment
l INTERACTIONS → Appendix 1: volatile halogenated
▶ Uncommon Appetite increased . chills . fatigue . oral
discomfort. paraesthesia . vision disorders
▶ Rare or very rare Hepatic disorders
l ALLERGY AND CROSS-SENSITIVITY Contra-indicated in
patients with hypersensitivity to fluorinated anaesthetics.
l PREGNANCY Manufacturer advises use with caution—
limited information available.
l BREAST FEEDING Manufacturer advises use with caution—
limited information available.
l HEPATIC IMPAIRMENT Manufacturer advises caution (risk
l RENAL IMPAIRMENT Manufacturer advises avoid.
l PRESCRIBING AND DISPENSING INFORMATION The
manufacturer of Penthrox ® has provided an Administration
Checklist and an Administration Guide for healthcare
l HANDLING AND STORAGE Manufacturer advises exposure
of healthcare professionals to methoxyflurane should be
minimised—risk of serious side-effects.
l PATIENT AND CARER ADVICE Manufacturer advises that
patients should be given advice on appropriate inhaler
A patient alert card should be provided.
Driving and skilled tasks Manufacturer advises patients and
carers should be counselled on the effects on driving and
performance of skilled tasks—increased risk of dizziness
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Butylated hydroxytoluene
Methoxyflurane 999 mg per 1 gram Penthrox inhalation vapour
3ml bottles with device | 1 bottle P £17.89 (Hospital only)
Mild to moderate pain | Pyrexia
▶ Adult: 0.5–1 g every 4–6 hours; maximum 4 g per day
▶ Adult (body-weight up to 50 kg): 15 mg/kg every
4–6 hours, dose to be administered over 15 minutes;
▶ Adult (body-weight 50 kg and above): 1 g every
4–6 hours, dose to be administered over 15 minutes;
▶ Adult: 0.5–1 g every 4–6 hours; maximum 4 g per day
Mild to moderate pain in patients with risk factors for
hepatotoxicity | Pyrexia in patients with risk factors for
▶ Adult (body-weight up to 50 kg): 15 mg/kg every
4–6 hours, dose to be administered over 15 minutes;
▶ Adult (body-weight 50 kg and above): 1 g every
4–6 hours, dose to be administered over 15 minutes;
Pain | Pyrexia with discomfort
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