These medications are usually used in conjunction with classical analgesics.
Options include:
- Non steroidal anti-inflammatories: see NSAID section
- Steroids: see Steroid section
- Radiotherapy
- Bisphosphonates/Denosumab
In all cases seek specialist advice if needed.
Consider the use of steroids: see Steroid section
Consider the use of steroids:
Consider radiotherapy: Seek specialist advice
Diazepam
Oral: 2mg–10mg daily increase if necessary
Preparations:
Tablets: 2mg, 5mg and 10mg
Oral solution: – 2mg/5ml
Contraindicated in:
- Severe or acute respiratory insufficiency/depression
- Sleep apnoea syndrome
- Severe hepatic insufficiency
Baclofen
Oral: 5mg TDS after food (gradually increase to a max total daily dose of 30mg if necessary)
Preparations:
Tablets: 10mg
Sugar free oral solution: 5mg/5ml
Cautioned use in epilepsy and psychotic disorders, schizophrenia depressive or manic disorders, confusional states or Parkinson’s disease may be exacerbated by treatment with baclofen.
Hyoscine butylbromide
Dose SC: 20mg stat, or SC infusion 60mg up to 120mg in 24 hours
Tablets are poorly absorbed
Preparations:
Tablets: 10mg
Injection: 20mg/ml
Contraindicated in patients with myasthenia gravis, megacolon, narrow angle glaucoma, tachycardia, prostatic enlargement with urinary retention, mechanical stenoses in the region of the gastrointestinal tract or paralytic ileus.
Glycopyrronium
Dose SC: 200 micrograms stat and SC infusion 600 mcg up to 1200 mcg in 24hours
Contraindicated in patients with myasthenia gravis, megacolon, narrow angle glaucoma, tachycardia, prostatic enlargement with urinary retention, mechanical stenoses in the region of the gastrointestinal tract or paralytic ileus.
NB: Glycopyrronium is more sedating than hyoscine butylbromide
Treat initially as for neuropathic pain (see separate section below). Additional option is nifedipine.
Nifedipine
Oral: 5mg–20mg BD
Preparations:
- Capsules: 5mg, 10mg
- Tablets SR: 10mg, 20mg
There is a risk of rapid onset hypotension with immediate release preparations and reflex tachycardia therefore immediate release preparation should not be used in patient with angina.
Should be brand prescribed due to non-bioequivalence.
Also consider nerve block.
Step 1
Antidepressant (tricyclic) e.g. amitriptyline OR anticonvulsant
Step 2
Antidepressant (tricyclic) PLUS anticonvulsant
For nerve compression pain consider steroids also consider Transcutaneous Nerve Stimulation (TENS) or nerve block.
Neuropathic agents
Oral: 10mg–25mg at night increasing slowly up to 75mg nocte
Preparations:
Tablets: 10mg, 25mg, 50mg
Solution: 10mg/5ml, 25mg/5ml and 50mg/5ml
Oral: 100mg–300mg nocte increasing gradually to maximum daily dose of 900mg–1800mg in divided doses
Preparations:
• Capsules 100mg, 300mg, 400mg (can be opened and sprinkled on food or administered via PEG tube for patients with impaired swallow)
• Tablets 600mg, 800mg
Dose adjust in renal failure (see: Analgesia in renal disease)
Oral: 150mg daily in divided doses (25mg–50mg bd in frail patients) increasing gradually to maximum daily dose of 600mg in divided doses
Preparations:
• Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 300mg
Dose adjust in renal failure (see: Analgesia in renal disease)
Oral Starting Dose: 200mg m/r PO, increase as per BNF
Preparations:
• Tablet EC 200mg and 500mg
• Crushable tablets 100mg
• MR tablets 200mg, 300mg, 500mg
• Oral solution 200mg/5ml
Caution: Not for use in women and girls of childbearing potential
Oral: 100mg BD increasing gradually if tolerated up to 1200mg daily in divided doses if necessary
Preparations:
• Tablets 100mg, 200mg, 400mg
• Chewable tablets 100mg and 200mg
• MR tablets 200mg, 400mg
• Oral liquid ‘sugar free’ 10mg/5ml
• Suppositories 125mg (equivalent to 100mg tablets)
Monitoring:
Check LFT’s and FBC once started
Caution:
Potent inducer of CYP3A4 therefore, can reduce the levels of buprenorphine, methadone, paracetamol (long term administration of carbamazepine and paracetamol (acetaminophen) may be associated with hepatotoxicity), tramadol.
See the current BNF for all other drug interactions.
Oral: 500 micrograms nocte; increasing gradually to 2mg nocte
Preparations:
Tablets 500 micrograms and 2mg
Use with caution in patients with chronic pulmonary insufficiency, or with renal or hepatic function impairment, and in the elderly or debilitated. In these cases dosage should generally be reduced.
Advice: to start small and titrate up
Oral: 60mg OD (consider 30mg OD orally in frail patients) increasing gradually up to maximum daily dose of 120mg in divided doses
Preparations:
Cymbalta® 30mg capsules and 60mg capsules
Contraindicated in severe renal impairment (creatinine clearance <30 ml/min) and severe hypertension
Monitor blood pressure and heart rate
Consider in localised neuropathic pain one 5% plaster; use up to three plasters over 12hrs per 24hrs.
Preparations:
Versatis® 5% medicated plaster
Consider in localised neuropathic pain
Preparations:
• Cream: Topical: 0.025% and 0.075% cream. Apply using gloves 2 to 4 times daily
• Patch: 8%. Qutenza®. Apply for one hour only
Advice to patients: Burning sensation can occur during initial treatment
Benefit reported in neuropathic pain but not tested in RCT.
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.