Step 1: Paracetamol & NSAIDS

Therapeutic effects

  • Analgesic
  • Anti-pyretic

Dose: 500mg – 1g, 4–6 hourly. Max dose 4g in 24 hours


Tablets and caplets: 500mg, 1g

Tablets soluble and dispersible: 500mg, 1g
(note these have high sodium content)

Tablets orodispersible: 250mg

Capsules: 500mg

Caplets: 500mg

Oral solution: 120mg/5mL, 500mg/5ml

Oral suspension: 120mg/5mL, 250mg/5mL, 500mg/ml
(SF options available)

Suppositories: 60mg, 80mg, 120mg, 125mg, 240mg, 250mg, 500mg, 1g

Specialist use: 

Injection: (for IV infusion) 10mg/mL; 10mL (100mg) amp, 50mL (500mg) vial, 100mL (1g) vial

Advice: Intravenous paracetamol (Perfalgan): risk of accidental overdose
search for “Perfalgan”

Therapeutic effects

• Anti-inflammatory

• Anti-pyretic

• Analgesic

Indications: for analgesia in palliative care, including action as adjuvant analgesic.

1. Bone pain

2. Soft tissue pain due to malignant infiltration 

3. Arthritis

4. Possible role in early management of neuropathic pain

Choice of NSAID will depend on reducing risk of side effects as much as possible. Select the safest drug at the lowest dose, taking into account availability and local formulary and guidance.

Assess analgesic response after regular use for one week.

Patients considered to be at risk of NSAID induced gastroduodenal ulceration (age over 65 years, past history of peptic ulcer disease, concomitant oral steroids or anticoagulants, serious comorbidity) should receive a gastro-protective drug such as a proton pump inhibitor.

Use with extreme caution in renal failure. Fluid retention and renal function may all be worsened by NSAIDs. There is little evidence to suggest that any particular NSAID is safer than another in respect of renal toxicity.

NSAIDs may be considered for asthmatic patients unless they have a history of sensitivity.

Non-steroidal anti-inflammatory drugs

Celecoxib is the NSAID of choice if the patient is at high risk of GI complications. This needs to be considered alongside the patient’s cardiovascular history.

Adult Dose
Oral: 100mg-200mg BD

Dosage Forms
Capsules: 100mg, 200mg

Additional Information
Celecoxib does not affect platelet function or bleeding time, and it does not reverse the anti-platelet effect of aspirin.  The risk of cardiac events and risk of renal impairment is similar for all NSAIDs. (Previous data was felt to overestimate the risks with celecoxib).

Adult Dose
Up to 150mg in 24 hours. Can be given via CSCI but not compatible with other drugs. Injection can cause skin necrosis.

Dosage Forms
Tablet: 25mg, 50mg

Modified Release tablets and capsules: 75mg, 100mg

Dispersible tablets: 50mg

Suppositories: 12.5mg, 25mg, 50mg, 100mg

Injection: 25mg/ml

Gel: For topical use

Additional Information
Low GI Risk   |   Higher cardiac risk

Ibuprofen has generally been the first line NSAID of choice. However, celecoxib would be considered first line if risk of GI complications is high for the patient.

Adult Dose
Oral: 200mg-400mg TDS

Dosage Forms
Tablet: 200mg, 400mg, 600mg

Capsules: 200mg, 400mg

Caplets: 200mg

Orodispersible tablets: 200mg

MR tablet: 800mg OD

MR capsule: 200mg, 300mg BD

Suspension: 100mg/5ml, 200mg/5ml

Granules: 600mg sachet

Gel for topical use 5% and 10%

Additional Information
Current evidence suggests an increased risk of cardiovascular thrombotic events with NSAIDs. For those at risk consider lowest dose.

Adult Dose
Oral: 250mg-500mg BD

Dosage Forms
Tablet: 250mg, 500mg

Additional Information
It appears to be associated with a lower risk of cardiovascular
thrombotic events.

Parecoxib is an injectable NSAID which can be given subcutaneously.
Seek advice from specialist palliative care.

In patients who are terminally ill the increased risk of renal, cardiovascular and GI toxicity associated with NSAIDs must be  weighed against the potential for improved pain control.

For further guidance on the use of NSAIDs (including alternative parenteral agents) consult your local Specialist Palliative Care Team.

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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.