Canterbury DHB

Context

Co-Analgesics

These are used in addition to paracetamol +/- NSAID and an appropriate opioid.

In This Section

Corticosteroids

NSAIDs

Tricyclic Antidepressants

Anticonvulsants

Ketamine

Benzodiazepines

Antiarrhythmics – local anaesthetic class

Baclofen

Neuroleptics

Bisphosphonates

Calcitonin

Corticosteroids

Dexamethasone and prednisone are the medications of choice.

These are particularly useful for pain related to:

It is advisable to use a high dose initially in order to gain symptomatic benefit as soon as possible, e.g. dexamethasone 8 – 16 mg daily PO or subcut infusion.

This can be given as a 5 -10 day trial and then stopped if not effective. If continued longer the dose must be tapered, not stopped immediately.

Can be given as a subcutaneous bolus up to a maximum of 8 mg (must be injected slowly).

If effective, the dose should be reduced as low as possible to minimise side effects. Beware of hyperglycaemia – regular review is essential.

It is preferable to give the dose as a once daily mane dose, or divided mane and midday to mimic the physiologic release of steroid and minimize insomnia.

Note: An important side effect in patients with high dose steroids is paranoia/mania and depression.

NSAIDs

These may be a useful addition in bone pain or when anti-inflammatory effect is desirable. Diclofenac is also available as a suppository. See Non Steroidal Anti-inflammatory Drugs (NSAIDs).

Tricyclic Antidepressants

Anticonvulsants

These are generally recommended for neuropathic pain secondary to tumour infiltration, post-herpetic neuralgia, and phantom limb pain. It is important to check the side effects before prescribing. Sedation and nausea are minimal if introduced slowly.

Especially useful for “shooting” and “electric shock-like” pain.

 

Usual starting dose

Increase by

Usual effective dose

1. Gabapentin

300 mg/day

300 mg every 3 days

900 – 3600 mg/day

2. Clonazepam

0.5 mg/nocte

0.5 mg every 3 days

2 – 4 mg/day

3. Sodium valproate

200 mg/day

200 mg every 3 days

400 – 1000 mg/day

4. Carbamazepine

100 mg/day

100 mg every 3 days

400 – 800 mg/day

Gabapentin

Ketamine

Note: A Palliative Care Referral is essential.

See the Ketamine Information Sheet.

Benzodiazepines

Clonazepam

Other Alternatives

Diazepam 2-5 mg PO TDS

Lorazepam 0.5-2.5 mg PO TDS

Antiarrhythmics – local anaesthetic class

Note: A referral to Palliative Care is strongly recommended if considering the use of either of these drugs.

Baclofen

Neuroleptics

Levomepromazine (Nozinan™) 25 mg PO (12.5 mg subcut) stat then nocte – can titrate 8 hourly to a maximum dose of 100 mg subcut / 200 mg PO per 24 hours. (Note: levomepromazine was previously known as methotrimeprazine.)

Note: A Palliative Care Referral is recommended.

Bisphosphonates

Calcitonin

Note: A referral to Palliative Care is essential.

About this Canterbury DHB document (4065):

Document Owner:

Kate Grundy (see Who's Who)

Issue Date:

February 2013

Next Review:

August 2014

Keywords:

hiccups

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 4065