CKS Clinical solutions - Analgesia

THE CASE An otherwise fit and healthy 45-year-old man fractured his ankle and is asking for 'stronger painkillers'. Paracetamol (1g four times a day) together with ibuprofen (400mg three times a day) is not providing adequate pain relief.

Fractured ankle: use a stepwise strategy for analgesia use (Photograph: SPL)
Fractured ankle: use a stepwise strategy for analgesia use (Photograph: SPL)

What are the next steps?
Continue with full-dose paracetamol and increase the dose of ibuprofen to 800mg three times a day. If this does not provide adequate pain relief, replace the ibuprofen with an alternative NSAID, such as diclofenac (50mg three times a day) or naproxen (250mg to 500mg twice a day).

If paracetamol and diclofenac or naproxen do not provide adequate pain relief, start a full therapeutic dose of a weak opioid (codeine 30mg to 60mg every four hours, maximum 240mg daily; dihydrocodeine 30mg every four to six hours, maximum 240mg daily; or tramadol 50mg to 100mg every four hours, maximum 400mg daily) in addition to full-dose paracetamol and/or an NSAID.

What if he is at increased risk of a thrombotic event?
Low dose ibuprofen is preferred for people who are at risk of thrombotic events because at lower doses, such as 1,200mg daily or less, epidemiological data does not suggest an increased risk of MI.

Although there may be a small increased risk of a thrombotic event at higher doses (up to 2,400mg daily), this may be necessary for effective pain relief and the benefit is likely to outweigh the risk involved.

If an alternative NSAID is necessary, naproxen is preferred because it has a lower thrombotic risk than COX-2 inhibitors and diclofenac and, overall, epidemiological data does not suggest an increased risk of MI. There is less evidence on the thrombotic risk associated with other NSAIDs.

What if he is at risk of a gastrointestinal event?
Consider prescribing a full therapeutic dose of a weak opioid as an alternative to an NSAID. If an NSAID is necessary, prescribe ibuprofen with a PPI. If an alternative NSAID is necessary consider prescribing naproxen or diclofenac with a PPI.

Celecoxib or etoricoxib are also options if prescribed within their licensed indications (osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and, for etoricoxib only, gouty arthritis) but are more expensive than standard NSAIDs.

The evidence
This stepwise strategy for managing mild-to-moderate pain in adults is based on expert opinion from the British Pain Society and the MHRA1, the National Prescribing Centre2 and the WHO.3

The evidence on increased risk of thrombotic and gastrointestinal adverse events for NSAIDs and COX-2 inhibitors is summarised in the 'supporting evidence' section of the CKS topic on 'NSAIDS - prescribing issues'.

References
1. MHRA (2004) Advice from the CSM Expert Working Group on analgesic options in treatment of mild to moderate pain. Medicines and Healthcare products Regulatory Agency.

2. MeReC (2006) The withdrawal of co-proxamol: alternative analgesics for mild to moderate pain. MeReC Bulletin 16(4).

3. WHO (2010) WHO's pain ladder. World Health Organization.

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