Specific dosage instructions should be written on the prescription, i.e. "X to be taken x hourly when required for pain", rather than simply "PRN". This ensures a maximum dose is stated and will prevent dose escalation without prescriber approval.

See also section 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

Soluble tablets: Taking 8 tablets per day of soluble paracetamol or co-codamol will increase intake of sodium chloride by 8g daily. The Department of Health recommended daily intake of sodium chloride is 6g. This may be a significant risk in patients with heart failure or hypertension. Dispersible preparations should be reserved only for patients who cannot swallow solid forms. They are also more expensive.

Paracetamol

• Tablets 500mg (£2.34 = 100 tablets)
• Soluble tablets 500mg (contains Na+ 18.6mmol/tablet) (£13.67 = 100 soluble tablets)
• Oral suspension sugar free 120mg/5ml, 250mg/5ml (£3.80 = 120mg/5ml x 100ml)
• Suppository 60mg, 125mg, 250mg, 500mg (£27.60 = 250mg x 10 suppositories)
• Intravenous infusion 1000mg/100ml, 500mg/50ml

Indications

• Mild to moderate pain
• Pyrexia (pyrexia with discomfort in children)

Dose

• Adult: 0.5g-1g every 4–6 hours to a maximum of 4g daily
• The maximum daily dose of paracetamol should not exceed 60mg/kg when prescribed for adults weighing less than 50kg
• In adult patients <50kg with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition, or dehydration, the maximum daily dose should be reduced to 3g
• Child: see BNFC for dose

Notes

1. Shortage of paracetamol suppositories (April 2024):
   1. A Medicine Supply Notification (MSN/2023/062) for paracetamol suppositories was issued on 29 June 2023 with resupply dates expected in 2024. Anticipated resupply dates have been amended to 31 January 2025 for the following:
      1. Paracetamol 60mg suppositories.
      2. Paracetamol 125mg suppositories.
      3. Paracetamol 250mg suppositories.
   2. Please refer to the SPS for advice on prescribing.
2. Paracetamol should be used as a first line analgesic unless contra-indicated
3. Paracetamol suppositories are very expensive and other forms should be substituted as soon as possible
4. Concomitant use of paracetamol (4g/day for at least 4 days) with oral anticoagulants may lead to slight variations of INR values. Monitor INR more frequently during concomitant use and for one week after paracetamol has been discontinued

Nefopam

The routine commissioning of nefopam is not accepted in Devon for the management of chronic pain (see Commissioning Policy for more information).

Compound analgesics

There may be advantages to prescribing an opioid and non-opioid separately; consideration should be given to the increased tablet burden on an individual patient basis. Prescribing medication separately gives flexibility in both the adjustment of the doses and in the selection of the most appropriate combination.

Co-codamol

(combination of codeine and paracetamol)

• Tablets 30mg/500mg (£3.83 = 100 tablets)
• Capsules 30mg/500mg (£3.78 = 100 capsules)

Indications

• Moderate pain

Dose

• 1–2 tablets every 4–6 hours when necessary; maximum 8 tablets daily

Notes

1. Co-codamol 30mg/500mg is an option for patients taking regular high dose paracetamol and codeine
2. Use co-codamol with caution in opiate naïve patients
3. No additional pain relief is obtained from use of the fixed-dose combination product compared to the ingredients used separately
4. Preparations containing 8mg codeine phosphate may not provide significant additional relief of pain but is enough to cause opioid side effects
5. The capacity to metabolise codeine to morphine can vary considerably between individuals; there is a marked increase in morphine toxicity in patients who are ultra-rapid codeine metabolisers, and a reduced therapeutic effect in poor codeine metabolisers. Prescribers should counsel patients on the symptoms of opioid toxicity prior to prescribing codeine and review patients shortly after initiating treatment. If no beneficial analgesic effect, treatment should be discontinued and alternative options discussed with the patient.

Co-proxamol

Following national guidance from NHS England, co-proxamol is not recommended for use due to significant safety concerns. Click here for more information. Prescribers should not initiate co-proxamol for any new patient. Click the following link for a patient information leaflet to support deprescribing.

Paracetamol and tramadol combination products (e.g. Tramacet)

Following national guidance from NHS England, these products are not recommended for use due to significant extra costs and no evidence of increased efficacy or safety over the individual products. Click here for more information. Prescribers should not initiate paracetamol and tramadol combination products for any new patient. Click the following link for a patient information leaflet to support deprescribing.