ANALGESICS


offer an alternative should first-line treatment fail. Migraleve is a short term (up to three days) treatment for nausea and headache associated with a migraine attack when this is not relieved by paracetamol, ibuprofen or aspirin. This product contains codeine, paracetamol and an anti- sickness medicine called buclizine.7 Sumatriptan is a 5HT1


agonist that


is licensed for the acute relief of migraine attacks where there is a clear diagnosis of migraine. The supply of sumatriptan is associated with various product license restrictions and the pharmacist should satisfy that these are fulfilled before selling.


DENTAL PAIN


Analgesics should be used prudently in dental care as a temporary measure until the cause of the pain has been dealt with. Most dental pain is relieved effectively by NSAIDs such as ibuprofen. Paracetamol has analgesic and antipyretic effects but no anti-inflammatory action. Combination analgesic preparations containing ibuprofen or paracetamol with codeine have not been shown to provide greater relief of pain than an adequate dose of ibuprofen or paracetamol given alone.9


PERIOD PAIN


Period pain is a normal part of the menstrual cycle usually felt as painful muscle cramps in the abdomen, which can spread to the back and thighs. The pain normally lasts 48 to 72 hours, although it can last longer. Studies


have shown that NSAIDs, when given orally, are effective in 80-85 per cent of women. A Cochrane review concluded NSAIDs were significantly more effective in relieving moderate to severe period pain compared to placebo, but there was little evidence of superiority of any individual NSAID. Current OTC NSAIDs for the treatment of period pain include ibuprofen and naproxen. The latter is licensed to relieve period pain in women aged between fifteen and 50 years (Feminax Ultra).


SPRAINS AND STRAINS Sprains are caused by forcing a joint into an abnormal position that overstretches or twists ligaments. Strains involve the partial or complete tearing of muscle fibres. Although varied in presentation, OTC treatment for sprains and strains tend to be the same. In addition to advising rest, icing, compression and elevation of the affected area, OTC analgesia can be recommended.5


Paracetamol


should be offered first line, with oral NSAIDs (ibuprofen) only considered 48 hours after the initial injury as inflammation is a necessary part of the healing process.10


A recent Cochrane


review found no significant difference between NSAIDs and paracetamol in people with sprains and strains for pain relief, swelling or return to function at seven days or over. However, there was some evidence that those treated with NSAIDs had slightly more side-effects related to the stomach or intestines.11


Topical NSAIDs


offer an alternative to oral analgesics with minimal adverse systemic side effects. There is strong evidence to support the use of topical diclofenac and topical ibuprofen gel in the treatment of acute soft tissue injuries like strains and sprains.12


BACK PAIN


Acute low back pain (acute LBP) is most often caused by a sudden injury to the muscles and ligaments supporting the back, resulting in muscle spasms or a strain or tear in the muscles and ligaments.5


and the joint swells. In addition to non-pharmacological treatments such as exercise, paracetamol or NSAID (ibuprofen) tablets can be recommended in the management of pain in patients with hip or knee OA.15 Topical therapies, namely diclofenac or ibuprofen gel, are also a first-line treatment for osteoarthritis, with strong evidence supporting their use, particularly for those who find the gastrointestinal side effects of oral NSAIDs intolerable.11,15


Topical NSAID Although


often prescribed by doctors, recent studies have called the effectiveness of paracetamol into question for relieving acute LBP. Studies found that paracetamol does not produce better outcomes compared to placebo for people with acute LBP (it is uncertain if it has any effect on chronic LBP).13 Cochrane reviews suggest oral NSAIDs are effective for short-term symptomatic relief in patients with acute LBP without sciatica. A seven- day course of ibuprofen tablets can be recommended unless patient is contra-indicated from using NSAIDs.14 There is less robust evidence to support of use of topical NSAIDs such as ibuprofen and diclofenac gels in treating this condition.


OSTEOARTHITIS


Osteoarthitis (OA) is a painful, degenerative joint disease that often affects the hips, knees, neck, lower back, or small joints of the hands. Joint flexibility is reduced


Table 1: Common OTC oral and topical analgesics dosage and advice information9 Analgesic Name Paracetamol tablets


Ibuprofen tablets Aspirin tablets


Standard OTC Adult Dosage


500mg - 1000mg every four to six hours (max 4g in 24 hours)


200mg - 400mg three times daily


300mg - 900 mg every four to six hours (max 4g in 24 hours)


Naproxen tablets 250mg three times daily OTC Advise


Do not take any other products containing paracetamol


Take with or just after food Take with or just after food


Do not take any other products containing aspirin


Take with or just after food


Do not take for more than three days at a time


Codeine and Paracetamol tablets


(Co-codamol)


Two 8mg + 500mg tablets every four to six hours (max eight tablets in 24 hours)


Do not take any other products containing paracetamol


Do not take for more than three days at a time


This medicine can cause addiction Ibuprofen gel Diclofenac gel


5% - 10% gel applied three times daily Do not use for longer than seven days at a time unless recommended by a doctor


1.16% gel applied three times daily OR 2.32% gel applied twice daily


18 - SCOTTISH PHARMACIST


Do not use for longer than seven days at a time unless recommended by a doctor


formulations act most effectively on more superficial sites of pain such as in osteoarthritic joints in the hands and knees. A recent Cochrane review cited that approximately 60 per cent of patients with OA using a topical NSAID preparation reported reduced pain after six to twelve weeks.16


• REFERENCES


1 – British Pain Society. Media resources. https://www.britishpainsociety.org/media- resources/ [Online]


2 – NHS Choices. Headaches. http://www. nhs.uk/conditions/Headache/Pages/ Introduction.aspx [Online] 3 – Migraine Trust. https://www. migrainetrust.org/about-migraine/ migraine-what-is-it/facts-figures/ [Online] 4 – Chronic Pain Scotland. http:// chronicpainscotland.org/patients-area/ understanding-chronic-pain/ [Online] 5 – P. Rutter. Community Pharmacy: Symptoms, Diagnosis and Treatment 6 – Cochrane Review. Caffeine as an analgesic adjuvant for acute pain in adults. http://www.cochrane.org/ CD009281/SYMPT_caffeine-as-an- analgesic-adjuvant-for-acute-pain-in- adults [Online]


7 – Migraleve. http://www.migraleve. co.uk/ [Online]


8 – NICE Clinical Knowledge Summaries. Analgesia - mild to moderate pain. https://cks.nice.org.uk/analgesia-mild-to- moderate-pain [Online]


9 – British National Formulary Issue 72 10 – NICE Clinical Knowledge Summaries. Sprains and strains. https://cks.nice.org.uk/ sprains-and-strains [Online] 11 – Cochrane Review. Oral non-steroidal anti-inflammatory drugs compared with other oral pain killers for sprains, strains and bruises. http://www.cochrane.org/ CD007789/MUSKINJ_oral-non-steroidal- anti-inflammatory-drugs-compared- other-oral-pain-killers-sprains-strains-and [Online]


12 – C. Argoff. Mayo Clinic Review. Topical analgesics in the management of acute and chronic pain. 13 – Cochrane Review. Paracetamol for low back pain. http://www.cochrane.org/ CD012230/BACK_paracetamol-low-back- pain [Online]


14 – Cochrane Review. Non-steroidal anti-inflammatory drugs for low back pain. http://www.cochrane.org/CD000396/ BACK_non-steroidal-anti-inflammatory- drugs-for-low-back-pain [Online] 15 – SIGN Guideline 136. Management of chronic pain.


16 – Cochrane Review. Can topical NSAIDS help relieve the pain of arthritis. http:// uk.cochrane.org/news/can-topical-nsaids- help-relieve-pain-arthritis [Online]


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