Treatment Plan

Treatment Plan

Under 16 years:

• First line: paracetamol or ibuprofen only
• Avoid combination drugs
• Avoid aspirin and codeine
• If not controlled: specialist referral required

Over 16 years (WHO pain ladder):

• First line: paracetamol
• Second line: add/switch to ibuprofen or codeine
• Can combine paracetamol with ibuprofen (can be replaced by alternative NSAID’s) or codeine

Specific medications:

Paracetamol:

• Safe in pregnancy and breastfeeding
• Avoid effervescent form in hypertension, heart failure and renal failure Rare effects: thrombocytopenia, allergic cystitis, arrhythmias •     Paracetamol overdose manifestations:
  • First 24 hours: nausea, vomiting, pallor, abdominal pain o 24-48 hours: hepatic dysfunction, hepatic pain
  • Severe cases: encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, acute renal failure with acute tubular necrosis, loin pain, haematuria, proteinuria
• Risk factors for paracetamol OD & hepatotoxicity that may suggest caution/reduced dose:

o  Chronic alcohol consumption
o  Malnutrition
o  Dehydration
o  BMI/body weight < 50
o  Severe liver disease
o  Increased frailty
o  Use of enzyme-inducing drugs

Weak Opioids:

Codeine contraindications:

• Under 12 years
• Liver disease
• Paralytic ileus
• Acute diarrhoeal conditions
• Breathing problems

Tramadol considerations:

• Schedule 3 controlled drug
• Contraindicated: acute respiratory depression, increased intracranial pressure, head injuries, COPD exacerbation, uncontrolled epilepsy
• Reduced doses: hypothyroidism, moderate-severe CKD, elderly, adrenocortical deficiency
• Avoid MAOIs (2-week washout period)
• Increased serotonin syndrome risk with antidepressants
• Increased convulsion risk with antipsychotics, SSRIs, and SNRIs

Aspirin contraindications:

• Peptic ulcers
• hepatic impairment
• Haemophilia + other bleeding disorders
• Asthma with nasal polyps
• Under 16 years (Reye Syndrome)
• Third-trimester pregnancy
• Breastfeeding
• CKD 4