Introduction This slide set is intended for use by qualified clinical staff e.g. Nurse Advisors and Dental Nurse Advisors It provides basic information.

Introduction This slide set is intended for use by qualified clinical staff e.g. Nurse Advisors and Dental Nurse Advisors It provides basic information on: The use of analgesics in managing pain The dangers of deliberate or accidental overdose with common, simple analgesics Guidance on restarting analgesics after accidental overdose Further information can be found in the BNF and NHS Evidence Dental Pain Guidance UKMi October 2015

Learning outcomes Outline the key features of paracetamol, ibuprofen and other simple analgesics Understand how and why overdoses of analgesics occur Know when to refer calls about paracetamol and ibuprofen Be able to give appropriate restarting guidance Dental Pain Guidance UKMi October 2015

Why worry about overdoses?
Very common Harm to the patient Self harm / psychological issues Medicines readily available Patient misconceptions of safety Risk factors Dental pain Overdoses may be taken on purpose or accidentally, but are a common occurrence. Prolonged or large overdoses can cause many types of harm to the patient, depending on patient factors and the drug that has been taken. There can be many reasons for overdoses. If it is suspected that self harm is involved, the patient will require referral. Paracetamol and ibuprofen are readily available over the counter and GSL. Pack size reductions in paracetamol have reduced the number of overdoses caused by this agent. However it may appear in different formulations such as cold remedies etc. Because paracetamol and ibuprofen are so readily available and widely used, there may be a public perception that they are unlikely to cause harm if a couple of extra doses are taken or the maximum dose on the pack is disregarded. Patients may have risk factors that they may not consider when taking medicines. If they have persistent pain, they may be more likely to take doses more frequently than is directed. Dental Pain Guidance UKMi October 2015

Supratherapeutic overdoses
Taking more than the recommended maximum dose for therapeutic purposes Examples: Taking ibuprofen every 3 hours instead of every 6-8 hours as pain isn’t controlled Taking paracetamol along with co-codamol tablets for extra pain relief, without realising both contain paracetamol Taking 3 paracetamol tablets per dose instead of 2 tablets Dental Pain Guidance UKMi October 2015

Single dose overdoses ‘Classic’ overdose scenario Possible self-harm
Impulses may last 30 mins, then regret and seek help Alcohol related Peak age range years; Women > Men Refer these calls – large single doses are unlikely to be an accidental overdose Dental pain – more likely to be staggered overdoses over a period of time Women are often more involved than men in self harm scenarios, but the gap is closing. Generally, men are more successful at committing suicide than women. In dental pain scenarios, you will be more likely to be dealing with staggered overdoses over a period of time. People taking large single doses should be referred as this is unlikely to be an accidental overdose. Dental Pain Guidance UKMi October 2015

WHO Analgesic ladder for acute & chronic pain
Severe Pain Step 3 Strong opioids Morphine Tramadol Oxycodone If pain persists Moderate Pain Step 2 Weaker opioids Codeine Dihydrocodeine Co-codamol Co-dydramol Mild Pain Step 1 Simple painkillers Paracetamol NSAID (e.g.Ibuprofen) We will be focusing on analgesics in step 1 and 2 of the ladder. As pain persists move up to the next rung of the ladder. Dental Pain Guidance UKMi October 2015

First line treatment of pain
First choice Single painkiller at full dose Options if paracetamol alone or ibuprofen alone do not control symptoms For adults - consider an analgesic higher up the pain control ladder e.g. co- codamol Take regular paracetamol, if get breakthrough pain towards end of dose interval - take single dose of ibuprofen (or other way around) Risks if advise regular alternate doses of paracetamol and ibuprofen Confuse / forget what has been taken Delay diagnosis of a more serious condition Step 1: Simple painkiller Paracetamol Ibuprofen Step 2: Weak opioid Codeine Dihydrocodeine Co-codamol Co-dydramol Step 3: Strong opioid Morphine Tramadol Oxycodone

Paracetamol Uses Relieves mild to moderate pain Reduces fever
Licensed for use in children from 2 months by mouth Side effects Not usually a problem at recommended dose Dangerous in overdose Patients ingesting 75mg/kg/24hr or more should be referred to hospital Potentially fatal liver damage Kidney damage (less often) Dose Maximum adult dose 8 x 500mg tablets in 24 hours Cautions Patients with liver problems Patients with kidney problems Drug interactions Does not interact with many medicines Must not be taken with other paracetamol containing medicines due to overdose risk Dental Pain Guidance UKMi October 2015

Dangers of paracetamol in overdose
Very safe if used appropriately, but…. Highly toxic in overdose Supra-therapeutic doses may be as toxic as a one-off single overdose Be aware of hidden sources e.g. cold remedies, combination- medicines The more serious effects can be delayed Abdominal pain hours Delayed hepatotoxicity 2-3 days before liver function declines Antidote must be given as soon as possible to be effective Paracetamol has very few side effects if used as directed, and is generally very safe in use. However, in overdose it can be highly toxic. Evidence is emerging that supratherapeutic overdoses can be just as toxic as one off single doses. Hidden sources of paracetamol may be in cold remedies e.g. Sudafed combinations, Lemsip drinks etc, or co-medicines e.g. co-codamol, co-dydramol. A patient may not realise that a product has paracetamol in. A problem with overdoses with paracetamol is that the more serious effects can be delayed - so if an overdose is taken the patient may not feel very unwell (perhaps a little nausea and/or vomiting), yet develop serious features such as abdominal pain (12-36 hours) or signs of liver and renal failure after 2 to 3 days. There is an effective antidote to paracetamol overdose- N-acetylcysteine. However, this works better if it is given sooner rather than later so time is of the essence when dealing with these calls. Dental Pain Guidance UKMi October 2015

Combination analgesics
Many painkillers contain more than one drug and are known as combination, compound or co-analgesics Codeine and dihydrocodeine are stronger than paracetamol or ibuprofen and are known as opioid analgesics Co-analgesics available OTC can be used for short-term pain not relieved by paracetamol or ibuprofen Do not use for more than 3 days unless advised by doctor. Co-codamol Codeine & paracetamol Paracodol® Panadol Ultra® Solpadeine® Co-dydramol Dihydrocodeine & paracetamol Paramol®

Brand names Many Over-the-Counter (OTC) medicines have the same brand name attached to different products Similar sounding and looking products have different ingredients so it is important to obtain the exact name e.g. Lemsip Max Flu Lemon contains paracetamol Lemsip Max Flu 12 hour capsules contain ibuprofen Although both these products are called Lemsip Max, they contain completely different analgesics Dental Pain Guidance UKMi October 2015

Ibuprofen Uses Cautions (take only on advice)
Relieves mild to moderate pain Reduces fever Reduces inflammation Licensed for children from 3 months if 5kg or more Side effects Heartburn / indigestion Stomach ulcers Bleeding Contra-indications (must not take) Allergic to aspirin Previous peptic ulcer / bleed Taking another NSAID Severe heart failure Cautions (take only on advice) Asthma Kidney or liver problems High blood pressure Drug interactions Interacts with a number of other medicines Check the patient information leaflet for advice about other medicines Allergy Rash Wheezing / breathlessness Recommended dose without a prescription is 200mg to 400mg up to three times a day; maximum total daily dose of 1200mg in 24 hours. A prescribed dose can be higher than this. Dental Pain Guidance UKMi October 2015

Ibuprofen overdose Although it has a number of side effects with therapeutic use it has quite low toxicity in overdose Most patients develop no more than: Nausea, vomiting, epigastric pain or more rarely diarrhoea Tinnitus, headache, GI bleeding also possible Acute kidney damage - most serious complication (large doses) CNS toxicity in serious overdose Most patients who have ingested clinically important amounts of NSAIDS will develop no more than nausea, vomiting, epigastric pain, or more rarely diarrhoea. Tinnitus, headache and gastrointestinal bleeding are also possible. Acute kidney injury is the most frequent serious complication but is usually seen only after large doses and/or in patients with co-morbidity. In more serious poisoning, toxicity is seen in the central nervous system, manifesting as drowsiness, occasionally excitation and disorientation or coma. Occasionally patients develop convulsions. Metabolic problems in serious poisoning may include acidosis and an increase in INR, probably due to interference with the actions of clotting factors in the circulation. Liver damage is possible, but is not to be expected without other features of significant poisoning. Dental Pain Guidance UKMi October 2015

Ibuprofen – different salts
Ibuprofen products are most commonly available as “plain” ibuprofen Ibuprofen is also available in other forms in some products The following few slides describe non-standard ibuprofen products and their equivalencies Dental Pain Guidance UKMi October 2015

Ibuprofen Lysine 342 mg equivalent to 200 mg ibuprofen 684 mg equivalent to 400 mg ibuprofen Nurofen brand Nurofen Express 342mg Nurofen Express 684mg Nurofen Migraine Pain / Tension Headache 342mg Nurofen Maximum Strength Migraine Pain 684mg Plus others Paramed Migraine Relief 342mg Superdrug Migraine Relief 342mg Sainsbury's Migraine Relief 342mg Boots Rapid Ibuprofen Lysine 342 mg Morrisons Migraine Relief 342mg Tesco Migraine Relief 342mg Tesco Express Pain Relief 342 mg Asda Migraine Relief 342mg Feminax Express 342 mg Toxbase toxicity info as per ibuprofen 200mg and 400mg. Dental Pain Guidance UKMi October 2015

Ibuprofen Sodium 256 mg equivalent to 200 mg ibuprofen 512 mg equivalent to 400 mg ibuprofen Nurofen brand Nurofen Express 256mg Dental Pain Guidance UKMi October 2015

Nurofen Back Pain 300mg SR Capsules®
Ibuprofen 300mg Sustained Release Adults and children over 12 years: 1 capsule twice a day. Maximum 4 capsules in 24 hours Children under 12 years: Not to be given Do not take more frequently than every 8 hours Not to be chewed or sucked Not the usual strength or release pattern of ibuprofen  Refer for further guidance if necessary Dental Pain Guidance UKMi October 2015

Nuromol® Ibuprofen 200mg with Paracetamol 500mg
Adults over 18 years: 1-2 tablets up to three times a day. Maximum 6 tablets in any 24 hour period Under 18 years: Not to be taken Leave at least 6 hours between doses No matter how many tablets are taken, the paracetamol will cause toxicity before the ibuprofen Calculate total amount of paracetamol taken Maximum 6 tablets in any 24 hour period: 6 x 200mg is the same maximum OTC dose as for simple ibuprofen 200mg tablets. The maximum OTC paracetamol dose is 8 x 500mg. Dental Pain Guidance UKMi October 2015

ASPIRIN (incl. low dose) AZAPROPAZONE
Table 1: List of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) ACECLOFENAC ACEMETACIN ASPIRIN (incl. low dose) AZAPROPAZONE CELECOXIB DEXIBUPROFEN DEXKETOPROFEN DICLOFENAC ETODOLAC ETORICOXIB FENBUFEN FENOPROFEN FLURBIPROFEN IBUPROFEN INDOMETACIN KETOPROFEN KETORALAC MEFENAMIC ACID MELOXICAM NABUMETONE NAPROXEN PARECOXIB PIROXICAM PHENYLBUTAZONE SALICYLATE SALICYLIC ACID SULINDAC TENOXICAM TIAPROFENIC ACID IMPORTANT NOTE: the patient may also be taking other NSAIDS prescribed by their GP and so adding in ibuprofen would not be recommended. Dental Pain Guidance UKMi October 2015 19

Ibuprofen Tell the caller:
The recommended OTC dose of ibuprofen is 1 x 400mg or 2 x 200mg every 6-8 hours but no more than 3 x 400mg or 6 x 200mg (1200mg) in 24 hours Be aware of hidden sources of ibuprofen (e.g. in cold remedies, muscle creams) Do not take any other anti-inflammatory medicines (NSAIDs) (except in oral gels) when taking ibuprofen (see list of NSAIDs in Table 1) You can restart ibuprofen provided you do not take more than 1200mg (3 x 400mg or 6 x 200mg) ibuprofen in any 24 hour period Dental Pain Guidance UKMi October 2015

Codeine An overdose of tablets containing codeine:
Co-codamol 30/500 Co-codamol 8/500 May cause drowsiness, constipation, GI upset Severe - respiratory depression Calls involving too much of the 8/500 co-codamol ie. 8mg codeine and 500mg paracetamol combined, would mean the patient would reach paracetamol toxicity before the codeine level would be a cause for concern (other than predictable side effects such as constipation). However, the 30/500mg combination (or any combination with more than 8mg codeine to 500mg paracetamol) would mean that the patient may experience codeine toxicity in addition to paracetamol toxicity so those calls need to be referred for further guidance. Dental Pain Guidance UKMi October 2015

Co-analgesics Co-Codamol = Codeine & Paracetamol
Amount of codeine in co-codamol can be 8mg, 15mg or 30mg. Co-codamol 8/500 OTC Codeine 8mg & paracetamol 500mg Brands: e.g. Feminax®, Migraleve Yellow®, Panadol Ultra®, Paracodol®, Panadeine® Co-codamol 15/500 POM Codeine 15mg & paracetamol 500mg Brands: e.g. Codipar® Co-codamol 30/500 Codeine 30mg & paracetamol 500mg Brands: e.g. Kapake®, Tylex®, Solpadol® Dental Pain Guidance UKMi October 2015

Co-Dydramol = Dihydrocodeine & Paracetamol
Amount of dihydrocodeine can be 7.46mg, 10mg, 20mg, 30mg. Co-dydramol OTC Paracetamol 500mg, dihydrocodeine 7.46mg Paramol® POM Paracetamol 500mg + dihydrocodeine 10mg If no strength specified on the prescription. Co-dydramol POM Paracetamol 500mg + dihydrocodeine 20mg Remedeine® Paracetamol 500mg + dihydrocodeine 30mg Remedeine Forte® Dental Pain Guidance UKMi October 2015

Co-Codamol / Co-dydramol
Uses Mild to moderate pain Lowers fever (paracetamol alone is first choice) Side effects Codeine / Dihydrocodeine  collapse, drowsiness, confusion, constipation Paracetamol overdose 150 mg/kg/24hr or if risk factors, 75mg/kg/24hr Cautions Kidney or liver problems Limit use to 3 days unless advised by doctor Drug interactions Other paracetamol and / or opiate containing medicines Antidepressants Anti-anxiety medicines / sleeping tablets Check the patient information leaflet for advice about other medicines Dental Pain Guidance UKMi October 2015

Guidance for restarting paracetamol following inadvertent overdose
This is designed to help you deal with patients who have taken more than the recommended amount of paracetamol but less than a toxic amount requiring referral Commonly, these patients will want to know when they can take their next dose of paracetamol. However we need to ensure not to restart too soon which would put them back into an overdose situation again Advise the patient that they may restart such that they take no more than the maximum recommended amount in any 24 hour period. i.e. 8 x 500mg (4000mg) paracetamol in 24 hrs The easiest way to do this is to use a timeline and mark the 24 hour period. It is important to check exactly how much has been taken and at what times Dental Pain Guidance UKMi October 2015

Restarting guidance case study
46 years old Symptoms of toothache No medical health issues, no other medicines, no allergies Has taken Paracetamol 500mg tablets Friday : 08: tablets 12: tablets 18: tablets 21: tablets 23: tablets Saturday: 07: tablets When can she take her next dose? “ I have an impacted wisdom tooth and it’s really hurting me. I know I’ve taken some extra doses of my painkillers today – will I be ok?” Rings at 8:00 am on Sat morning. Has been avoiding seeing the dentist. Flare up for the last 2 days. Weight 13 stone Dental Pain Guidance UKMi October 2015

Restarting guidance Step 1: Draw a timeline
Step 2: Fill in the doses the patient has taken Step 3: Find how many tablets the patient has taken in the last 24 hours Step 4: At 8am when the caller rings, they have had 12 paracetamol tablets in the last 24 hours. Now you can “shift“ the 24 hour period along, until they are under the recommended amount in 24 hours (the amount on the pack, which is 8 x 500mg tablets in 24 hours) Step 5: Work out how many paracetamol tablets the patient can still have in this 24 hour period. Restart so that there is the recommended dose interval (4 hrs for paracetamol) since the last dose was taken Dental Pain Guidance UKMi October 2015

At 8:00 - 12 tablets have been taken in the preceding 24 hours
Restarting guidance Day 1 Day 2 Step 1: Draw a timeline Step 2: Fill in the doses the patient has taken Step 3: Find how many tablets the patient has taken in the last 24 hours Step 4: At 8am when the caller rings, they have had 12 paracetamol tablets in the last 24 hours. Now you can “shift“ the 24 hour period along , until they are under the recommended amount in 24 hours (the amount on the pack, which is 8 x 500mg tablets in 24 hours) Step 5: Work out how many paracetamol tablets the patient can still have in this 24 hour period. 08:00 Phones Service At 8: tablets have been taken in the preceding 24 hours

Restarting guidance Day 1 Day 2 08:00 Phones Service At 12: tablets have been taken in the preceding 24 hours

Restarting guidance Day 1 Day 2 08:00 Phones Service At 16: tablets have been taken in the preceding 24 hours

Restarting guidance Day 1 Day 2 Since 18:30 on the patient had only had 6 paracetamol tablets in this 24 hour period, so she will be able to continue with another 2 tablets, providing she takes no more than the recommended amount from then on e.g. take at about 11:00pm. 08:00 Phones Service At 18: tablets have been taken in the preceding 24 hours The patient can restart paracetamol by taking another two tablets at 18:30 hours

Introduction This slide set is intended for use by qualified clinical staff e.g. Nurse Advisors and Dental Nurse Advisors It provides basic information.

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Introduction This slide set is intended for use by qualified clinical staff e.g. Nurse Advisors and Dental Nurse Advisors It provides basic information.

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Presentation on theme: "Introduction This slide set is intended for use by qualified clinical staff e.g. Nurse Advisors and Dental Nurse Advisors It provides basic information."— Presentation transcript:

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