Synopsis
Match analgesic treatment to the pain mechanism and clinical context, use practical adult regimens and review function, toxicity and continued need before escalation.
- Identify acute tissue injury, neuropathic pain, chronic primary pain or a mixture before choosing a drug strategy.
- Assess the cause and serious warning features while relieving pain; an analgesic response does not exclude dangerous pathology.
- Paracetamol in a suitable adult can be given orally 500 mg to 1 g every 4–6 hours, maximum four doses and 4 g in 24 hours, with individual reduction for risk factors.
Key red flags
Suspected excess paracetamol requires urgent assessment even when the person feels well; establish all products, doses and times and obtain toxicology advice.
Investigation priorities
Determine mechanism, severity and the outcome treatment should improve.
Management branches
A 56-year-old has painful diabetic neuropathy with burning feet, reduced distal sensation and disrupted sleep. There is no acute foot lesion, significant cardiac disease, urinary retention, glaucoma concern or interacting antidepressant; kidney function is stable.
- Confirm the neuropathic pattern and assess the feet for a separate cause of pain, ulceration or infection. Agree that better sleep and ability to walk to the local shop are the initial outcomes; do not promise complete pain abolition.
- Discuss NICE’s initial options for neuropathic pain and select according to comorbidity, likely adverse effects and preference. If amitriptyline is chosen, use a low oral evening starting dose and a planned titration, as detailed in the medicine entry.
Key medicines
Paracetamol for short-term adult pain500 mg to 1 g orally every 4–6 hours when required, maximum four doses and 4 g in 24 hours; use a short agreed course and reassess if pain persists.Include every paracetamol-containing product in the total. Low body weight, malnutrition, dehydration and hepatic or renal disease require an individual dose-limit assessment.
Ibuprofen for suitable acute inflammatory pain200–400 mg orally up to three times daily when required, at least 4 hours between doses and maximum 1,200 mg in 24 hours for this selected short-term regimen; seek review if worsening or required beyond 10 days.Avoid significant renal disease, active or recurrent ulcer/bleeding, severe heart failure or previous NSAID hypersensitivity. Avoid routine use in pregnancy, particularly from 20 weeks; it is contraindicated in the third trimester. Check anticoagulants and other NSAIDs.