Musculoskeletal pain

Prescribing Notes:

For older patients and other patients at high risk of gastro-intestinal adverse events:

• Prescribe a NSAID (as shown in this pathway) + omeprazole or lansoprazole (see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary).

Additional prescribing notes:

• Patients that require NSAIDs should be prescribed them at the lowest effective dose and long term use should be avoided if possible.
• Diclofenac is contraindicated in those with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease or established heart failure. The arterial thrombosis risk with diclofenac is similar to that of the COX-2 inhibitors.
• Low dose ibuprofen is considered to have the most favourable thrombotic cardiovascular safety profile.
• For patients with cardiovascular and cerebrovascular disease, current evidence suggests that the risk of heart failure is increased with all NSAIDs. The risk of myocardial infarction is also increased with most NSAIDs, with the possible exception of naproxen. The risk of stroke is increased with most NSAIDs with the possible exception of low dose (<200mg daily) celecoxib.
• Contra-indications to NSAIDs include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. They should be used with caution in patients with mild-moderate heart failure, renal impairment and history of peptic ulceration.
• NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
• Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
• Patients at high risk of gastrointestinal (GI) adverse effects should be prescribed NSAID + PPI, see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary. Risk factors for GI adverse effects include previous peptic ulcer, previous GI bleed, alcohol excess, systemic corticosteroids, anticoagulants, SSRIs, age>65 years, high dose NSAIDs.
• Intramuscular or intravenous diclofenac must only be used for up to 2 days due to the risk of tissue necrosis: if necessary, treatment can be continued with tablets or suppositories.
• For non-inflammatory conditions simple analgesics e.g. paracetamol or the opioid analgesics should be considered instead of NSAIDs.
• During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
• Modified release preparations should not be prescribed as initial treatment but may be of benefit in patients with inflammatory arthritis who remain symptomatic on standard preparations e.g. the treatment of night-time pain or early morning stiffness.
• The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.

Prescribing Notes:

For children at high risk of gastro-intestinal adverse events:

• First choice would be to avoid an NSAID. Second choice, prescribe an NSAID + omeprazole.
• Children at ‘high risk’ of developing serious gastro-intestinal adverse events include:
  • Children with previous peptic ulcer
  • Children with previous GI bleed
  • Children receiving systemic corticosteroids
  • Children receiving anticoagulants
  • Children requiring very high dose NSAIDs [greater than 120% average daily dose]
• Consider whether an NSAID is required; regular dosing of paracetamol is often adequate for pain.
• All long-term use of NSAIDs in children should be under the guidance of a specialist.
• Relative contra-indications to NSAIDs include heart failure, hypertension, renal impairment, history of gastro-intestinal bleeding, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin or any NSAID.
• NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma, although this rarely occurs in children.
• Naproxen is an alternative NSAID which combines good efficacy with a low incidence of side-effects.
• Naproxen is associated with a 10% risk of blistering skin rash in blonde, blue eyed, non-tanning children.
• Diclofenac e/c tablets are only suitable for children who are able to swallow tablets whole. Naproxen oral suspension may be a suitable alternative preparation for patients who cannot swallow tablets. For those patients in whom naproxen is not a suitable choice the rheumatology team will advise.
• If other therapy is successful in controlling arthritis, then consider withdrawing NSAIDs especially in children receiving conventional DMARDs and drugs affecting the immune system (see DMARD and biologics pathways).

Prescribing Notes:

• The area should be elevated if possible to remove fluid from area of injury.
• For sprains and strains, cold packs should be applied to reduce swelling and bruising for the first 72 hours. After this heat therapy should be applied to improve healing.
• Ibuprofen gel should only be used for the short term acute treatment of sprains and strains.
• Ibuprofen gel should not be used in chronic inflammation or if patient on oral NSAIDs.
• The combination of a NSAID and low dose aspirin may increase the risk of gastro-intestinal side effects and should be avoided if possible.
• Rest is essential to allow the injury to recover.
• Avoid NSAIDs including ibuprofen in patients with chickenpox or shingles.
• Paracetamol soluble tablets are available for patients who cannot swallow standard tablets. Ensure salt intake is considered when using soluble preparation.

Examples of Counselling Points
NSAIDs must be taken with or after food.

When to advise patient to contact GP
Suspected fracture.
Possible adverse reaction – falls, bruising.
Head injury.
Medication failure.
Arthritis.
Severe back pain.
Back pain (and/or pins and needles/numbness) radiating to leg.