Drug

Starting Dose*

Usual Effective Dose

(Maximum Dose)

Titration

Comments

NONOPIOIDS

Acetaminophen

(Tylenol)

325 mg q 4 h–

500 mg q 6 h

2–4 g/24 h

(4 g/24 h)

after 4–6 doses

Reduce maximum dose 50%–75% in patients with hepatic insufficiency, history of alcohol abuse

Anticonvulsants

Carbamazepine^OL

(Tegretol)

100 mg qd

800–1200 mg/24 h

(2400 mg/day)

after 3–5 days

Monitor liver enzymes, CBC, BUN/Creat., electrolytes

Approved only for trigeminal neuralgia and glossopharyngeal neuralgia; not approved for any other types of pain

Clonazepam^OL

(Klonopin)

0.25–0.5 mg hs

0.05–0.2 mg/kg/day

(20 mg)

after 3–5 days

Monitor sedation, memory, CBC

Gabapentin^OL

(Neurontin)

100 mg hs

300–900 mg tid     

(3600 mg)

after 1–2 days

Monitor sedation, ataxia, edema

Approved for post-herpetic neuralgia; not approved for any other types of pain

Pregabalin (Lyrica)

25 mg tid

100 mg tid

(200 mg tid)

may not be necessary; precise recommendations pending

Approved by FDA December 2004, made available September 2005; designated Schedule C-V.

Dizziness and somnolence are the most troubling adverse effects

Use caution when CrCl < 30

Baclofen^OL

(Lioresal)

5 mg

5–20 mg bid–tid

(200 mg)

after 3–5 days

Monitor muscle weakness, urinary function; avoid abrupt discontinuation because of CNS irritability

Choline magnesium trisalicylate

(Tricosal, Trilisate)

500–750 mg q 8 h

2000–3000 mg/24 h

(same)

after 4–6 doses

Long half-life may allow qd or bid dosing after steady state is reached

In frail patients or those with diminished hepatic or renal function, it may be important to check salicylate levels during dose titration and after steady state is reached

Corticosteroids (prednisone)

(eg, Deltasone, Liquid Pred, Orasone)

5.0 mg qd

variable

(NA)

after 2–3 doses

Use lowest possible dose to prevent chronic steroid effects; anticipate fluid retention and glycemic effects

Mexiletine^OL

(Mexitil)

150 mg

150 mg tid–qid

(variable)

after 3–5 days

Avoid use in patients with conduction block, bradyarrhythmia; monitor ECG

Salsalate

(eg, Disalcid, Mono-Gesic, Salflex)

500–750 mg q 12 h

1500–3000 mg/24 h

(3000 mg/24h)

after 4–6 doses

In frail patients or those with diminished hepatic or renal function, it may be important to check salicylate levels during dose titration and after steady state is reached

Tricyclic antidepressants:**

desipramine^OL (Norpramin), nortriptyline^OL (Aventyl, Pamelor)

10 mg hs

25–100 mg hs

(variable)

after 3–5 days

Significant risk of adverse effects in older patients; anticholinergic effects

OPIOIDS

Hydrocodone

(eg, Lorcet, Lortab,Vicodin, Vicoprofen)

5 mg q 4–6 h

5–10 mg

(see comments)

after 3–4 doses

Useful for acute recurrent, episodic, or breakthrough pain; daily dose limited by fixed-dose combinations with acetaminophen or NSAIDs

Hydromorphone

(Dilaudid, Hydrostat)

2 mg q 3–4 h

variable

(variable)

after 3–4 doses

For breakthrough pain or for around-the-clock dosing

Morphine, immediate release

(eg, MSIR, Roxanol)

2.5–10 mg q 4 h

variable

(variable)

after 1–2 doses

Oral liquid concentrate recommended for breakthrough pain

Morphine, sustained release

(eg, MSContin, Kadian)

15 mg q 12 h

variable

(variable)

after 3–5 days

Usually started after initial dose determined by effects of immediate-release opioid; toxic metabolites of morphine may limit usefulness in patients with renal insufficiency or when high-dose therapy is required; continuous-release formulations may require more frequent dosing if end-of-dose failure occurs regularly

Oxycodone, immediate release

(OxyIR)

5 mg q 4–6 h

5–10 mg

(see comments)

after 3–4 doses

Useful for acute recurrent, episodic, or breakthrough pain; daily dose limited by fixed-dose combinations with acetaminophen or NSAIDs

Oxycodone, sustained release

(OxyContin)

10 mg q 12 h

variable

(variable)

after 3–5 days

Usually started after initial dose determined by effects of immediate-release opioid

Tramadol

(Ultram)     

25 mg q 4–6 h

50–100 mg

(300 mg/24 h)

after 4–6 doses

Mixed opioid and central neurotransmitter mechanism of action; monitor for opioid side effects, including drowsiness and nausea. Exert caution when used with another serotonergic drug, and observe for symptoms of serotonergic syndrome. Lowers seizure threshold.

Transdermal fentanyl

(Duragesic)

25 μg/h patch q 72 h

variable

(variable)

after 2–3 patch changes

Usually started after initial dose determined by effects of immediate-release opioid; currently available lowest dose patch (25 μg/h) recommended for patients who require 60 mg per 24-h oral morphine equivalents; peak effect of first dose takes 18–24 h. Duration of effect is usually 3 days, but may range from 48 h to 96 h