Non-Opioid Analgesics

Acetylsalicyclic acid [aspirin] (Ecotrin®, Bayer®)

Acetaminophen (Tylenol®)

Mefenamic acid (Ponstel®)

Fenoprofen (Nalfon®)

Diclofenac (Voltaren®, Voltaren® XR, Cataflam®, Zipsor™)

Etodolac (Lodine®)

Ibuprofen (Motrin®)

Ketoprofen (Orudis®, Oruvail®)

Naproxen (Naprosyn®)

Naproxen Sodium (Anaprax®, Anaprox® DS)

Ketorolac (Toradol®)

Celecoxib (Celebrex®)

Acetylsalicyclic Acid

(Aspirin)

Ecotrin®, Bayer®

Dose: 325-1000 mg every 4-6 hours, MAX= 4g/day

MOA: Irriversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors

AE: GI upset, erosion, and bleeding

CI: Allergy to ASA, angioedema, bronchospasms to NSAIDs, syndrome of nasal polyps

MP: Relief of pain

Acetaminophen

Tylenol®

Dose: 325-1000 mg every 4-6 hours, MAX: 4 g/day

MOA: Inhibits the synthesis of prostaglandins in the central nervous system and peripherally blocks pain impulse generation; has anti-pyretic properties

AE: Overdose is hepatotoxic at doses >10 g

CI: hypersensitivity

MP: Relief of pain

Mefenamic acid

Ponstel®

Dose: 500 mg to start, then 250 mg every 4 hours PRN, MAX= 1 g/d, Only use for 1 week

MOA: Inhibits COX-1 and COX-2 enzymes, which inhibits prostaglandin synthesis

AE: Nausea, vomiting, abdominal pain, headache, dizziness, elevated liver transaminases

CI: Hypersensitivity, 3rd trimester of pregnancy, active peptic ulcer disease, renal disease

MP: CBC, BP

Fenoprofen

Nalfon®

Dose: 200 mg every 4-6 hours, MAX= 3200 mg/day

MOA: Inhibits COX-1 and COX-2 enzymes, which inhibits prostaglandin synthesis

AE: GI disturbances, dizziness, headache, rash, edema, renal impairment, hepatotoxicity

CI: NSAID sensitivity, 3rd trimester of pregnancy

MP: Cr at baseline, CBC, BP, auditory function (if used chronically)

Diclofenac

Voltaren®, Voltaren® XR, Cataflam®, Zipsor™

Dose: Initial 100 mg, then 50 mg TID, MAX= 150 mg/day

MOA: Reversibly inhibits COX-1 and COX-2 enzymes; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: Abdominal cramps, heartburn, GI ulceration, rash

CI: NSAID/aspirin allergy

MP: CBC, liver enzymes, BUN/serum creatinine

Etodolac

Lodine®

Dose: 200-400 mg every 6-8 hours,

MAX= 1 g/day

MOA: Reversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: Nausea, vomiting, diarrhea, abdominal cramps, dizziness, headache, depression, edema, renal impairment

CI: active GI ulcer

MP: Relief of pain

Ibuprofen

Motrin®

Dose: 200-400 mg every 6-8 hours,

MAX= 3200 mg/day

MOA: Reversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: Dizziness, peptic ulcer, platelet inhibition, worsening of renal insufficiency

CI: Severe hepatic impairment, 3rd trimester of pregnancy, upper GI bleed, ulcers, allergy, use with other NSAIDs

MP: CBC, Cr (if patient has severe renal disease), BP

Ketoprofen

Orudis®, Oruvail®

Dose: 25-50 mg every 6-8 hours, 

MAX= 300 mg/d

MOA: Reversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: GI upset, peptic ulcers, dizziness, edema, rash, increased BP, increased LFTs, renal dysfunction

CI: NSAID/ASA sensitivity

MP: Cr at baseline, CBC, BP

Naproxen

Naprosyn®

Dose: Initial 500 mg, then 500 mg every 12 hours or 250 mg every 6-8 hours, MAX= 1 g/d

MOA: Reversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: Dizziness, pruritis, GI upset, peptic ulcer, edema

CI: NSAIDs or ASA sensitivity, peptic ulcer, post-coronary artery bypass graft pain, 3rd trimester of pregnancy

MP: Occult blood loss, CBC, BUN, SCr

Naproxen Sodium

Anaprox®, Anaprox® DS

Dose: 200 mg every 8-12 hours, MAX= 660 mg/d

MOA: Reversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: Dizziness, pruritis, GI upset, peptic ulcer, edema

CI: NSAIDs or ASA sensitivity, peptic ulcer, post-coronary artery bypass graft pain, 3rd trimester of pregnancy

MP: Occult blood loss, CBC, BUN, SCr

Ketorolac

Toradol®

Dose: 10 mg every 4-6 hours, MAX= 40 mg/d

MOA: Reversibly inhibits COX-1 and COX-2 enzymes, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: Dizziness, allergy, bleeding, peptic ulcer disease, edema, increased Cr, increased LFTs, increased BP

CI: Peptic ulcer disease, GI bleed, anticipated major surgery, severe renal insufficiency, nursing, use with ASA/NSAIDs

BBW: Max duration of therapy is 5 days

MP: CBC, bleeding, bruising, LFTs, relief of pain

Celecoxib

Celebrex®

Dose: Initial 400 mg followed by 200 mg on first day, then 200 mg BID, MAX= 400 mg/d

MOA: Inhibits prostaglandin synthesis by decreasing COX-2 activity, which results in decreased prostaglandin precursors; has anti-pyretic, analgesic, and anti-inflammatory properties

AE: GI upset, hypertension, edema, renal failure, headache

CI: Sulfonamide allergy, perioperative coronary artery bypass graft

MP: BP

Opioid Analgesics

Morphine (MS Contin®, MSIR®, Avinza®, Kadian®, Roxanol®, Oramorph®)

Hydromorphone (Dilaudid®, Palladone®, Exalgo®)

Oxymorphone (Numorphan®, Numorphone®, Opana®, Opana® ER)

Codeine

Hydrocodone (Lorcet®, Lortab®, Vicodin®, Hycet®, Hydrocet®)

Oxycodone (Roxicodone®, OxyIR®, OxyFast®, Oxycontin®)

Meperidine (Demerol®)

Fentanyl (Duragesic®, Actiq®, Sublimaze®, Fentora®, Onsolis®)

Methadone (Dolophine®, Methadose®)

Propoxyphene (Darvocet-N®, Darvon®)

Pentazocine (Talwin®, Talwin® NX)

Butorphanol (Stadol®)

Nalbuphine (Nubain®)

Buprenorphine (Suboxone®, Subutex®)

Naloxone (Narcan®)

Tramadol (Ultram®, Ultram® ER)

Morphine 

MS Contin®, MSIR®, Avinza®, Kadian®, Roxanol®, Oramorph®

Dose: 10-30 mg every 3-4 hours PRN

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: Respiratory depression, sedation, constipation, nausea, vomiting, pruritis, diaphoresis, urinary retention

CI: Severe asthma, respiratory depression, GI obstruction

MP: Relief of pain, BP, respiratory and mental status

 Hydromorphone

Dilaudid®, Palladone®, Exalgo®

Dose: 2-8 mg every 3-4 hours PRN

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: Sedation, GI upset, dizziness

CI: Severe asthma, emphysema

MP: Relief of pain, BP, respiratory and mental status

Oxymorphone

Numorphan®, Numorphone®, Opana®, Opana® ER

Dose: 10-20 mg every 4-6 hours

MOA: Potent narcotic analgesic, binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways

AE: hypotension, sedation, GI upset, constipation, histamine release

CI: Severe respiratory depression, severe hepatic impairment

MP: Heart rate, respiratory rate, BP, CNS activity

Codeine

No brand name

Dose: 15-60 mg every 4-6 hours, MAX= 1 g/dose,

4 g/d

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: Drowsiness, constipation, hypotension

CI: Component sensitivity

MP: Relief of pain, BP, respiratory and mental status, heart rate

Hydrocodone

Lorcet®, Lortab®, Vicodin®, Hycet®, Hydrocet®

Dose: 1-2 tablet every 4-6 hours PRN, MAX= 4 g/d

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: GI upset, sedation, fatigue

CI: CNS depression, severe respiratory depression

MP: Relief of pain, BP, respiratory and mental status, heart rate

Oxycodone

Roxicodone®, OxyIR®, OxyFast®, Oxycontin®

Dose: 5-30 mg every 4-6 hours PRN

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: hypotension, sedation, respiratory depression, dizziness, GI upset, constipation

CI: Allergy, respiratory depression, acute asthma

MP: Relief of pain, BP, respiratory and mental status

Meperidine

Demerol®

Dose: 50-150 mg PO/SC/IM every 3-4 hours

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: Respiratory and CNS depression, sedation, constipation, seizures, nausea, vomiting, hypotension, rash, dyspnea

CI: Renal failure, patients taking MAOIs

MP: Relief of pain, BP, respiratory and mental status, CNS depression, seizures

Fentanyl

Duragesic®, Actiq®, Sublimaze®, Fentora®, Onsolis®

Dose: 50-100 mcg IV every 1-2 hours PRN, 25-100 mcg/hr every 72 hours (transdermal)

MOA: Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain perception, inhibits ascending pain pathways

AE: Respiratory depression, sedation, hypotension, constipation, bradycardia, nausea

CI: Mild pain, paralytic ileus, respiratory depression, severe renal/hepatic impairment

MP: Respiratory and cardiovascular status, BP, heart rate

Methadone

Dolophine®, Methadose®

Dose: 15-30 mg as a single dose, then 5-10 mg every 2-4 hours PRN, MAX= 40 mg/d

MOA: Binds to opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: Respiratory depression, sedation, constipation, urinary retention, QT prolongation, bradycardia, syncope, hypokalemia, hypomagnesimia

CI: Respiratory depression, acute asthma, paralytic ileus

MP: Relief of pain, BP, respiratory and mental status, baseline ECG within 30 days of initiation and then anually

Propoxyphene

Darvocet-N®, Darvon®

Dose: 1 tablet every 4-6 hours, MAX= 6 tablets/d

MOA: Weak narcotic analgesic, binds to the opiate receptors in the CNS causing inhibiton of the ascending pain pathways

AE: Hypotension, sedation, GI upset, increased LFTs

CI: Allergy, history of substance abuse, suicide risk

BBW: Excessive doses in combo with other CNS depressants may lead to death; use with caution in depressed or suicidal patients

MP: Relief of pain, BP, respiratory and mental status

Pentazocine

Talwin®, Talwin® NX

Dose: 30 mg IM/IV/SC every 3-4 hours PRN, MAX IM/SC= 60 mg/dose, MAX IV= 30 mg/dose

MOA: Binds to various opioid receptors producing agonist and antagonist effects

AE: Drowsiness, considerable dysphoria, GI upset, xerostomia, seizures

CI: Component allergy

MP: Relief of pain, BP, respiratory and mental status

Butorphanol

Stadol®

Dose: 0.5-2 mg IV every 3-4 hours PRN, 1-4 mg IM every 3-4 hours PRN, MAX= 4 mg/dose IM

MOA: Binds to various opioid receptors producing agonist and antagonist effects

AE: Drowsiness, dizziness, nasal congestion

CI: Hypersensitivity, history of substance abuse, CNS depression

MP: Relief of pain, BP, respiratory and mental status

Nalbuphine

Nubain®

Dose: 10 mg IV/IM/SC every 3-6 hours PRN, MAX=20 mg/dose, 160 mg/day

MOA: Agonist of Kappa opiate receptors and partial antagonist of Mu opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: CNS depression, drowsiness, hypotension

CI: Component sensitivity

MP: Relief of pain, BP, respiratory and mental status

Buprenorphine

Suboxone®, Subutex®

Dose: 300 mcg IM/IV every 6-8 hours, MAX IM= 600 mcg/dose, MAX IV= 300 mcg/dose

MOA: High affinity binding to Mu opiate receptors in the CNS; displays partial Mu agonist and weak Kappa antagonist activity

AE: Sedation, hypotension, respiratory depression

CI: Hypersensitivity

MP: Relief of pain, BP, respiratory and mental status, CNS depression, LFTs

Naloxone

Narcan®

Dose: 0.4-2 mg IV every 2-3 minutes PRN

MOA: Pure opioid antagonist that competes and displaces narcotics at opioid receptor sites

AE: Hypotension, tachycardia, irritability, GI upset, pulmonary edema

CI: Hypersensitivity

MP: Respiratory rate, heart rate, BP, temperature

Tramadol

Ultram®, Ultram® ER

Dose: IR: 50-100 mg every 4-6 hours PRN, MAX= 400 mg, ER: 100-300 mg/d, MAX= 300 mg/d

MOA: Binds to Mu opiate receptors in the CNS causing inhibition of ascending pain pathways

AE: Dizziness, headache, somnolence, GI upset, respiratory depression, anaphylaxis

CI: Opioid dependency, sensitivity to codeine, patients taking MAOIs

MP: Relief of pain, BP, pulse, signs of tolerance and abuse