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Additional resources for British National Formulary (BNF) 68
Bone metastases In addition to the above approach, radiotherapy, bisphosphonates (p. 512), and radioactive isotopes of strontium (p. 518) (Metastron ® available from GE Healthcare) may be useful for pain due to bone metastases. Neuropathic pain Patients with neuropathic pain (p. 291) may benefit from a trial of a tricyclic antidepressant. An antiepileptic may be added or substituted if pain persists; gabapentin and pregabalin (p. 303) are licensed for neuropathic pain. Ketamine is sometimes used under specialist supervision for neuropathic pain that responds poorly to opioid analgesics.
Oral medication is usually satisfactory unless there is severe nausea and vomiting, dysphagia, weakness, or coma, when parenteral medication may be necessary. Pain Pain management in palliative care is focused on achieving control of pain by administering the right drug in the right dose at the right time. g. g. antidepressants, antiepileptics). Drugs from the different classes are used alone or in combination according to the type of pain and response to treatment. Analgesics are more effective in preventing pain than in the relief of established pain; it is important that they are given regularly.
An antiemetic is usually necessary only for the first 4 or 5 days and therefore combined preparations containing an opioid with an antiemetic are not recommended because they lead to unnecessary antiemetic therapy (and associated side-effects when used longterm). Metoclopramide has a prokinetic action and is used in a dose of 10 mg 3 times daily by mouth for nausea and vomiting associated with gastritis, gastric stasis, and functional bowel obstruction. Drugs with antimuscarinic effects antagonise prokinetic drugs and, if possible, should not be used concurrently.