Drug | Suggested initial dose* and titration | Selected characteristics relevant to older adults |
Acetaminophen (paracetamol)¶ | 325 to 500 mg orally every 4 hours or 500 to 1000 mg every 6 to 8 hours (scheduled) Maximum 3 g per day, exceptions include:
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Opioid analgesicsפ: Older adults are more susceptible to opioid-induced adverse effects, including respiratory depression, hypotension, delirium, constipation, excessive sedation, and drug accumulation. Low doses should be used initially and titrated gradually to decrease risk of accumulation and overdose. The initial dose should be decreased by 25% for a 60-year-old patient and by 50% for an 80-year-old patient, from the initial dose that a 40-year-old would receive, but administered at the same intervals. | ||
Tramadol | ||
Immediate release¥ | Start with 25 mg orally once daily May increase daily dose by 25 to 50 mg after 3 to 7 days; give in 3 or 4 divided doses Age ≤75 years: Maximum 400 mg daily Age >75 years: Maximum 300 mg daily Renal impairment (CrCl <30 mL/min): Maximum 200 mg daily irrespective of age |
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Extended release | Start with 100 mg orally once daily May increase daily dose by 100 mg after 5 or more days (maximum 300 mg daily) Avoid use in renal impairment (CrCl <30 mL/min) | |
Oxycodone | ||
Immediate release¥ | Start with 2.5 to 5 mg orally every 4 hours as needed After 3 to 7 days, determine 24-hour dose requirement and convert to extended release |
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Extended release | Divide 24-hour dose requirement for oxycodone immediate release in 2 doses | |
Morphine | ||
Immediate release | Start with 2.5 to 10 mg orally every 4 hours as needed (an oral solution is available for initial low doses; lowest tablet strength available in the United States is 15 mg) After 3 to 7 days, determine 24-hour dose requirement and convert to extended release |
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Extended release◊ | Divide 24-hour dose requirement for immediate-release morphine in 1, 2, or 3 doses (depending on type of preparation) | |
Hydromorphone | ||
Immediate release | Start with 1 to 2 mg orally every 4 hours as needed After 3 to 7 days, determine 24-hour dose requirement and covert to extended release |
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Extended release◊ | Divide 24-hour dose requirement for immediate-release hydromorphone in 1 or 2 doses (depending on type of preparation) | |
Transdermal fentanyl◊ | Determine 24-hour dose requirement using an immediate-release oral opioid; after 3 to 7 days, convert to an equianalgesic dose of transdermal fentanyl (refer to drug monograph included within UpToDate for initial conversion) Or start with 12 mcg/hour patch every 72 hours; if ineffective after 1 week, increase to 25 mcg/hour patch |
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Transdermal buprenorphine◊ | 5 mcg/hour patch every 7 days |
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Methadone | Start with 1 mg orally, buccal, or subcutaneously every 12 to 24 hours Increase daily dose by 1 to 2 mg after 7 or more days Further increases in daily dose of 1 to 2 mg should be made no more frequently than once every 7 days |
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Adjuvant analgesics§: Includes options for painful polyneuropathies, muscle spasm, and multipurpose analgesics that may decrease opioid requirements. | ||
Serotonin-norepinephrine reuptake inhibitors (SNRIs) | ||
Duloxetine | Start with 20 to 30 mg orally per day May increase daily dose to 40 to 60 mg after 1 week Maximum 60 mg per day (CrCl ≥30 mL/min) |
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Venlafaxine (extended release) | Start with 37.5 mg orally per day May increase daily dose by 37.5 mg after 7 or more days; then may increase daily dose by 37.5 to 75 mg after 4 or more days Maximum 225 mg per day |
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Milnacipran | Start with 12.5 mg orally once per day (refer to drug monograph included within UpToDate for titration) |
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Tricyclic antidepressants | ||
Nortriptyline | Start with 10 mg orally at bedtime May increase daily dose by 10 mg after 7 or more days Maximum 50 mg per night | Applies to nortriptyline and desipramine:
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Desipramine | Start with 10 mg orally at bedtime May increase daily dose by 10 mg after 7 or more days Maximum 50 mg per night | |
Antiseizure medications | ||
Gabapentin | Start with 100 mg orally at bedtime May increase daily dose by 100 mg after 7 or more days; give in divided doses Maximum 3600 mg per day (CrCl ≥60 mL/min) | Applies to gabapentin and pregabalin:
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Pregabalin | Start with 25 to 50 mg orally at bedtime May increase daily dose by 25 to 50 mg after 7 or more days; give in divided doses Maximum 300 mg per day (CrCl ≥60 mL/min) | |
Oral nonsteroidal antiinflammatory drugs (NSAIDs) Applies to all:
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Naproxen sodium | 220 mg orally twice per day (equivalent to 200 mg naproxen base twice per day) |
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Ibuprofen¶ | 200 mg orally 3 times per day |
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Celecoxib | 100 mg orally per day |
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Diflunisal | 250 mg orally 2 or 3 times per day (United States: Requires splitting a non-scored 500 mg tablet) | Applies to both nonacetylated salicylates (ie, diflunisal and salsalate):
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Salsalate | 500 mg orally 2 or 3 times per day | |
Topical therapies: Topical medications (eg, NSAIDs, capsaicin, and lidocaine) should be considered before oral NSAIDs for localized pain (eg, hand or knee osteoarthritis pain). They may also be used in combination with systemic analgesics to reduce doses and side effects. Refer to separate UpToDate table showing topical analgesics. | ||
Intraarticular glucocorticoids: Refer to topic review of initial pharmacologic therapy of osteoarthritis. |
CrCl: creatinine clearance; EKG: electrocardiogram; ESRD: end-stage renal disease; GI: gastrointestinal; INR: international normalized ratio; OTC: over-the-counter (non-prescription) medicines; PHN: postherpetic neuralgia; SSRI: selective serotonin reuptake inhibitor.
* Lowest starting dose shown should be considered in frail older persons with a history of sensitivity to central nervous system-active drugs, reduced cardiac output, dehydration, low body weight, or poor oral intake. Doses shown are for oral administration except where noted.
¶ Also available for parenteral use.
Δ Medical supervision means close monitoring of hepatic function and limiting exposure to other potentially hepatotoxic medications and substances (eg, alcohol), usually as an inpatient.
◊ We suggest establishing dose and effects using an immediate-release opioid preparation prior to prescribing a sustained-release opioid for opioid-naïve older patients.
§ In general, dose tapering is recommended prior to discontinuation of antiseizure medications, opioids, and antidepressants.
¥ Also available in combination preparations with acetaminophen (paracetamol).Do you want to add Medilib to your home screen?