MHRA recommends alternatives to co-proxamol
Following its decision to withdraw co-proxamol by February 2006, the Medicines and Healthcare Products Regulatory Agency (MHRA) has published guidance to prescribers on selecting analgesics - including ibuprofen (http://medicines.mhra.gov.uk/ourwork/monitorsafequalmed/safetymessages/co-proxamol_healthprofessional.pdf). The guidance is intended for doctors switching patients from co-proxamol during the forthcoming months and to recommend alternative drugs for the treatment of new cases of mild to moderate pain.

The MHRA classifies pain as acute and self-limiting, either alone or against a background of chronic pain (Class I - for example, due to low back pain or osteoarthritis); or as chronic pain (Class IIa) which may be stable (Class IIa - osteoarthritis) or progressive (Class IIb - cancer pain, diabetic neuropathy).

The management of Class I pain is a 4-step process:

• Step 1 paracetamol
• Step 2 substitute ibuprofen
• Step 3 add paracetamol to ibuprofen
• Step 4 continue paracetamol but replace ibuprofen with a different NSAID

The low potency opioids codeine and dihydrocodeine are alternatives to an NSAID at Steps 2 and 3, and may be added at Step 4 if pain is not controlled.

Class IIa pain is treated in a similar way except that the use of a low potency opioid should be considered earlier; if this does not control pain, a tricyclic antidepressant or an anticonvulsant should be considered. The treatment of Class IIb pain is similar to that for Class IIa except that a tricyclic or anticonvulsant should be considered earlier. Strong opioids such as morphine are also indicated for patients with severe Class IIb pain but the MHRA says this is outside the scope of its guidance.

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