Kathi Rock
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Understanding Acetaminophen (Paracetamol)
A concise guide to its uses, safety profile, and alternatives
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1 What is Acetaminophen?
Generic name: Acetaminophen (also known as paracetamol in many countries).
Class: Analgesic (pain‑reliever) & antipyretic (fever‑reducing).
Common forms: Tablets, capsules, liquid suspensions, chewable tablets, and suppositories.
2 How Does It Work?
Acetaminophen reduces pain and fever primarily by:
Inhibiting cyclooxygenase enzymes in the central nervous system (CNS), which decreases prostaglandin synthesis.
Modulating the endocannabinoid system and serotonergic pathways, contributing to its analgesic effect.
3 Typical Uses
Indication Common Conditions
Pain Headache, dental pain, muscle aches, menstrual cramps, arthritis pain (mild‑moderate)
Fever Viral infections, flu, postoperative fever
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4 Dosing Guidelines (Adults)
Oral: 325–650 mg every 4–6 hours as needed.
Maximum daily dose: ≤3.5 g (usually <2 g).
Extended‑release formulations: Follow package instructions; avoid crushing or chewing.
Always consider patient weight, age, and comorbidities.
5 Contraindications & Precautions
Category Key Points
Allergy to NSAIDs / Salicylates Avoid.
Asthma/COPD Use with caution; monitor for bronchospasm.
Renal impairment Dose adjustment or avoid if severe CKD.
GI ulcers, bleeding disorders Risk of GI irritation/bleeding; consider gastroprotection.
Hepatic dysfunction Monitor liver enzymes; limit use in active hepatitis.
Pregnancy (especially 3rd trimester) Generally contraindicated.
Concomitant anticoagulants Increased bleeding risk.
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5. Clinical Use Cases & Recommendations
a) Managing Chronic Pain (e.g., Osteoarthritis)
Preferred: NSAIDs (e.g., diclofenac, ibuprofen) or acetaminophen if GI risk high.
Avoid: Opioids for chronic non-cancer pain unless all other options exhausted; risk of dependence and side effects outweigh benefits.
b) Acute Postoperative Pain
Preferred: Paracetamol + NSAIDs (if no contraindication) → multimodal analgesia.
If inadequate: Consider low-dose opioids with close monitoring for sedation, respiratory depression, especially in elderly or opioid-naïve patients.
c) Chronic Low Back Pain
First-line: Non-pharmacologic interventions (physical therapy), paracetamol/NSAIDs as needed.
Opioid use should be limited to short-term trials; long-term use rarely justified.
d) Cancer-Related Pain
Opioids are mainstay for moderate-to-severe pain. Start with low-dose morphine, titrate to effect while monitoring for adverse effects (constipation, sedation). Non-opioid adjuvants may reduce opioid requirements.
4. Practical "Rule of Thumb" for Selecting an Analgesic
Pain Type Initial Pharmacologic Step Key Considerations
Acute, mild-to-moderate pain (post‑operative, dental) Paracetamol 500 mg–1 g q6h PRN or NSAID if inflammation present. Avoid exceeding 4 g/day paracetamol; check renal function for NSAIDs.
Moderate to severe acute pain Add opioid (e.g., tramadol 50–100 mg q8h) if needed; consider NSAID + paracetamol combo. Monitor sedation, respiratory depression; adjust dose in elderly/renal/hepatic impairment.
Chronic pain (non‑malignant) Start with low‑dose opioid or add non‑opioid adjuvants (gabapentinoids, antidepressants). Use titration; evaluate for dependence.
Malignant pain Baseline opioid therapy (e.g., morphine 10 mg q4h PRN); consider continuous infusion if severe. Monitor side effects; provide breakthrough dosing; adjust as needed.
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6. Key Points to Remember
Use the WHO ladder: Step‑wise, titrate up until adequate pain relief or unacceptable side effects.
Assess every 3–4 h initially: Determine if the current dose is effective and whether side‑effects are present.
Adjust doses in small increments (10–20 % of current dose) to avoid overshooting and causing excessive sedation or respiratory depression.
Monitor for opioid tolerance, hyperalgesia, and delirium—adjust analgesic strategy accordingly.
Document pain scores, dosing changes, side‑effects, and patient responses meticulously.
By following these structured guidelines, you can safely titrate opioids to manage pain while minimizing adverse events.
