Simple Prescribing Question

Hi I have a couple of prescribing questions:

-I find prescribing inhalers really confusing. For combination inhalers do you use the brand name or name the individual ingredients? And what do you write for the quantity where for other medicines you might say "please supply 28 tablets"?

- Can you prescribe morphine in tablet form for analgesia after a fracture? In the BNF it only mentions injections for acute pain which I thought was strange.

Thank you very much!

Reply 1

Helenia

Original post by Kerryy94

I tend to use brand names for most inhalers, as they're not all the same! If the pharmacists are fussy I might write the brand name with the generic in brackets.

And yes, immediate-release morphine is available both in tablet and liquid (oramorph) form. Remember that its oral bioavailability is different from IV though.

Reply 2

nexttime

Main pain relief for a fracture is fixation of the fracture. Until then paracetamol and morphine, often IV initially, and sometimes nerve block are probably the best things.

The most common form of oral morphine used in the short tern is PRN oramorph, which is a liquid (unless its different in other hospitals). Modified-release morphine tablets tend not to be used in this circumstance in the UK (though are dished out like smarties in the US because you can make so much money selling someone oxycodone).

(edited 7 years ago)

Reply 3

Etomidate

For inhalers, I tend to write the generic name e.g. budesonide/formoterol and then the strength (e.g. 200/6).

Yes, immediate release oral morphine (e.g. oramorph being the most commonly used) is fine for acute pain.

Reply 4

RosaPonselle

Combination LABA/ICS inhalers are (to my knowledge) all unique so you can prescribe generically or branded. Plain ICS inhalers though can vary in their potency depending on the particle size of steroid so should be prescribed by brand e.g Clenil/QVar are not equivalent. You can simply write "supply 1 inhaler" though if the pharmacy is being picky they might insist you write "supply 1 x 120 dose inhaler".

Oramorph is used for acute pain. You can work out an MST (tablet) equivalent dose though which is what usually happens once patients are in the community who need to continue on this in the longer term. Or consider switching to patches (usually buprenorphine patches)

Reply 5

Hygeia

Sevredol is the quick release tablet form of morphine (I needed it for a while and couldn't stand the liquid form)

Reply 6

MonteCristo

Original post by nexttime

Main pain relief for a fracture is fixation of the fracture. Until then paracetamol and morphine, often IV initially, and sometimes nerve block are probably the best things.

No nerve blocks, please, with the exception of fascia-iliaca blocks for hip fractures, as these will happily mask a compartment syndrome!

Reply 7

nexttime

Original post by MonteCristo

No nerve blocks, please, with the exception of fascia-iliaca blocks for hip fractures, as these will happily mask a compartment syndrome!

That was the one i was referring to yes. Good job you clarified!

Reply 8

Spencer Wells

Original post by MonteCristo

No nerve blocks, please, with the exception of fascia-iliaca blocks for hip fractures, as these will happily mask a compartment syndrome!

There's not very much evidence of this.

Linky

Reply 9

MonteCristo

Original post by Spencer Wells

There's not very much evidence of this. Linky

It's not really a question that's likely to be addressed, let alone answered, by clinical studies. Compartment syndrome is a clinical diagnosis that is difficult enough to make and depends on the patient's ability to report pain. This article cites a (very limited) study that highlights the difficulties of clinically diagnosing compartment syndrome but the truth is that pain is all we have got to go on.

Compartment pressure monitoring is not trusted any longer and so a patient with pain+pain+pain* gets urgent decompression in my world.

The pain associated with most tibial fractures can be adequately managed with stabilisation, simple analgesia, and opioids. If this isn't sufficient analgesia for a patient, then I really want to know about it...

*pain out of proportion to the injury, pain on passive stretch of the compartment, pain unresponsive to opioids.