Individual generic drug information

capsaicin

Reference monograph

Part of registered formulation

DICLOFENAC DIETHYLAMINE+ METHYL SALICYLATE + VIRGIN LINSEED OIL + CAPSAICIN + RACEMENTHOL

Reference record: Capsaicin
Source: BNF 80 (2020–2021)
Printed source pages: 527, 528, 529, 530
Age groups indexed: 1

Individual active ingredientSource records are displayed separately

Some source sections could not be separated reliably in the extraction. Review the printed source pages when a field is missing or incomplete.

Overview

Extracted information for Capsaicin only.

Indications And Dose

Localised neuropathic pain ▶TO THE SKIN USING CREAM ▶Adult: Apply 3–4 times a day, using 0.075% strength; apply sparingly, not more often than every 4 hours AXSAIN ® Post-herpetic neuralgia ▶TO THE SKIN ▶Adult: Apply 3–4 times a day, apply sparingly; important; after lesions have healed, not more often than every 4 hours Painful diabetic neuropathy (under expert supervision) ▶TO THE SKIN ▶Adult: Apply 3–4 times a day for 8 weeks then review, apply sparingly, not more often than every 4 hours QUTENZA ® Peripheral neuropathic pain (under the supervision of a physician) ▶BY TRANSDERMAL APPLICATION USING PATCHES ▶Adult: (consult product literature) ZACIN ® Symptomatic relief in osteoarthritis ▶TO THE SKIN ▶Adult: Apply 4 times a day, apply sparingly, not more often than every 4 hours l UNLICENSED USE g Capsaicin is used in the treatment of localised neuropathic pain, l but is not licensed for this indication.

Source page 527

Cautions

GENERAL CAUTIONS Avoid contact with broken skin. avoid contact with inﬂamed skin SPECIFIC CAUTIONS ▶With topical use Avoid contact with eyes. avoid hot shower or bath just before or after application (burning sensation enhanced). avoid inhalation of vapours. not to be used Nervous system under tight bandages ▶With transdermal use avoid contact with the face, scalp or in proximity to mucous membranes. avoid holding near eyes or mucous membranes. recent cardiovascular events. uncontrolled hypertension

Source page 528

National Funding Access Decisions

QUTENZA ® Scottish Medicines Consortium (SMC) decisions The Scottish Medicines Consortium has advised (January 2011) that capsaicin 179 mg (8%) patch (Qutenza ®) is accepted for restricted use within NHS Scotland for the treatment of postherpetic neuralgia in patients who have not achieved adequate pain relief from, or who have not tolerated conventional ﬁrst and second line treatments. Treatment should be under the supervision of a specialist in pain management.

Source page 528

Safety

Extracted information for Capsaicin only.

Side Effects

GENERAL SIDE-EFFECTS ▶Uncommon Cough SPECIFIC SIDE-EFFECTS ▶Common or very common ▶With transdermal use Sensation abnormal ▶Uncommon ▶With transdermal use Atrioventricular block. eye irritation. muscle spasms. nausea. palpitations. peripheral oedema. skin reactions. tachycardia. taste altered. throat irritation ▶Rare or very rare ▶With topical use Sneezing. watering eye ▶Frequency not known ▶With topical use Asthma exacerbated. dyspnoea. skin burning sensation (particularly if too much used or if administered more than 4 times daily). skin irritation

Source page 528

Monitoring Requirements

▶With transdermal use Monitor blood pressure during treatment procedure. l HANDLING AND STORAGE ▶With topical use Wash hands immediately after use (or wash hands 30 minutes after application if hands treated). ▶With transdermal use Nitrile gloves to be worn while handling patches and cleaning treatment areas (latex gloves do not provide adequate protection).

Source page 528

Dose and formulations

Extracted information for Capsaicin only.

Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: cream Cutaneous patch EXCIPIENTS: May contain Butylated hydroxyanisole ▶Qutenza (Grunenthal Ltd) Capsaicin 179 mg Qutenza 179mg cutaneous patches | 1 patch P £210.00 DT = £210.00 Cream EXCIPIENTS: May contain Benzyl alcohol, cetostearyl alcohol (including cetyl and stearyl alcohol) ▶Axsain (Teva UK Ltd) Capsaicin 750 microgram per 1 gram Axsain 0.075% cream | 45 gram P £14.58 DT = £14.58 ▶Zacin (Teva UK Ltd) Capsaicin 250 microgram per 1 gram Zacin 0.025% cream | 45 gram P £17.71 DT = £17.71 Sleep disorders Insomnia 7.1 Hypnotics and anxiolytics Overview Most anxiolytics (‘sedatives’) will induce sleep when given at night and most hypnotics will sedate when given during the day. Prescribing of these drugs is widespread but dependence (both physical and psychological) and tolerance occur. This may lead to difﬁculty in withdrawing the drug after the patient has been taking it regularly for more than a few weeks. Hypnotics and anxiolytics should therefore be reserved for short courses to alleviate acute conditions after causal factors have been established. Benzodiazepines are the most commonly used anxiolytics and hypnotics; they act at benzodiazepine receptors which are associated with gamma-aminobutyric acid (GABA) receptors. Older drugs such as meprobamate p. 363 and barbiturates are not recommended—they have more side- effects and interactions than benzodiazepines and are much more dangerous in overdosage. Benzodiazepine indications . Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short- term psychosomatic, organic, or psychotic illness. . The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate. . Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or causing the patient extreme distress. Dependence and withdrawal Withdrawal of a benzodiazepine should be gradual because abrupt withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. The benzodiazepine withdrawal syndrome may develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one. It is characterised by insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances. Some symptoms may be similar to the original complaint and encourage further prescribing; some symptoms may continue for weeks or months after stopping benzodiazepines. Benzodiazepine withdrawal should be ﬂexible and carried out at a reduction rate that is tolerable for the patient. The rate should depend on the initial dose of benzodiazepine, duration of use, and the patient’s clinical response. Short- term users of benzodiazepines (2–4 weeks only) can usually taper off within 2–4 weeks. However, long-term users should be withdrawn over a much longer period of several months or more. A suggested protocol for withdrawal for prescribed long- term benzodiazepine patients is as follows: . Transfer patient stepwise, one dose at a time over about a week, to an equivalent daily dose of diazepam preferably taken at night. . Reduce diazepam dose, usually by 1–2 mg every 2– 4 weeks (in patients taking high doses of benzodiazepines, initially it may be appropriate to reduce the dose by up to one-tenth every 1–2 weeks). If uncomfortable withdrawal symptoms occur, maintain this dose until symptoms lessen. . Reduce diazepam dose further, if necessary in smaller steps; steps of 500 micrograms may be appropriate towards the end of withdrawal. Then stop completely. . For long-term patients, the period needed for complete withdrawal may vary from several months to a year or more. Approximate equivalent doses, diazepam 5 mg : alprazolam 250 micrograms : clobazam 10 mg : clonazepam 250 micrograms : ﬂurazepam 7.5–15 mg : chlordiazepoxide 12.5 mg : loprazolam 0.5–1 mg : lorazepam 500 micrograms : lormetazepam 0.5–1 mg : nitrazepam 5 mg : oxazepam 10 mg : temazepam 10 mg Withdrawal symptoms for long-term users usually resolve within 6–18 months of the last dose. Some patients will recover more quickly, others may take longer. The addition of beta-blockers, antidepressants and antipsychotics should be avoided where possible. Counselling can be of considerable help both during and after the taper. Hypnotics Before a hypnotic is prescribed the cause of the insomnia should be established and, where possible, underlying factors should be treated. However, it should be noted that some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of the insomnia. Short-acting hypnotics are preferable in patients with sleep onset insomnia, when sedation the following day is undesirable, or when prescribing for elderly patients. Long-acting hypnotics are indicated in patients with poor sleep maintenance (e.g. early morning waking) that causes daytime effects, when an anxiolytic effect is needed during the day, or when sedation the following day is acceptable. Transient insomnia may occur in those who normally sleep well and may be due to extraneous factors such as noise, shift work, and jet lag. If a hypnotic is indicated one that is rapidly eliminated should be chosen, and only one or two doses should be given. Short-term insomnia is usually related to an emotional problem or serious medical illness. It may last for a few weeks and may recur; a hypnotic can be useful but should not be given for more than three weeks (preferably only one week). Intermittent use is desirable with omission of some doses. A short-acting drug is usually appropriate. Chronic insomnia is rarely beneﬁted by hypnotics and is sometimes due to mild dependence caused by injudicious prescribing of hypnotics. Psychiatric disorders such as anxiety, depression, and abuse of drugs and alcohol are common causes. Sleep disturbance is very common in depressive illness and early wakening is often a useful pointer. The underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia. For example, clomipramine hydrochloride p. 391 or mirtazapine p. 389 prescribed for depression will also help to promote sleep if taken at night. Other causes of insomnia include daytime cat-napping and physical causes such as pain, pruritus, and dyspnoea. Hypnotics should not be prescribed indiscriminately and routine prescribing is undesirable. They should be reserved for short courses in the acutely distressed. Tolerance to their effects develops within 3 to 14 days of continuous use and long-term efﬁcacy cannot be assured. A major drawback of long-term use is that withdrawal can cause rebound insomnia and a withdrawal syndrome. Where prolonged administration is unavoidable hypnotics should be discontinued as soon as feasible and the patient warned that sleep may be disturbed for a few days before normal rhythm is re-established; broken sleep with vivid dreams may persist for several weeks. Elderly Benzodiazepines and the Z–drugs should be avoided in the Nervous system elderly, because the elderly are at greater risk of becoming ataxic and confused, leading to falls and injury. Dental patients Some anxious patients may beneﬁt from the use of hypnotics during dental procedures such as temazepam p. 509 or diazepam p. 360. Temazepam is preferred when it is important to minimise any residual effect the following day. Benzodiazepines Benzodiazepines used as hypnotics include nitrazepam p. 509 and ﬂurazepam p. 508 which have a prolonged action and may give rise to residual effects on the following day; repeated doses tend to be cumulative. Loprazolam p. 508, lormetazepam p. 509, and temazepam act for a shorter time and they have little or no hangover effect. Withdrawal phenomena are more common with the short-acting benzodiazepines. If insomnia is associated with daytime anxiety then the use of a long-acting benzodiazepine anxiolytic such as diazepam given as a single dose at night may effectively treat both symptoms. Zolpidem, and zopiclone Zolpidem tartrate p. 512 and zopiclone p. 512 are non- benzodiazepine hypnotics (sometimes referred to as Z- drugs), but they act at the benzodiazepine receptor. They are not licensed for long-term use; dependence has been reported in a small number of patients. Both zolpidem tartrate and zopiclone have a short duration of action. Chloral and derivatives There is no convincing evidence that they are particularly useful in the elderly and their role as hypnotics is now very limited. Clomethiazole Clomethiazole p. 511 may be a useful hypnotic for elderly patients because of its freedom from hangover but, as with all hypnotics, routine administration is undesirable and dependence occurs. Antihistamines Some antihistamines such as promethazine hydrochloride p. 301 are on sale to the public for occasional insomnia; their prolonged duration of action can often cause drowsiness the following day. The sedative effect of antihistamines may diminish after a few days of continued treatment; antihistamines are associated with headache, psychomotor impairment and antimuscarinic effects. Alcohol Alcohol is a poor hypnotic because the diuretic action interferes with sleep during the latter part of the night. Alcohol also disturbs sleep patterns, and so can worsen sleep disorders. Melatonin Melatonin p. 511 is a pineal hormone; it is licensed for the short-term treatment of insomnia in adults over 55 years; and for the short-term treatment of jet-lag in adults. Anxiolytics Benzodiazepine anxiolytics can be effective in alleviating anxiety states. Although these drugs are sometimes prescribed for stress-related symptoms, unhappiness, or minor physical disease, their use in such conditions is inappropriate. Benzodiazepine anxiolytics should not be used as sole treatment for chronic anxiety, and they are not appropriate for treating depression or chronic psychosis. In bereavement, psychological adjustment may be inhibited by benzodiazepines. Anxiolytic benzodiazepine treatment should be limited to the lowest possible dose for the shortest possible time. Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders. Nervous system Some antidepressant drugs are licensed for use in anxiety and related disorders. Some antipsychotic drugs, in low doses, are also sometimes used in severe anxiety for their sedative action, but long-term use should be avoided because of the risk of adverse effects. The use of antihistamines (e.g. hydroxyzine hydrochloride p. 299) for their sedative effect in anxiety is not appropriate. Beta-adrenoceptor blocking drugs do not affect psychological symptoms of anxiety, such as worry, tension, and fear, but they do reduce autonomic symptoms, such as palpitation and tremor; they do not reduce non-autonomic symptoms, such as muscle tension. Beta-blockers are therefore indicated for patients with predominantly somatic symptoms; this, in turn, may prevent the onset of worry and fear. Benzodiazepines Benzodiazepines are indicated for the short-term relief of severe anxiety; long-term use should be avoided. Diazepam, alprazolam p. 360, chlordiazepoxide hydrochloride p. 360, and clobazam p. 353 have a sustained action. Shorter-acting compounds such as lorazepam p. 355 and oxazepam p. 362 may be preferred in patients with hepatic impairment but they carry a greater risk of withdrawal symptoms. In panic disorders (with or without agoraphobia) resistant to antidepressant therapy, a benzodiazepine may be used; alternatively, a benzodiazepine may be used as short-term adjunctive therapy at the start of antidepressant treatment to prevent the initial worsening of symptoms. Diazepam or lorazepam are very occasionally administered intravenously for the control of panic attacks. This route is the most rapid but the procedure is not without risk and should be used only when alternative measures have failed. The intramuscular route has no advantage over the oral route. Buspirone Buspirone hydrochloride p. 358 is thought to act at speciﬁc serotonin (5HT1A) receptors. Response to treatment may take up to 2 weeks. It does not alleviate the symptoms of benzodiazepine withdrawal. Therefore a patient taking a benzodiazepine still needs to have the benzodiazepine withdrawn gradually; it is advisable to do this before starting buspirone hydrochloride. The dependence and abuse potential of buspirone hydrochloride is low; it is, however, licensed for short-term use only (but specialists occasionally use it for several months). Meprobamate Meprobamate p. 363 is less effective than the benzodiazepines, more hazardous in overdosage, and can also induce dependence. It is not recommended. Barbiturates The intermediate-acting barbiturates have a place only in the treatment of severe intractable insomnia in patients already taking barbiturates; they should be avoided in the elderly. Intermediate-acting barbiturate preparations containing amobarbital sodium, butobarbital, and secobarbital sodium are available on a named patient basis. The long-acting barbiturate phenobarbital is still sometimes of value in epilepsy but its use as a sedative is unjustiﬁed. The very short-acting barbiturate thiopental sodium p. 354 is used in anaesthesia. Increased hostility and aggression after barbiturates and alcohol usually indicates intoxication. HYPNOTICS, SEDATIVES AND ANXIOLYTICS › BENZODIAZEPINES eiiii F 359

Source pages 528, 529, 530

Dose text by age group

Filter the extracted dose blocks for this individual drug.

Adults

First line only; read the complete Indications and dose section above.

Apply 3–4 times a day, using 0.075% strength;

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

Apply 3–4 times a day, apply sparingly;

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

Apply 3–4 times a day for 8 weeks then review,

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

(consult product literature)

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

Apply 4 times a day, apply sparingly, not more

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Age labels are extracted from the printed dose headings and require clinical review. Confirm current local guidance, dose, route, formulation, contraindications and interactions before prescribing.

Individual generic drug information

capsaicin

Reference monograph

Part of registered formulation

DICLOFENAC DIETHYLAMINE+ METHYL SALICYLATE + VIRGIN LINSEED OIL + CAPSAICIN + RACEMENTHOL

Reference record: Capsaicin
Source: BNF 80 (2020–2021)
Printed source pages: 527, 528, 529, 530
Age groups indexed: 1

Individual active ingredientSource records are displayed separately

Some source sections could not be separated reliably in the extraction. Review the printed source pages when a field is missing or incomplete.

Overview

Extracted information for Capsaicin only.

Indications And Dose

Source page 527

Cautions

Source page 528

National Funding Access Decisions

Source page 528

Safety

Extracted information for Capsaicin only.

Side Effects

Source page 528

Monitoring Requirements

Source page 528

Dose and formulations

Extracted information for Capsaicin only.

Medicinal Forms

Source pages 528, 529, 530

Dose text by age group

Filter the extracted dose blocks for this individual drug.

Adults

First line only; read the complete Indications and dose section above.

Apply 3–4 times a day, using 0.075% strength;

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

Apply 3–4 times a day, apply sparingly;

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

Apply 3–4 times a day for 8 weeks then review,

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

(consult product literature)

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Adults

First line only; read the complete Indications and dose section above.

Apply 4 times a day, apply sparingly, not more

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 527

Age labels are extracted from the printed dose headings and require clinical review. Confirm current local guidance, dose, route, formulation, contraindications and interactions before prescribing.