Guide to
Over-the-Counter Painkillers
Russell K. Portenoy, MD
Beth Israel Medical Center
very day, 36 million Americans take an
over-the-counter (OTC) painkiller,
usually
acetaminophen (Tylenol),
ibuprofen (Advil,
Motrin) or aspirin.
We take those medications to stop a headache... ease an
arthritis flare-up... soothe a sore shoulder after a weekend of
yard work... or relieve any one of the everyday aches and pains
that inevitably disrupt our lives.
But do you know which painkiller to take first for maximum
effectiveness and safety?
Here are the latest guidelines...
HOW painkillers WORK
All three of the most common pain relievers -- acetaminophen,
ibuprofen and aspirin -- reduce the production
of cyclooxygenase (COX) enzymes. These enzymes
play a key role in the formation of prostanoids,
biochemicals that sensitize the nerve fibers that produce pain and
trigger inflammation.
What you may not know: There is
no "best" OTC painkiller for every pain problem. That’s because not
everyone responds to pain relievers in the same way -- none of
these drugs works consistently for everyone or for every type of
pain.
You may find that ibuprofen relieves your headaches, but it may
do nothing for your spouse, who swears by aspirin when his/her
temples start to throb.
Even if ibuprofen works for both your and your spouse’s
headaches, the amount each of you needs for pain relief may be
different -- and the amount that one person needs may cause a
distressing side effect that never troubles the other. How can you
determine the right drug and dose for you, and
you alone? Follow the three-step plan below.
Important: This self-care plan is
best for relief of mild-to-moderate acute pain, such as a toothache
or headache. It is not appropriate for chronic pain. Long-term use
of any painkiller should be monitored by a doctor because of the
risk for side effects. All dosages listed are for adults. Also,
don’t use products that combine two or more of these ingredients,
such as Extra-Strength Excedrin, which includes acetaminophen and
aspirin. Combination products have not been proven to work any
better and may have an increased risk for side effects.
START WITH ACETAMINOPHEN
Because there’s no way to tell which OTC painkiller will work
best for you, it’s sensible for most people (though not all) to
start with the safest -- the one that decades of clinical use has
shown poses the lowest risk for side effects. That drug is
acetaminophen.
Starting dosage: 500 milligrams
(mg) to 1,000 mg.
Maximum dosage: Two
extra-strength 500-mg capsules, four times daily. If you take
acetaminophen repeatedly over many days, don’t exceed 4,000 mg a
day.
Warning: The biggest risk from
acetaminophen is liver damage, which can occur when more than the
maximum dosage is taken. Don’t use acetaminophen at any dosage
without a physician’s supervision if you have a liver disease, such
as hepatitis C, or a history of heavy drinking (three or more
drinks a day). Although ibuprofen generally would be preferred over
the other painkillers in these cases, all painkillers have added
risks for people who have liver disease or who are heavy
drinkers.
If you haven’t been drinking heavily for several months, it is
probably safe to use acetaminophen unless there is a history of
liver damage.
NEXT, TRY IBUPROFEN
If acetaminophen doesn’t relieve your acute pain, switch to
ibuprofen or one of the other nonsteroidal anti-inflammatory drugs
(NSAIDs), such as naproxen (Aleve)
orketoprofen (Actron).
Starting dosage: 200 mg to 400
mg.
Maximum dosage: Use of more than
2,400 mg daily requires monitoring by a physician because high
dosages can cause serious side effects.
Precautions: Like all NSAIDs,
regular use of ibuprofen can damage the gastrointestinal tract,
causing problems ranging from heartburn to bleeding
ulcers.Other possible side effects...
Kidney damage, with swelling of the legs,
worsening of high blood pressure and/or kidney failure.
Risk for blood clots, which increase the likelihood of
angina, heart attack and/or stroke. If you have unstable
angina (not effectively controlled with medical care), PAD
(narrowing of the arteries in the legs) or have had a heart
attack, a transient ischemic attack or a stroke, or have
otherwise been diagnosed with cardiovascular disease, do not
take ibuprofen regularly. The more severe the circulatory
disease, the greater the need for caution with ibuprofen.
Acetaminophen is probably the better choice, but talk to your
doctor.
ASPIRIN IS the LAST choice
If acetaminophen and ibuprofen don’t work, you can try switching
to aspirin, with the understanding that aspirin is the most likely
of these drugs to cause side effects in most people.
Starting dosage: Two 325-mg
tablets.
Maximum dosage: Do not exceed
4,000 mg daily.
Precautions: The greatest risk
with aspirin is bleeding ulcers.