A tough day at work leaves you with a nasty headache, and you head for the medicine cabinet to seek relief. From the row of bottles lining the shelf, you have an array of options. Which do you choose?
For the garden variety headache, it really does not matter. But there are occasions when the choice is more difficult: you bang up your knee playing softball, and it is badly bruised and swollen; your toddler wakes in the night with a fever, tugging at her ears and crying. In such instances, the choice of painkiller is important.
If you are old enough, you may remember when the choice was limited to aspirin or Anacin. Actually, Anacin is aspirin plus caffeine, which speeds the effect and adds some painkilling qualities of its own...unless you are already consuming a lot of caffeine in your coffee. Too much caffeine can cause a headache...as can lack of caffeine if you have developed a habit.
In 1955, acetaminophen (Tylenol) was approved, adding another approach to zapping pain. Whereas aspirin works at the site of pain, inhibiting the swelling and inflammation that sensitize nerve endings, acetaminophen works in the brain by shutting down the pain signals.
Tylenol is now the best-selling over-the-counter painkiller, and it has two major advantages: 1) it does not cause gastrointestinal bleeding, as aspirin can in some individuals, and 2) it is safer for children under age 18 who are at increased risk of Reye’s Syndrome if they take aspirin for a fever or the flu.
Three additional painkillers have been added in recent years: ibuprofen (Advil, Motrin), naproxen sodium (Aleve) and ketoprofen (Orudis KT). All three are NSAIDs, similar to aspirin in both their benefits and risks. All are effective against swelling and inflammation as well as pain and fever, whereas acetaminophen works only against the latter. While these newer NSAIDs may be gentler on the stomach than aspirin, they too can irritate the stomach and cause gastrointestinal bleeding.
In addition, there are several products that contain a range of formulations and strengths of these approved painkillers plus antihistamines, decongestants, caffeine and other ingredients. Excedrin, for example, usually is a combination of aspirin, acetaminophen and caffeine. But there is also an aspirin-free version and a PM version with an antihistamine added to aid sleep.
Don’t Overdose on NSAIDs
Because of their antiinflammatory properties, the new NSAIDs were welcomed by recreational athletes. At least in some cases, the antiinflammatory action of these drugs is quicker and stronger than that of aspirin, and they are the same medications often prescribed by doctors to treat minor sports or overuse injuries. Prescription doses are, however, much larger than those recommended on the over the counter (OTC) label, and studies show that a relatively large dose is needed to get a true antiinflammatory effect.
If you are used to popping pills to self treat a swollen knee or sprained ankle, you should exercise some caution. First-line treatment for swelling is rest, ice and elevation, along with a modest dose of painkilling medication. If that does not work, you are better off having a doctor look at the knee to rule out a more serious injury and to prescribe the right antiinflammatory medication at a dose that is safe for you.
An even riskier practice is to use NSAIDs as a preventive measure against aches and pains. Pain is part of the body’s warning system to prevent overuse. Additionally, all of the NSAIDs can cause severe kidney problems if used by someone who is dehydrated by extended physical activity.
Even for headaches, it is important not to use OTC pain relievers more than twice a week since chronic use can lead to rebound headaches.
Aspirin is often recommended to heart disease patients because it inhibits the clotting action of blood. The same quality makes aspirin and other NSAIDs unsafe for anyone at risk of bleeding because of surgery or open injuries.
NSAIDs are generally recommended to fight swelling, but swelling accompanied by bruising is another matter. The bruises represent bleeding under the surface; as a result, acetaminophen is usually recommended.
Major Cause of Liver Failure
Even though it is recommended as safer for children, surgical patients and others at risk of bleeding, acetaminophen is not without its risks. Acetaminophen overdose is the major cause of liver failure, leading to about 57,000 hospitalizations each year.
The maximum daily dose for adults is 4,000 milligrams daily, and, unlike most OTC medications, the toxic dose is only slightly higher. One reason is that the drug leaves toxic remains in the liver that can be cleared away through food and fluids but are made worse by alcohol. A risk of overdose occurs if acetaminophen is used for a longer period or by anyone drinking alcoholic beverages on a regular basis. Signs of liver toxicity include nausea and vomiting, often leading patients to avoid eating when food would be helpful in clearing away toxic residues.
In one highly publicized case, resulting in an $8 million settlement, a 37-year-old man who drank two or three glasses of wine each night, experienced liver failure while taking Tylenol at the maximum recommended dose. In another case, a non-drinker died of liver failure when he followed up a prescribed dose of the drug with over-the-counter pills plus TheraFlu, which he did not know contained acetaminophen.
Many doctors still consider acetaminophen to be the safest over-the-counter pain medication since it has the fewest side effects when used at recommended doses. But there is really no safe medication. Persons taking Tylenol are advised to check the labels of all other OTC drugs they are taking. There are more than 300 products on the market that contain large quantities of acetaminophen.
All of the over-the-counter pain medications have excellent safety records when used as intended–to get rid of a nagging headache, reduce fever or help treat minor swelling and inflammation. All have side effects that may become dangerous with heavy or long-term use. For selected situations, each product has its own benefits and risks. The choice is yours, but remember: extra pain does not necessarily mean extra pills.
By: Kerri Musselman, Pharm.D.
