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Key considerations in OTC analgesia

Your patients may not realize that an OTC pain reliever they used in the past may no longer be the most appropriate choice for them, based on their age, coexisting medical conditions, and medications. Your guidance can help.

HCP Acetaminophen & NSAIDs Comparison Charts

Quick reminders for making patient-appropriate analgesic recommendations

Coexisting medical conditions to consider when recommending OTC analgesics
Gastritis or ulcers

Patients with existing GI risks who take NSAIDs are at higher risk of developing serious GI toxicities such as an ulcer or bleeding

Renal abnormalities

Patients with renal abnormalities who take NSAIDs may develop chronic kidney disease.4 NSAID-related renal adverse events may be dependent on dose and duration of therapy, and can include reduced glomerular filtration, nephritic syndrome, and chronic renal failure5

Cardiovascular risks

Patients with cardiovascular disease are at increased risk for cardiovascular events (myocardial infarction, stroke) when taking NSAIDs6

Liver disease or liver cirrhosis

When not used as directed, acetaminophen can increase the risk of hepatotoxicity in patients with liver dysfunction. NSAIDs are also metabolized in the liver and can pose risks for individuals with hepatic problems7

Hypertension

NSAIDs may be associated with modest increases in blood pressure. The adverse effect of NSAIDs on blood pressure may have the most clinical significance in the elderly, among whom the prevalence of arthritis, hypertension, and NSAID use is high2,3

Asthma

In some adult patients with asthma, aspirin and other NSAIDs that inhibit cyclooxygenase-1 can exacerbate the condition8

Concomitant medicines to consider before recommending OTC analgesics

Acetaminophen

Other acetaminophen-containing medicines Taking multiple medicines containing acetaminophen can increase the risk of overdose, which can lead to severe liver damage

Warfarin Acetaminophen may increase the anticoagulant effect of warfarin

NSAIDs

Other NSAIDs Frequent chronic NSAID use can increase the risk of serious side effects, including GI bleeding and cardiovascular problems6

Anticoagulants/antiplatelet medications Co-administration of NSAIDs and anticoagulants can increase the risk of GI bleeding. Antiplatelet medications have recognizable
risks—including GI complications and related bleeding. These risks may be compounded by the use of other adjunctive medications, including NSAIDs1,2

Corticosteroid use The chance of severe stomach bleeding is higher when corticosteroid drugs are used with NSAIDs. This may be due to steroids decreasing the production of gastric mucus and delayed healing of NSAID-induced erosions9,10

Antihypertensive agents NSAIDs may be associated with modest increases in blood pressure, and they may blunt the effects of common classes of antihypertensive medicine, including angiotensin-converting enzyme (ACE) inhibitors, diuretics, and beta-blockers3

Aspirin-specific interactions Ibuprofen can reduce the cardioprotective benefit of an aspirin regimen.11 Taking other NSAIDs with aspirin can increase the risk of GI bleeding.2 Aspirin may interact with some prescription drugs, including medications for diabetes, arthritis, and gout12

Other considerations
Alcohol Use

If an individual consumes three or more alcoholic drinks every day while taking NSAIDs, the risk of GI bleeding is increased. If drinking this amount while taking acetaminophen, severe liver damage may occur

Other Helpful Resources

Acetaminophen & NSAIDs Gastrointestinal Considerations

See a brief animation on NSAIDs and the GI system

Acetaminophen & NSAIDs Renal Considerations

See how NSAIDS may affect patients with renal dysfunction

References: 1. Risser A, Donovan D, Heintzman J, Page T. NSAID prescribing precautions. Am Fam Physician. 2009;80(12):1371-1378. 2. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Circulation. 2008;118(8):1894-1909. 3. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51:1403-1419. 4. National Kidney Foundation. Pain medicines (analgesics). https://www.kidney.org/atoz/content/painmeds_analgesics. Accessed May 19, 2016. 5. Decloedt E, Maartens G. Drug-induced renal injury. CME. 2011;29(6):252-255. 6. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidal anti-inflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115(12):1634-1642. 7. Chandok N, Watt KDS. Pain management in the cirrhotic patient: the clinical challenge. Mayo Clin Proc. 2010;85(5):451-458. 8. Peterson GM. Selecting nonprescription analgesics. Am J Ther. 2005;12:67-79. 9. Guslandi M. Steroid ulcers: any news? World J Gastrointest Pharmacol Ther. 2013;4(3):39-40. 10. Hernández-Díaz S, García Rodríguez LA. Steroids and risk of upper gastrointestinal complications. Am J Epidemiol. 2001;153:1089-1093. 11. Catella-Lawson F, Reilly MP, Kapoor SC, et al. Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med. 2001;345(25):1809-1817. 12. National Institutes of Health. Aspirin. https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682878.html#precautions. Accessed May 19, 2016.