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Uses, Dosage, and Side Effects – KnowYourOTCs

What is ibuprofen?

Ibuprofen is an internal analgesic available in over-the-counter (OTC) medicines that temporarily relieve minor aches and pains and reduce fevers. It is also available in prescription-strength medicines. Ibuprofen is part of a group of pain relievers and fever reducers called non-steroidal anti-inflammatory drugs (NSAIDs).

Ibuprofen can be the only ingredient in oral pain relievers and fever reducers or it can be found in medicines that treat migraines. It is also available in medicines that not only relieve pain or reduce fever, but treat additional symptoms as well, such as occasional sleeplessness, allergies, the multiple symptoms of the common cold, and symptoms associated with menstruation.

The U.S. Food and Drug Administration (FDA) is warning that use of nonsteroidal anti-inflammatory drugs (NSAIDs) around 20 weeks or later in pregnancy may cause rare but serious kidney problems in an unborn baby. Click here to learn more.

What is ibuprofen used to treat?

Temporarily relieves minor aches and pains due to:

Temporarily reduces fever.

Common brands containing ibuprofen:
  • Advil®
  • MOTRIN®
  • Store Brands (ex. Walmart’s “Equate” store brand or CVS Health store brand)

How much ibuprofen can you take?

The U.S. Food and Drug Administration (FDA) recommends adults take no more than 1,200 milligrams (mg) of ibuprofen in a 24-hour period.

Different types of products containing ibuprofen have different strengths. That’s why it is always important to read and follow the Drug Facts label. Most medicines warn against use of an active ingredient for longer than 7-10 days. Stop use and ask a doctor if symptoms persist.

Safety guide for ibuprofen

Ibuprofen is approved by the FDA and is safe and effective when used according to the Drug Facts label. You should never take more ibuprofen or for a longer period of time than the label instructs unless your healthcare provider tells you to. Certain health risks such as heart attack, stroke, or stomach bleeding may increase if you use more than directed or for longer than directed.

Ask a healthcare professional before use if:
  • You are currently using another medicine containing an NSAID (e.g., aspirin, magnesium salicylate, naproxen sodium, ibuprofen, or ketoprofen).
  • You are taking a blood thinner (anticoagulant), steroid, diuretic, or any other drug.
  • You are pregnant or breastfeeding. Women in the last three months of pregnancy are specifically told not to use ibuprofen or any NSAID without a healthcare provider’s permission.
  • You are over the age of 60.
  • You have had stomach ulcers or bleeding problems.
  • You drink three or more alcoholic drinks every day.
  • You are under a healthcare provider’s care for any serious condition.
  • You are taking aspirin for heart attack or stroke. Ibuprofen may decrease this benefit of taking aspirin.
  • You are unsure about child dosing instructions. Read the label and contact your healthcare professional as directed.
  • Before giving ibuprofen to a child if the child has not been drinking fluids, has lost a lot of fluid due to vomiting or diarrhea, or is taking a diuretic.
Do not use if:
  • You are preparing to have heart surgery or if you just had heart surgery.
  • You have ever had an allergic reaction to any other pain reliever or fever reducer.
  • You are a woman in the last three months of pregnancy, unless your healthcare professional specifically tells you to. Problems in the unborn child or complications during delivery could occur.
  • Tamper-evident packaging features such as seals, locks, and films are not clear or seem broken.
  • Do not give ibuprofen to children under six months of age.
Stop use and ask a doctor if:
  • An allergic reaction occurs. Seek medical help right away.
  • Your fever gets worse or lasts more than three days, or if your pain gets worse and lasts more than 10 days.
  • You have signs of stomach bleeding, such as if you feel faint, vomit blood, have stomach pain or upset that lasts or does not get better, or have bloody or black stools.
  • Redness or swelling is present in the painful area or if any new symptoms appear.
  • You take too much. Immediately contact a healthcare provider or the poison control national helpline at 800.222.1222.
  • If your child has a severe sore throat that lasts for more than two days, or is accompanied or followed by high fever, headache, nausea, or vomiting.

What are the side effects of ibuprofen?

  • Ibuprofen, like other NSAIDs, may cause a severe allergic reaction, especially in people allergic to aspirin. Symptoms may include hives, facial swelling, asthma (wheezing), shock, skin reddening, rash, or blisters.
  • Severe stomach bleeding may occur. The chance is higher if you are age 60 or older; have had stomach ulcers or bleeding problems; or if you are taking a blood thinner (anticoagulant), steroid drug, or other medicines containing NSAIDs (e.g., aspirin, magnesium salicylate, naproxen sodium, ibuprofen, or ketoprofen).
  • If upset stomach occurs, you may take the medicine with milk or food.

Ibuprofen – Advil Motrin etc – Dosage Table | Health & Wellness Library | University Hospitals Rainbow Babies & Children’s Hospital | Cleveland, OH

Ibuprofen (Advil, Motrin, etc.) Dosage
Child’s weight 12 – 17 lbs. 18 – 23 lbs. 24 – 35 lbs. 36 – 47 lbs. 48 – 59 lbs. 60 – 71 lbs. 72 – 95 lbs. Over 96 lbs.
Infant Drops 50 mg/1.25 ml 1.25 1.875 2.5 3.75 5
Liquid 100 mg/5 milliliters (ml) 2.5 4 5 7.5 10 12.5 15 20
Chewable 50 mg. tablets 2 3 4 5 6 8
Junior-strength 100 mg tablets 2 3 4
Adult 200 mg. tablets 1 1 2

Indications:

Treatment of fever and pain.

Table Notes:

  • AGE LIMIT: Don’t use under 6 months of age unless directed by child’s doctor. (Reason: safety not established and doesn’t have FDA approval). Avoid multi-ingredient products in children under 6 years of age (FDA recommendations 1/2008).
  • DOSAGE: Determine by finding child’s weight in the top row of the dosage table.
  • MEASURING the DOSAGE: Syringes and droppers are more accurate than teaspoons. If possible, use the syringe or dropper that comes with the medication. If not, medicine syringes are available at pharmacies. If you use a teaspoon, it should be a measuring spoon. Regular spoons are not reliable. Also, remember that 1 level teaspoon equals 5 ml and that ½ teaspoon equals 2.5 ml.
  • IBUPROFEN DROPS: Ibuprofen infant drops come with a measuring syringe.
  • FREQUENCY: Repeat every six to eight hours as needed
  • ADULT DOSAGE: 400 mg
  • BRAND NAMES: Motrin, Advil, generic ibuprofen

Author and Senior Reviewer: Barton D. Schmitt, M.D.
Content Set: Pediatric HouseCalls Symptom Checker
Pediatric HouseCalls Symptom Checker

FDA approves combination ibuprofen-acetaminophen drug for U.S.

March 02, 2020

Dr. Mia Geisinger

The Food and Drug Administration has approved the first over-the-counter ibuprofen and acetaminophen combination drug for the U.S.

The product — called Advil Dual Action — will be available nationwide later in 2020 and contains 250 mg of ibuprofen and 500 mg of acetaminophen, said GlaxoSmithKline, the drug’s manufacturer, in a news release.

The ADA has long advocated for the development of a single strength-controlled acetaminophen-ibuprofen combination drug to be available over-the-counter for dental patients — particularly as the nation continues to battle the opioid epidemic.

Dr. Mia Geisinger, chair, ADA Council on Scientific Affairs, cheered the news and pointed to the ADA Science Institute’s 2018 overview of systematic reviews of acute pain medications that concluded combinations of ibuprofen and acetaminophen “offered the most favorable balance between benefits and harms” for treating dental pain.

“Many other studies point to using nonsteroidal medications with or without acetaminophen as being safe, effective and a preferred alternative to opioid medications in most patients,” said Dr. Geisinger, who also cited studies led by past and present CSA members published in the Journal of the American Dental Association. “The introduction of this medication may simplify this medication protocol for use in dental practice and further reduce the use of opioid prescriptions as first-line pain control therapy.”

The approval was based on data from several clinical studies, including three efficacy and safety trials, for the product, according to GlaxoSmithKline. The company also noted the data demonstrated “a fixed-dose combination of ibuprofen and acetaminophen achieves a superior level of pain relief compared to the individual components alone.”

“For decades, many consumers have been using ibuprofen and acetaminophen to get the benefits of both active ingredients when safely treating their headaches, muscle aches, backaches, arthritis and other joint pain,” said Franck Riot, head of research and development, GlaxoSmithKline, Consumer Healthcare. “[Advil Dual Action] will offer U.S. consumers the first-ever alternative option – a single, fixed-dose combination pain reliever.”

For information about the ADA’s advocacy efforts with opioids education, visit ADA.org/opioids. Additional online resources can be found on the ADA Center for Professional Success. The ADA Catalog also features “The ADA Practical Guide to Substance Use Disorders and Safe Prescribing.”

Advil or Motrin (ibuprofen) – Dr. Adam Stewart

Advil” is a brand name for the drug, “ibuprofen“. It also the same drug as “Motrin“. All of these are the same medication, just different names.

Advil is an ANTI-INFLAMMATORY. It is commonly used to treat pain, inflammation, or fever. Other examples of anti-inflammatory medications are: “Naproxen,” “Aleve,” “Celebrex,” “Arthrotec,” or “Meloxicam.”

Never take more than one type of anti-inflammatory in the same day. (However, Tylenol is different. Tylenol is not an anti-inflammatory, so you can take Tylenol in addition to Advil or other anti-inflammatory medications.)

 

You should avoid Advil (and other anti-inflammatory medications) if you have kidney problems, bleeding from your stomach or bowels, or if you are taking certain blood pressure medications.

 

FOR ADULTS:

Advil usually comes in a 200mg pill (Regular Strength), or a 400mg pill (Extra Strength). You can also find equivalent non-brandname versions of ibuprofen that are usually less expensive.

Adults can take up to 600mg of Advil every 6 hours, as needed:

  • i.e. take THREE regular strength 200mg pills every 6 hours.
  • or, 1 and 1/2 extra strength 400mg tablets every 6 hours.

Alternatively, you may wish to take 400mg every 4 hours, as needed:

  • i.e. take TWO regular strength 200mg pills every 4 hours.

 

 

FOR CHILDREN:

Children’s doses are based on their weight. Be sure you know your child’s weight.

 

Children’s Advil comes in many different strengths and forms. Be sure you look on the bottle to know what form you are using. The most common forms are:

“PEDIATRIC Drops” – contains 200mg of Advil per 5ml.

“CHILDREN’s suspension” – contains 100mg of Advil per 5ml

“JUNIOR STRENGTH Tablets” – contain 100mg of Advil per tablet.

 

The doses recommended on the bottles are usually less than your child can actually take.

 

THE PROPER DOSE FOR ADVIL IN CHILDREN IS:

  • 10mg per kilogram body weight every 6 hours as needed.
  • Up to a maximum of 600mg per dose.

 

*** CLICK HERE TO FIND OUT HOW MUCH ADVIL YOU CAN GIVE YOUR CHILD ***

Uses, Complications, Recalls and Warnings

Tylenol (acetaminophen) is the most popular over-the-counter (OTC) pain relief medication used in the U.S. and around the world. Acetaminophen is the active ingredient in Tylenol and the generic name of the drug that is commonly found in other medications.

The drug was first sold in 1955 as Tylenol Elixir for Children, and today millions of American adults and children use the drug every week for common ailments such as head and body aches, colds, and fevers. In fact, according to the Consumer Healthcare Products Association, about 52 million consumers in the U.S. use products containing Tylenol each week.

Manufactured by Johnson & Johnson subsidiary McNeil Laboratories, the drug generates more than $1 billion a year. It is marketed as an effective painkiller that is safer than non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, which are associated with stomach discomfort or bleeding.

Tylenol Uses

Tylenol belongs to a class of drugs called analgesics and antipyretic agents. An analgesic relieves pain. An antipyretic reduces fevers. For more than 50 years, doctors have recommended Tylenol for both uses.

Unlike other analgesics like aspirin and ibuprofen (Advil, Motrin), Tylenol does not treat inflammation. It is most effective for minor aches and pains but can be used safely for long-term chronic pain such as arthritis. In fact, the American College of Rheumatology recommends Tylenol to treat arthritis, and it is especially useful in types of arthritis that are not accompanied by inflammation, like osteoarthritis.

How Tylenol Works

Researchers don’t fully understand how Tylenol works. Although there are several theories, none seems to satisfy everyone.

One theory is that Tylenol controls fever and pain by blocking an enzyme called cyclooxygenase (COX-1). COX sends out chemicals known as prostaglandins that make the body feel pain and induce fever in response to an injury or illness. If this theory is correct, then Tylenol works very similarly to aspirin, ibuprofen, and other NSAIDs.

Some researchers believe Tylenol works on the endocannabinoid system, which plays a part in the sensation of pain in the body. The main ingredient in marijuana, THC, also works through this system, which explains why some people look to marijuana for a form of pain relief.

A third theory is that Tylenol may also alter signaling from the neurotransmitter serotonin. Other researchers believe the drug’s effectiveness stems from the fact it inhibits neurotransmitter receptors in the brain that register pain, such as N-methyl-D-aspartate and substance P.

Still, other researchers say Tylenol may work through a combination of all of these theories. And if you ask Johnson & Johnson: “It works by elevating the body’s overall pain threshold so you feel less pain, and lowers your fever by helping your body eliminate excess heat.”

Common Side Effects of Tylenol

Tylenol on its own is a non-prescription (over-the-counter) medication. While prescription medications are required to include certain prescribing information, such as common side effects, non-prescription medications like Tylenol do not typically contain the same information. Therefore, much of the information regarding side effects provided for over-the-counter Tylenol medications refers to serious side effects of the drug, usually due to overdose.

Common Side Effects of Acetaminophen Include:

  • Constipation (infrequent or difficult to pass bowel movements)
  • Agitation
  • Headaches
  • Insomnia (trouble falling asleep or staying asleep)
  • Vomiting

Complications Associated with Tylenol

Tylenol is associated with serious complications, including liver damage and rare but dangerous skin reactions. It is the leading cause of acute liver failure in the U.S., and the drug in some cases has led to fatalities. The active ingredient in Tylenol, acetaminophen, accounts for more than 100,000 calls to poison centers, roughly 60,000 emergency-room visits and hundreds of deaths each year in the U.S. In England, it is the leading cause of liver failure requiring transplants.

“Acetaminophen is a dangerous drug,” Dr. John Brems, professor of surgery and chief of intra-abdominal transplantation at Loyola University in Chicago told ABC News. “Many of these patients took acetaminophen in addition to alcohol. I end up transplanting three to four patients per year, and two to three die before we can transplant them. It is probably the most dangerous OTC drug in this country.”


Timeline of FDA Tylenol Actions:

  • 2009

    FDA issued guidelines for adding overdose information to products.

  • 2011

    The agency confirmed the link between acetaminophen and liver damage and added a black box warning, the agency’s strongest warning, to the label of prescription products containing the drug.

  • 2011
    FDA asked drug manufacturers to limit the strength of acetaminophen in prescription drug products to 325 mg.
  • 2011

    The agency added a warning highlighting the potential for allergic reactions (e.g., swelling of the face, mouth, and throat, difficulty breathing, itching, or rash) to the label of all prescription drug products that contain acetaminophen.

  • 2013

    FDA released a safety warning about acetaminophen and rare but serious skin reactions.

  • 2014

    The agency announced its intent to take steps to withdraw approval of prescription combination drug products containing more than 325 mg of acetaminophen.

  • 2015

    FDA announces findings from review of acetaminophen use during pregnancy.

Tylenol Use During Pregnancy

The FDA reviewed possible risks of acetaminophen use during pregnancy and released its findings in a January 2015 Drug Safety Communication.

According to the safety communication, two U.S. studies indicate that 65 to 70 percent of pregnant women in the U.S. reported using acetaminophen anytime during pregnancy.

One study reported an increased risk between acetaminophen use in pregnancy and attention deficit hyperactivity disorder (ADHD) in children. Women reporting any acetaminophen use in pregnancy were also significantly more likely to have a child with a hyperkinetic disorder (HKD) diagnosis or a child who used ADHD medications, compared to unexposed women.

“Associations for all outcomes were strongest for acetaminophen use in multiple trimesters and for more than 20 weeks during pregnancy,” the FDA noted.

The FDA said the study “had a number of methodologic limitations” and concluded “the weight of evidence is inconclusive regarding a possible connection between acetaminophen use in pregnancy and ADHD in children.”

Tylenol Recalls

Tylenol faced a string of recalls from 2009 to 2012. Some Tylenol products didn’t return to store shelves until 2013.

In 2009, McNeil recalled many Tylenol brands because a chemical for treating wood made it into the medicine, causing nausea, vomiting and diarrhea. In 2011, it expanded the recall to include several more lots of the medication. The recall involved tens of thousands of Tylenol products and prompted Johnson & Johnson to close a manufacturing plant. Furthermore, the FDA stepped in to supervise quality control measures at three plants. Then in 2012, McNeil recalled nearly 600,000 bottles of infant Tylenol for faulty dosing systems that could result in babies receiving too little or too much medicine.

Chicago Tylenol Murders

The drug was also linked to several murders in 1982 called the Chicago Tylenol Murders. Several people in Chicago died after taking Extra-Strength Tylenol caplets that were laced with cyanide. McNeil was not implicated in the murders because the bottles came from different factories, and all seven deaths took place in the Chicago area, ruling out the possibility of tampering during production.

After the murders, Johnson & Johnson sent warnings to hospitals and distributors, stopped all advertising and producing Tylenol and recalled approximately 31 million bottles. The murders remain unsolved.

Other Examples of Tylenol Recalls

Product Reason Date
TYLENOL®, Extra Strength Caplets, 225 count Uncharacteristic musty, moldy odor 6/28/11
TYLENOL® 8 Hour, TYLENOL® Arthritis Pain, and TYLENOL® upper respiratory products, and certain lots of BENADRYL®, SUDAFED PE®, and SINUTAB® products Insufficient development during manufacturing 1/14/11
Tylenol Cold Multi Symptom Daytime Liquid 8 oz Citrus Burst Mislabeled – alcohol content not listed on front panel 11/27/10
Tylenol 8 Hour Caplets in 50 count bottles Off odor – musty/moldy 10/18/2010

Tylenol Forms and Doses

Tylenol is available in tablet, chewable tablet, capsule, suspension or solution (liquid), extended-release (long-acting) tablet and orally disintegrating tablet forms and as a suppository for rectal use. There is also an intravenous form of acetaminophen that is used in the hospital setting.

Most formulations are available in several dose amounts, usually from 300 mg to 1000 mg. People can obtain it in prescription and non-prescription strengths; however, the strength of acetaminophen in prescription drug products is limited to 325 mg per request by the FDA.

The maximum indicated dose in a 24-hour period should not exceed 4,000 mg for most patients. Taking more than 4,000 mg of Tylenol a day puts users at risk for liver failure. Experts say anyone taking Tylenol long-term for chronic pain should consider having liver function tests done once or twice a year.

Taking Tylenol

Users do not need to take Tylenol with food or on a full stomach. Don’t take acetaminophen if you drink three or more alcoholic drinks a day, and don’t take more than one product that contains acetaminophen at a time.

Child-Specific Product
To administer the medicine to children, use the child-specific product with a dosing cup or dropper that comes with it. Teaspoons found in the home vary in size and their use to administer Tylenol could overdose or underdose a child. You may need to shake the liquid before each use.

Chewable Tablet
The Tylenol Meltaways chewable tablet softens in the mouth to make it easier to chew. Chew the tablet thoroughly before swallowing it.

Meltaways
Meltaways are orally disintegrating tablets. Place the tablet in your mouth and either wait for it to dissolve or chew it before swallowing.

Extended–Release Tablets
Extended-release tablets are meant to be swallowed whole. Do not split, chew, crush or dissolve these tablets before swallowing.

Acetaminophen Labels

Because acetaminophen is present in hundreds of medications, it’s important to read the labels of all prescription and OTC drugs to see if they contain it.


Some labels may replace the word acetaminophen with:

  • APAP

  • AC

  • Acetaminoph

  • Acetaminop

  • Acetamin

  • Acetam

  • Paracetamol

The FDA, National Council for Prescription Drug Programs (NCPDP) and pharmacies across the nation are working to ensure “acetaminophen” is fully spelled out on prescription labels. NCPDP estimates that more than 75 percent of pharmacies in the U.S. are part of this effort.

Products Containing Tylenol

Tylenol is used in combination with other active ingredients in a number of prescription and OTC medications.


Most Common Tylenol Products:

  • Tylenol Brand Products

  • Extra Strength Tylenol

  • Tylenol Arthritis Pain

  • Tylenol Cold Multi-Symptom Severe

  • Tylenol Cold & Flu Severe

  • Simply Sleep

  • Children’s Tylenol Meltaways Chewable Tablets

  • Children’s Tylenol Plus Cold

  • Children’s Tylenol Plus Cough & Sore Throat

  • Regular Strength Tylenol

  • Regular Strength Tylenol

  • Tylenol Sinus Congestion and Pain Severe

  • Tylenol Cold Multi-Symptom Daytime

  • Tylenol Cold Sore Throat

  • Children’s Tylenol Oral Suspension

  • Tylenol Meltaways Chewable Tablets

  • Children’s Tylenol Plus Cold & Cough

  • Children’s Tylenol Plus Flu

  • Tylenol 8 Hour Muscle Aches and Pain

  • Tylenol Sinus Congestion and Pain Daytime

  • Tylenol Cold Multi-Symptom Nighttime

  • Tylenol PM

  • Infant’s Tylenol Oral Suspension

  • Children’s Tylenol Plus Multi-Symptom Cold

  • Children’s Tylenol Plus Cough & Runny Nose


Over-the-Counter Brand-Name Medications with Acetaminophen:

  • Actifed

  • Alka-Seltzer Plus LiquidGels

  • Anacin

  • Benadryl

  • Cepacol

  • Contac

  • Coricidin

  • Dayquil

  • Dimetapp

  • Dristan

  • Excedrin

  • Feverall

  • Formula 44

  • Goody’s

  • Powders Liquiprin

  • Midol

  • Nyquil

  • Panadol

  • Robitussin

  • Saint Joseph

  • Aspirin-Free Singlet

  • Sinutab

  • Sudafed

  • Theraflu

  • Triaminic

  • TYLENOL Brand Products

  • Vanquish

  • Vicks

  • Zicam

  • Zydone


Prescription Brand-Name Medications with Acetaminophen:

  • Endocet

  • Fioricet

  • Hycotab

  • Hydrocet

  • Hydrocodone Bitartrate

  • Lortab

  • Percocet

  • Phenaphen

  • Sedapap

  • Tapano

  • Tylenol with Codeine

  • Tylox

  • Ultracet

  • Vicodin

Chronic Pain Medications: Anti-Depressants to Opioids

Pain is our body’s way of warning us that something may be wrong. It’s very important to “listen” to our bodies when you don’t feel right because pain that isn’t treated can become chronic and negatively-impact your health. From OTC meds such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) to opioids and other prescription drug options, here’s what to know. 

Medications play a crucial role in managing pain but every body is different and responsiveness can vary greatly. Some benefit from OTC or prescription-strength NSAIDs (ibuprofen aka Motrin) while others may need something stronger, such as an opioid.

Acute Versus Chronic Pain

Pain is classified in two ways. It’s either acute or chronic. Acute pain begins suddenly and feels sharp. It may be caused by broken bones or cuts. It usually resolves right away or may last up to three months.

Sometimes acute pain transitions to chronic pain. This may happen when the physical condition causing the pain is unresolved such as cancer or arthritis. It can also happen if the nervous system gets impaired and sends pain signals when there isn’t a specific cause of pain. 

Chronic pain is ongoing pain that lasts for more than three months and is usually harder to daignose. It’s important to distinguish between acute and chronic pain as treatment choices differ. Over-the-counter (OTC) medications, such as aspirin, acetaminophen, or ibuprofen (an NSAID), may not be strong enough. In fact, most chronic pain patients need prescription medications to cope with pain.

Non-Opioid Options for Pain

Although there are many types and brands of medications, what medication your doctor recommends depends on you—your pain level, treatment goals, and overall health.

Our  Smart Patient’s Guide (below) can be printed and gives a  more detailed look at some of the non-opioid medications—NSAIDS, antidepressants, and more—that can be used to  for managing a variety of chronic pain conditions.

Before taking any medication, even if it’s an over-the-counter medication, discuss it with your doctor. Some medications have serious side effects if they’re not taken as directed. Your doctor should be aware of everything you’re taking, including herbal remedies and supplements, because of possible drug interactions or side effects.

How to Explain Your Pain

Now that you know the difference between acute and chronic pain, lets drill down a bit more. The cause of your pain will for the most part determine the type of pain you are experiencing. Describing your symptoms accurately is important because it helps your healthcare provider choose the best treatment for your pain.

Nociceptive pain and neuropathic pain are the two most common types of pain.

Nociceptive Pain

Nociceptive pain is caused by tissue damage or injury to the skin, bones, muscles, or joints. Think broken arm, sprained ankle, a puncture wound from a dog bite, or a banged-up knee.

Treatment for nociceptive pain may range from mild OTC meds such as Advil to powerful prescription drugs like Percocet.

Treating Nociceptive Pain with NSAIDs

Most doctors will start with an NSAID for pain. NSAIDs are divided in two categories: COX-1 inhibitors and COX-2 inhibitors. COX-1 inhibitors include medications like ibuprofen (Advil, Motrin) and naproxen (Aleve). This class can be harsh on the stomach and may cause ulcers or bleeds, so taking it with food is a good idea.

If you experience black or tarry stools, bright red blood in vomit, or severe cramps,  seek medical attention immediately as these symptoms indicate a stomach bleed. These reactions can occur at any time during use and without warning symptoms.

COX-2 inhibitors are easier on the stomace and include medications like celecoxib (Celebrex) and meloxicam (Mobic). The bad news is they may increase the risk of heart attack or stroke so be sure to discuss with your doctor.

If pain exists in just one area of your body, such as arm or leg, consider treating it with a topical NSAID such as diclofenac (Voltaren gel). Voltaren gel must be applied to clean, dry, and intact skin

Acetaminophen (Tylenol) can also be used but the daily dose should not exceed 4 grams to avoid liver damage. Keep in mind that acetaminophen may be contained in other prescription medications as well as OTC medications.

Let your doctor know about all the medications you are taking, including herbal remedies and supplements, to avoid any drug interactions or toxicities. 

Treating Nociceptive Pain with Opioids  

If the pain is still not adequately controlled, opioid therapy (for a limited period) may be recommended until the pain is controlled. Prolonged use of opioids is ill advised due to the many health risks associated with them.

Sadly, the long-term use of opioids increased significantly—despite the numerous serious risks associated with them—during the past few years.

In 2017, more than 191 million opioid prescriptions were dispensed to Americans—with wide variation across states. To avoid unnecessary risks without a justified benefit, it is important for that you and your doctor establish pain goals. For example, experiencing less pain rather than NO pain may be a reasonable goal to set. 

What Are Opioids?

Opioids are sometimes referred to as narcotics. They are stong painkillers derived from the opium poppy plant and are used to block pain signals between the brain and the body. Opioids are sometimes prescribed to alleviate moderate to severe acute pain and chronic pain.

Opioids provide immediate relief to intense pain by changing your brain’s perception of the pain message but other medication options are typically attempted to treat the pain first. They may be prescribed for low back pain, neuropathic pain, or arthritis pain. 

Because of the risk of addiction, abuse, or misuse, opioid use must be closely monitored by your doctor and should not be used regularly.

Examples of opioids include hydrocodone, hydromorphone, methadone, fentanyl, meperidine, morphine, tramadol, and oxycodone. The most common drugs involved in prescription opioid overdose deaths include methadone, oxycodone, and hydrocodone.

Respiratory depression is one of the most dangerous risks associated with opioids. All opioids slow down breathing, and in severe cases can cause the breathing to completely stop. The risk is higher if you have underlying breathing conditions such as asthma or sleep apnea.

If you have liver or kidney disease, opioids can build up in your body and put you at a higher risk for complications. Benzodiazepines (such as Xanax, Ativan) or Z-drugs (such as Ambien) or muscle relaxants (such as Flexeril) can also increase the risk for respiratory depression when used with opioids. 

Constipation is a very common, and very unpleasant, side effect of opioids. Constipation does not resolve with time and requires treatment. Stimulant laxatives such as senna, are the most effective treatment.

Neuropathic Pain

Pain that results from damage to the nerves is known as neuropathic pain. It presents as tingling, numbing, or shooting pain. Some describe it as “pins and needles”.

This type of pain may occur due to poorly-managed diabetes (referred to as diabetic neuropathy), trauma, the aftermath of surgery, infections, chemotherapy, fibromyalgia, or shingles (referred to as postherpetic neuralgia). Neuropathic pain requires a different treatment which may involve antidepressants, anti-seizure drugs, or topicals such as lidocaine and capsaicin. 

Antidepressants for Pain

Not all antidepressants can work for pain. Only antidepressants that affect norepinephrine (adrenaline in the nerves) are found to be effective for chronic pain.

These antidepressants are tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs). Selective serotonin reuptake inhibitors (SSRI) such as fluoxetine (Prozac) and sertraline (Zoloft) are also a class of antidepressants but have not been found to be effective in treating neuropathic pain. SSRIs do not have any effect on norepinephrine, the main component involved in pain relief. 

SNRIs are the preferred treatment for neuropathic pain as they are generally better tolerated by patients. The most used SNRIs are duloxetine (Cymbalta) and milnacipran (Savella).

Duloxetine is FDA approved for the treatment of diabetic neuropathy and milnacipran is FDA approved for fibromyalgia. Other SNRIs like venlafaxine (Effexor) and desvenlafaxine (Pristiq) are not commonly used for pain.

Unfortunately, SNRIs don’t work immediately. It may take weeks to feel the effects so be patient and take your meds as prescribed for best results. Common side effects include diarrhea, nausea, dry mouth, and dizziness.

What Is Serotonin Syndrome?

Since SNRIs have a serotonin component, they are referred to serotonergic drugs. Serotonergic drugs may cause serotonin syndrome, a dangerous condition which results when too much serotonin builds up in your body.

Symptoms of serotonin syndrome may range from mild (diarrhea and chills) to severe (fever and seizure). Serotonin syndrome may be life-threatening if left untreated.

It can occur if two serotonergic agents are used together or if one serotonergic agent is taken excessively. To avoid overlap of serotonergic agents be sure your doctor is aware of all the medications you are taking.  

Tricyclic Antidepressants (TCAs) for Neuropathic Pain

TCAs are the most studied antidepressants for the treatment of neuropathic pain as they have been around for a long time. Their pain-relieving properties were noted in research from the 1960s.

Similar to SNRIs, TCAs work by regulating norepinephrine, which mediates the analgesic effect. TCAs used for pain are amitriptyline, nortriptyline (Pamelor), doxepin (Silenor), imipramine (Tofranil), Desipramine (Norpramin) and clomipramine (Anafranil).

Side effects may include dry mouth, blurred vision, dizziness, nausea, weight gain, sweating and constipation. Due to the side effects, TCAs are less commonly used in the elderly population. If your doctor recommends TCAs for your pain, he will likely start with a low dose and gradually increase it until an effective dose is achieved. TCAs are also inexpensive which is a plus for low-income people or those without insurance. 

The dose used for neuropathic pain treatment is lower than the dose used for depression treatment. Higher doses are not effective for pain treatment and are associated with more side effects. 

Both TCAs and SNRIs are great options in patients who are suffering from depression or anxiety along with pain. However, they are still considered great options even if depression or anxiety are not present. It is important to note that antidepressants are associated with increased risk of suicidal thoughts or behaviors.

Talk to your doctor or counselor immediately if you feel depressed or suicidal.

Anti-Seizure Medications

Antiseizure medications are also known as anticonvulsants or antiepileptic drugs. This class works by calming down the overactive pain signals caused by damaged nerves.  

As with antidepressants, anti-seizure medications can treat chronic neuropathic pain and may be used even if no seizure disorder is present.

Examples of anti-seizure medications are pregabalin (Lyrica) and gabapentin (Neurontin). Gabapentin is FDA approved for postherpetic neuralgia but can be used in other types of neuropathic pain.

The target dose for pain is 1800mg and the maximum dose is 3600mg. Doses must be adjusted if the patient has any renal problems. Pregabalin is also FDA approved for postherpetic neuralgia as well as diabetic neuropathy and fibromyalgia. The typical starting dose is usually 75mg twice daily. The maximum dose is 600mg. Dose must also be adjusted if patient has kidney problems.

Side effects of gabapentin and pregabalin include weight gain, fluid buildup, sleepiness, and drowsiness. Gabapentin and pregabalin cannot be stopped abruptly; they must be withdrawn gradually to minimize withdrawal symptoms such as confusion, delusions, agitation, and sweating.

Topical Anesthetics

Topical drugs are valuable options in pain management as they achieve relief with a low risk of side effects and drug interactions.

There are many formulations available such as creams, ointments, gels, lotions, and patches. Counterirritants are an over-the-counter class of medications such as salicylates, camphor, and menthol.

Counterirritants work by irritating the nerves as a distraction from the original pain. aCapsaicin can be an effective option and is available as an 8% patch (Qutenza) and as cream, gel, and liquid.

Qutenza is available by prescription only and is FDA approved for neuropathic pain associated with postherpetic neuralgia. The initial response may be seen at one week as opposed to over the counter formulations, which may take up to 6 weeks.

Lidocaine 5% patch (Lidoderm) is also FDA approved for the treatment of postherpetic neuralgia. A maximum of 3 patches may be applied to the painful area per day. Apply the patch for 12 hours then take it off for 12 hours.

Wash hands after application and avoid contact with eyes. Avoid exposing application site to any heat sources such as heat lamps or electric blankets. The patch may cause some redness in application site. 

Corticosteroids

Steroids are powerful anti-inflammatory medications that can be taken orally or injected. If prescription-strength NSAIDs haven’t reduced your pain, your doctor may recommend that you try corticosteroids. They’re responsible for stopping your body from producing the chemical that causes inflammation.

However, as mentioned above, steroids have certain side effects (eg, weight gain), and you can’t just stop taking them—your dose must be slowly decreased. Corticosteroids are used to treat migraines, osteoarthritis, rheumatoid arthritis, and low back pain. Prednisone (Deltasone) and Decadron (Dexamethasone) are examples of corticosteroids.

Muscle Relaxants

These medications are used to reduce aches and pains associated with muscles strains, sprains, or spasms. Muscle relaxants can provide the pain relief you need to manage your daily activities by helping relax tight muscles and improve the quality of sleep you get. Muscle relaxants aren’t typically recommended for treating chronic pain, but they may help with fibromyalgia and low back pain symptoms. Examples of muscle relaxants are carisoprodol (Soma) and baclofen (Lioresal).

Pain Medication Drug Interactions

NSAIDs

  • May increase risk of bleeding
  • Multiple NSAIDs should not be used together, except if patient is using baby aspirin for heart benefit. If using aspirin for heart and ibuprofen for pain, take aspirin 1 hour before or 8 hours after ibuprofen
  • Avoid if you have kidney problems 
  • Avoid with alcohol  

Acetaminophen

  • Can be used with warfarin, but if used chronically, need to monitor closely as it may increase INR
  • Avoid or limit alcohol use due to risk of liver damage

Opioids

  • Avoid alcohol completely with all opioids, especially if extended release formulations
  • Use caution if already taking a benzodiazepine or muscle relaxant as they can increase the risk for respiratory depression where the breathing slows and can completely stop

SNRIs

  • Serotonin syndrome if combined with serotonergic agents such as SSRIs 
  • Increases bleeding risk if using along with an NSAID or a blood thinner such as warfarin or supplements like gingko. 
  • If taking a blood pressure medication, use caution and monitor blood pressure as SNRIs may increase blood pressure readings
  • Separate from Monoamine Oxidase Inhibitors (MAOIs) such as isocarboxazid (Marplan), phenelzine (Nardil), Tranylcypromine (Parnate) and linezolid, by two weeks

TCAs

  • Caution if you have existing heart problems as TCAs may cause Qt prolongation, which happens when the heart’s electrical system takes longer than normal to recharge between beats. 
  • Separate from Monoamine Oxidase Inhibitors (MAOIs), such as isocarboxazid (Marplan), phenelzine (Nardil), Tranylcypromine (Parnate) and linezolid, by two weeks

Anticonvulsant

  • Monitor closely if patient is on opioid therapy

Your Chronic Pain Treatment Plan

The most important thing to remember when taking medications to treat your chronic pain is that you need to be an active participant in your own treatment plan. Don’t be afraid to ask questions—you have to be your own advocate.

Over time, you may need to increase or decrease your dose of medication or perhaps change medications, so it’s essential that you carefully follow your doctor’s directions. Also, be on the lookout for side effects. If you notice any new symptoms, tell your doctor immediately. But don’t stop taking your medication unless your doctor tells you to do so.

Updated on: 07/22/21

Medication Guide

Non-opioids and Other Drugs to Treat Cancer Pain

Non-opioids or non-narcotics, like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) control mild to moderate pain. Some can be bought without a prescription (over-the-counter). These medicines are stronger pain relievers than most people realize. In many cases, non-opioids are all you’ll need to relieve your pain, especially if you “stay on top of the pain.” Staying on top of the pain means you should take pain relievers regularly, and not wait until your pain level becomes too intense. Waiting too long can make the pain harder to treat.

Acetaminophen

Acetaminophen is commonly known as Tylenol. It relieves pain much the same way NSAIDs do, but it doesn’t reduce inflammation as well as NSAIDs do. People rarely have side effects from the usual dose of acetaminophen. But liver and kidney damage may result if you take large doses of this medicine every day for a long time or drink alcohol with the usual dose. Even moderate amounts of alcohol (3 drinks per day) can lead to liver damage in people taking acetaminophen. You also need to be careful about taking other drugs that have added acetaminophen. See the section on Precautions about aspirin, acetaminophen, and ibuprofen in other medicines.

Your doctor may not want you to take acetaminophen regularly if you’re getting chemotherapy because it can cover up a fever. Your doctor needs to know if you have a fever because it could mean you have an infection, which needs to be treated quickly.

Non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) work a lot like aspirin. Either alone or used with other medicines, NSAIDs can help control pain. Before you take any NSAIDs or other non-opioids, ask your doctor, pharmacist, or nurse if it’s safe for you to take it with your other medicines, and how long you can take it. See the chart below for examples of commonly used NSAIDs.

Precautions about NSAIDs

Some people have a higher risk of complications related to NSAIDS. In general, NSAIDs should be avoided by people who:

  • Are allergic to aspirin or any other NSAIDs
  • Are on chemotherapy
  • Are taking steroids
  • Are taking blood pressure medicines
  • Have stomach ulcers or a history of ulcers, gout, or bleeding disorders
  • Are taking oral medicine (drugs by mouth) for diabetes or gout
  • Have kidney problems
  • Will have surgery within a week
  • Are taking blood-thinning medicine
  • Are taking lithium

If you drink alcohol, be careful taking NSAIDs. It can cause stomach upset and raise the risk of having reflux or even bleeding in the stomach. Smoking may also increase this risk. NSAIDs may also raise your risk of heart attack or stroke, especially if you take them for a long time.

Children and teens should not take aspirin or products that contain it.

Precautions about aspirin, acetaminophen, and ibuprofen in other medicines

Some opioids also contain aspirin or acetaminophen in the same pill. A few also contain ibuprofen. It can be dangerous if you take these drugs without being aware of this.

  • If one of your doctors tells you not to take aspirin or ibuprofen, or if you can’t take NSAIDs for some reason, be sure to check your medicine labels carefully.
  • If one of your prescription medicines has acetaminophen in it, and you also take over-the-counter acetaminophen for pain, you can get too much without knowing it. Too much acetaminophen can damage your liver.
  • If you’re not sure if a medicine contains aspirin, acetaminophen, or ibuprofen, ask a pharmacist.
  • If you take any non-prescription medicine for a cold, sinus pain, or menstrual symptoms while you’re taking pain medicines, read the label carefully. Most of these drugs are combination products that contain aspirin, ibuprofen, or acetaminophen. Check with a pharmacist to find out what you can safely take with your pain medicines.

Side effects of acetaminophen and NSAIDS*

Common non-opioid pain relievers

Action

Precautions

acetaminophen (Tylenol)

Reduces pain and fever

Large doses (more than 4 grams in 24 hours) can damage the liver or kidneys.

May cause liver damage in people who have 3 or more alcoholic drinks per day.

Acetaminophen reduces fever, so ask your doctor what to do if your body temperature is higher than normal (98.6oF or 37oC) while you’re taking this medicine.

Over-the-counter NSAIDs

aspirin

ibuprofen (Motrin, Advil)

naproxen sodium (Aleve or Naprosyn)

Prescription NSAIDs

celecoxib (Celebrex)

diclofenac (Voltaren, Cambia, Cataflam, Zipsor, Zorvolex)

indomethacin (Indocin)

ketorolac

meloxicam (Mobic)

nabumetone

naproxen (Naprosyn or Anaprox)

oxaprozin (Daypro)

piroxicam (Feldene)

sulindac

Reduce pain, inflammation, and fever

Can irritate the stomach

Can cause bleeding of the stomach lining, especially if combined with alcohol or if you smoke

Can cause kidney problems

Avoid these drugs if you are on anti-cancer drugs that may cause bleeding, or if you are taking blood thinners, steroids, blood pressure medicines, or lithium.

Aspirin and NSAIDs reduce fever, so ask your doctor what to do if your body temperature is higher than normal (98.6oF or 37oC) while you are taking one of these medicines.

May increase your risk of stroke or heart attack.

Children and teens should not take aspirin products, which can cause Reye syndrome.

* NSAIDs = Non-steroidal anti-inflammatory drugs

How drugs are named

A drug may have as many as 3 different names: Brand, generic, and chemical. For example:

Brand names: Tylenol, Tempra, Liquiprin, Anacin, Paramol (and many more)

Drug companies give their products brand names, and some products have more than one brand name. You should also know that the same brand name may be used on different drugs, since the name belongs to the company. Read the labels to see what ingredients are in each medicine.

Generic names: acetaminophen

The US Food and Drug Administration (FDA) approves the generic names by which drugs are usually known. Sometimes medicines can have the same generic name, but are made by different companies. Because the companies may produce the medicines differently, they may differ slightly in the way they’re absorbed by the body. For this reason, your doctor may sometimes prefer that you take a brand-name drug. Generic drugs usually cost less than brand-name ones. Ask your doctor, nurse, or pharmacist if you can use a cheaper generic medicine. Pharmacists are careful to get high-quality generic products, so it’s often possible to substitute a generic.

Chemical names: N-(4-hydroxyphenyl) acetamide

Chemical names tend to be long and hard to pronounce, so they are not used often.

What you need to know about drug names

Many pain relievers are available under both generic and brand names. Your doctor, nurse, or pharmacist can tell you the generic and common brand names of any medicines you’re taking. It’s always good to know both because you may hear either name when talking about your medicines. Knowing both names can also keep you from getting confused when keeping track of prescriptions and pill bottles. It can also keep you from taking too much of the same medicine if it’s prescribed using 2 different names.

Drug additives

Along with the main substance (for example aspirin, acetaminophen, or ibuprofen), some brands contain additives. Common additives include:

  • Buffers (such as magnesium carbonate or aluminum hydroxide) to decrease stomach upset
  • Caffeine to act as a stimulant and to improve the effect of some pain medicines
  • Antihistamines (such as diphenhydramine or pyrilamine) to help you relax or sleep

Medicines with additives can cause side effects you wouldn’t expect from the main drug. For example, antihistamines sometimes cause drowsiness. This may be all right at bedtime, but it could be a problem during the day. Additives tend to increase the cost of non-prescription pain relievers. They can also change the action of other medicines you may be taking or even keep your body from absorbing the other drug. When you start a new drug, even one you can get over the counter, always talk with your doctor or pharmacist about what you’re already taking to see if the combination can cause harmful effects.

Plain aspirin, acetaminophen, or ibuprofen probably works as well as the same medicines with additives. But if you find that a brand with certain additives is a better pain reliever, ask your doctor, nurse, or pharmacist if the additives are safe for you. Talk with them about any concerns you may have about the drugs contained in your non-prescription pain medicines.

Other medicines commonly used to help treat cancer pain

Many different types of medicines can be used along with (or instead of) opioids and non-opioids to help relieve cancer pain. Some of these medicines can help relieve pain or increase the effect of the pain medicine. Others lessen the side effects of pain medicines. These drugs are often started at low doses and increased over time. The table shows the classes and some examples of drugs that are not really pain medicines, but might be used to help you get the best pain relief with as few side effects as possible.

Drug class

Generic (brand) name

Action

Side effects

Antidepressants

amitriptyline (Elavil),

bupropion (Wellbutrin, Zyban),

imipramine (Tofranil),

nortriptyline (Pamelor),

desipramine,

doxepin (Silenor), 

duloxetine (Cymbalta),

venlafaxine (Effexor)

Used to treat tingling or burning pain from damaged nerves. Nerve injury (and nerve pain) can be caused by surgery, radiation, chemo, or the cancer itself.

Dry mouth, blurred vision, trouble passing urine, sleepiness, constipation, Drop in blood pressure with dizziness or fainting when standing. May cause irregular heartbeat, especially in patients with heart disease.

Antihistamines

hydroxyzine (Atarax, Vistaril),

diphenhydramine (Benadryl)

Can help control nausea and help people sleep. Help control itching.

Drowsiness, dry mouth and nose, irritability, restlessness, nervousness, trouble passing urine

Anti-anxiety drugs

diazepam (Valium),

lorazepam (Ativan)

Used to treat muscle spasms that may go along with severe pain. Also lessen anxiety.

Drowsiness. May cause urinary incontinence (loss of bladder control).

Stimulants and amphetamines

caffeine,

dextroamphetamine (Dexedrine),

methylphenidate (Ritalin),

modafinil (Provigil)

Increase the pain-relieving action of opioids and reduce the drowsiness they cause.

Irritability, rapid heartbeat, decreased appetite

Anti-convulsants

carbamazepine (Tegretol),

clonazepam (Klonopin),

gabapentin (Neurontin),

pregabalin (Lyrica)

Help to control tingling or burning from nerve pain caused by the cancer or cancer treatment.

Liver problems, low red and white blood cell counts. Some may cause sleepiness and dizziness.

Steroids

dexamethasone (Decadron),

prednisone

Help relieve bone pain, pain caused by spinal cord and brain tumors, and pain caused by inflammation.

Increased appetite and thirst. Fluid build-up in the body, increased blood sugar, stomach irritation, confusion. Changes in behavior, trouble sleeping.

How to decipher a prescription for eyeglasses.

2017-04-01 01:32:25
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