NSAIDS and Acetaminophen in Adults
By Laurence Degelsmith, MD
October 12, 2007
My last article focused on ibuprofen and acetaminophen for children. Now I will discuss their uses in adults, which are a bit more complicated.
Only short term use of these medications will be addressed in this article since long-term therapy with NSAIDS (“non-steroidal anti-inflammatory drugs”) or acetaminophen should be discussed with one’s physician.
Tylenol
Acetaminophen derives its name from the scientific name N-acetyl-p-aminophenol. Tylenol is the common brand name for acetaminophen and the most recognized term. Acetaminophen is the most widely used pain and fever reducer in the world. It is an ingredient in more than 100 over-the-counter products as well as numerous prescription medications.
Tylenol is an incredibly safe medication for adults of all ages and can be combined with most prescription and over-the-counter products as long as they don’t also contain acetaminophen.
A typical adult dose is 650-1000 mg and this can be taken every 4-6 hours as long as the maximum daily dose of 4 grams per day is not exceeded. This maximum daily dose should be adjusted to 2 grams per day in persons who engage in moderate alcohol consumption. Alcohol increases the toxic metabolites produced when the liver breaks down acetaminophen, which can produce serious complications. Liver failure is the most feared complication from Tylenol toxicity. But if dosing regimens are followed, the risk of liver damage is very small. It usually takes more than 7 grams ingested as a single dose or similar amounts taken over a short period of time to produce liver toxicity
Alcoholics taking Tylenol are obviously more susceptible to liver damage, but Tylenol can still be taken if the lower recommended dose is adhered to. Intentional or accidental overdoses can be treated in the hospital within 1-2 days using a drug called Mucomyst, which prevents the toxic metabolites of Tylenol from injuring the liver. If left untreated, a liver transplant is the only available option to prevent death once liver failure ensues after about a week.
Tylenol should never be taken continuously to treat pain for more than 10 days without consulting a physician (five days for children). If using it to treat a fever, a physician should be consulted after three days. The possibility of accidentally overdosing on acetaminophen is present when simultaneously taking several medications that all contain acetaminophen without realizing it. Darvocet, Percocet, Vicodin and Fiorcet are just some of the common prescription pain relievers that contain acetaminophen, but numerous over-the-counter cough and cold remedies also contain it.
Motrin and Advil (NSAIDS)
NSAIDS are relatively safe in most adults under the age of 60 when taken short term. Ibuprofen is the most common over-the-counter NSAID and is commonly recognized under the brand names Advil and Motrin. Aleve (naproxen) is an over-the-counter form of the prescription medication Naprosyn, which is a slightly stronger and longer-acting NSAID, but similar to ibuprofen. There are of course many other prescription NSAIDS often prescribed by specialists and primary physicians, such as Voltaren and Toradol.
Recommended doses of ibuprofen are 400-600 mg every six hours but a dose of 800 mg every eight hours is often prescribed for acute pain especially when accompanied by swelling or inflammation. Dosing for naproxen is 250-500 mg every 12 hours.
The most serious acute complications from NSAID are those that affect the gastrointestinal system. Stomach bleeding from ulcers or gastritis can be life-threatening and anyone with a history of either should refrain from NSAID use either short or long term.
The good news is that ibuprofen and naproxen do NOT increase the risk of heart complications which is the concern with the newer NSAIDS such as Vioxx, Bextra and Celebrex. These COX-2 inhibitors (COX standing for cyclooxygenase) are NSAIDS that were developed to decrease the risk of gastrointestinal bleeding. They do have a slightly lower risk of bleeding compared with other NSAIDS, but they carry with them an increased cardiac risk. This risk was extremely high and unacceptable for Vioxx and Bextra, which caused their removal from the market. Celebrex has only a mild increased risk and is still widely used. NSAIDS should be used with extreme caution in people taking Lithium, Lasix (furosemide), ACE inhibitors and Coumadin (warfarin). They should also be used with caution in persons who have moderate to severe hypertension, congestive heart failure, kidney disease, liver disease, people with asthma, people taking diuretics (water pills) and people over the age of 60.
Although I prefer NSAIDS over Tylenol for treating most acute painful conditions that I encounter in the Emergency Department, I tend to recommend only Tylenol or Tylenol and narcotic combinations for most elderly patients or any patients with a complicated medical history. In healthy adults with mild-to-moderate pain or fever and no contraindications, I will usually suggest high dose ibuprofen (600-800mg) for a short period of a few days. Long term use of any NSAID for treating chronic pain, arthritis or other ailment is a topic for discussion with one’s primary physician.
Author’s note: This article encompasses general guidelines taken from several published sources as well as my ten years of personal experience as an emergency physician. There will often be exceptions to the above guidelines because the risk vs. benefit ratio of using any medication will be different for each patient.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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