Mixing anti-inflammatories can cause serious complications.
Aspirin, ibuprofen, naproxen, diclofenac, and celecoxib, what do these drugs have in common? They are all anti-inflammatory drugs that can be used for treating pain. How about acetaminophen, also known as paracetamol and Tylenol? Well, acetaminophen is an analgesic and fever medication, not an anti-inflammatory drug, but I’ll talk about it in this article too.
I am a physician, specialist in pain medicine, and today I’ll answer some questions that people ask me all the time:
“How are they different, is one better than the other?”
“Can I mix them?”
“Can I use these drugs if I have high blood pressure?”
“Are they safe for children?”
First, let me start by explaining what inflammation is.
Inflammation is a normal reaction of the body to any insult, trauma, attack or infection. So, if a part of your body is invaded by bacteria, for example, your body will send an army of cells to combat and kill the bacteria. This makes that part of your body get hot, red, painful, and swollen.
However, the body will always overreact, and this makes the inflammatory reaction usually much exaggerated than what is needed.
The body overreacts because it is better to send more inflammatory cells to kill the bacteria than to take the risk of not sending enough cells and lose the battle, which could mean spreading the infection to the whole body.
But inflammation occurs not only when we have an invasion by bacteria, but it also happens in auto-immune diseases, or when there is a fractured bone, or a ruptured tendon, we call this tendinitis.
Basically, anything that ends with “itis” means inflammation.
In the appendix, we get appendicitis.
In the brain, we get meningitis.
In the throat, we get tonsillitis.
In the ear, we get otitis. And so on.
Therefore, the way to combat inflammation is by using anti-inflammatory drugs. There are mainly two types of anti-inflammatories: steroidal and non-steroidal. This article is about non-steroidal anti-inflammatory drugs, the short form is NSAIDs.
A week ago I posted this question to my Youtube subscribers: When you are in pain, what do you do? Thirty-seven percent said they take a painkiller medicine, 30% do some exercise, 17% try to distract their mind out of it, 6% just cry and be miserable, and the remaining 9% said a variety of other things, like drinking warm water, deep breathing, and taking a hot shower.
There are dozens of different types of NSAIDs. They are usually sold over the counter without a prescription, but some will need a physician’s prescription.
In another question that I posted on my youtube channel, I asked which painkiller do you take? Forty-eight percent said they take Tylenol, 22% take Advil, 13% take Naproxen and 10% take Aspirin.
The oldest anti-inflammatory medicine that we know of, that has been used for more than 3500 years is acetylsalicylic acid or ASA.
It was used by the Egyptians and ancient Sumerians who extracted it from willow bark. It was patented as Aspirin in 1897 by a German manufacturer. Aspirin is an excellent anti-inflammatory drug, it helps to reduce pain and fever. However, it cannot be used in children younger than 12 years of age to treat fever because it can cause a serious reaction known as Reye’s syndrome. It is a rare but serious condition that causes swelling in the brain and liver.
Aspirin affects the platelets, which are blood cells that are responsible for blood clots. Aspirin blocks the platelets from forming blood clots, so, low-dose aspirin can be used to reduce the risk of stroke and heart attacks. However, in people with a high risk of bleeding, aspirin is not a good idea because there is an increased risk of bleeding, like hemorrhagic bleeding in the brain.
The maximum dose of aspirin a person can take per day is 4,000 mg. so the person may take up to 2 tablets of 500 mg 4 times per day.
Another type of NSAID is naproxen, known as Aleve or Anaprox. It is very similar to aspirin, but with a few differences.
Naproxen does not block the platelets, so it cannot be used to prevent strokes and heart attacks. In fact, the FDA in the US warns that all non-aspirin NSAIDs may increase the risk of heart attack and stroke, and they can occur as early as the first weeks of using the NSAID. People with high blood pressure, kidney failure or a history of heart disease should avoid taking NSAIDs, mainly the non-aspirin type of NSAIDs.
Naproxen takes longer to start working, it usually takes 30 minutes. Aspirin usually takes 15 minutes. But naproxen will last longer than aspirin, so it is better for people with chronic pain.
The maximum dose of naproxen is 660 mg per day. The tablets have 220 mg each, so we tell the person to take one pill 3 times a day.
Ibuprofen is the drug name for a variety of brands such as Motrin and Advil.
The low-dose tablets of 200 and 400 mg are available over the counter without a prescription. But the higher dose tablets of 800 mg usually need a doctor’s prescription.
The maximum dose should not exceed 2400 mg per day because higher doses are linked to heart attack and stroke.
The main uses of ibuprofen are for fever, menstrual cramps, headaches, rheumatoid arthritis and osteoarthritis.
Diclofenac, is sold with brand names like Cambia, Voltaren, and Cataflam.
This medication is not safe for people under the age of 18.
Women who are thinking of getting pregnant should avoid this NSAID because it can affect ovulation and it is hard to get pregnant, but also, it can cause a serious heart or kidney problem in the unborn baby and possible complications during pregnancy.
The maximum dose is 150 mg per day. Higher doses are related to heart attack and stroke.
All of these NSAIDs that I mentioned before are medications that block Cox 1 and Cox 2 enzymes. These enzymes are involved in the inflammatory response and production of prostaglandins. Ideally, we don’t want to block the cox 1 because it produces a substance that protects the stomach.
Now, there is a special type of NSAIDs called Cox-2 inhibitors. A few anti-inflammatories are specific to Cox-2, but only one is available in Canada and the US: celecoxib and the brand name is Celebrex.
Celecoxib is good for short-term pain relief after trauma, like muscle sprains, post-surgical pain and pain following dental extraction. In these situations, the prescription should be for a maximum of 7 days.
The maximum daily dose should not exceed 200 mg per day.
How about headaches and migraines?
Despite having many other migraine-specific drugs with better effects, like triptans, NSAIDs are the most commonly used medications for migraines.
This might be because NSAIDs are widely available, easy to access without prescription and less expensive than triptans.
However, overuse of NSAIDs is associated with the persistence of headache, known as medication overuse headache or MOH.
All NSAIDs have similar side effects:
The most common are stomach pain, stomach bleeding and ulcers. So, it is advisable to take it with food. And if the person continues having stomach pain, then they may use some gastric protector, like ranitidine, which is sold over the counter.
All NSAIDs should be avoided in the 3rd trimester of pregnancy because they may cause pulmonary hypertension in the newborn, prolong labour by inhibiting uterine contractions and also cause hemorrhage in the fetus.
Elderly patients need to be carefully monitored if they take NSAIDs for more than 7 days. NSAIDs may increase blood pressure, damage the kidneys, interfere with other blood clots medications, cause gastric or bowel bleeding, and altered liver function.
In people who have kidney failure, we need to monitor the levels of creatinine in the blood because the NSAIDs may worsen the kidney problem.
I could not finish this article without talking about acetaminophen, also known as paracetamol. The brand name is Tylenol.
Acetaminophen is not an anti-inflammatory drug because it does not reduce inflammation. It is a medication that is used to reduce the temperature in case of fever, especially in children. It is also a medication that helps to reduce pain, like headaches and muscle aches.
The main disadvantage is that many people get poisoned by acetaminophen. In Canada, the main cause of acute liver failure is acetaminophen toxicity. Some people will need a liver transplant or die because of this poisoning.
Most of these acetaminophen poisonings are by accident. A lot of people don’t know that acetaminophen is included in cough syrup, cold medications, or mixed with anti-allergic medications. They end up taking acetaminophen without even knowing it.
The maximum daily dose should not exceed 4,000 mg for adults and children 12 years and older.
This is equivalent to 8 extra-strength pills per day that contain 500 mg each. The person can take 2 pills at a time, and wait 6 hours to take the next 2 pills.
How about mixing these drugs?
It is not a good idea to mix an NSAID with another NSAID, as they do the same effect and the person will just be adding the risk of adverse effects.
However, it is possible to mix acetaminophen with NSAIDs because they are different classes of medications. In case of fever, for example, we can alternate taking Tylenol and Advil, like one tablet of Tylenol, then 4 hours later a tablet of Advil, then 4 hours later Tylenol, and so on.
So, in summary, it is not because these drugs can be bought without a prescription that they are safe. I recommend you talking to your pharmacist before you use any of these medications. As you see, NSAIDs and acetaminophen may be harmful and lead to serious adverse effects.
This article is not intended to give you medical advice. Please talk to your physician or healthcare professional if you have any health issues. If you leave a comment about your own medical condition, I will not be able to provide you medical advice. But, please, leave a comment if you feel that this article has helped you to learn something new.
This article is available as a YouTube video on my channel.
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