General Question

ETpro's avatar

What OTC analgesics are mutually potentiating and safe in combination?

Asked by ETpro (34208 points ) May 1st, 2012

Tylenol (acetaminophen), Asprin (acetylsalicylic acid), and caffeine are the base ingredients of Excedrin. In combination, each helps potentiate the analgesic (pain killing) effect of the other two. It’s also common to pair acetaminophen with codeine in prescription cough medicines and with Percocet (oxycodone) and Vicodin (hydrocodone) in moderate to severe prescription pain medications. The acetaminophen amplifies the analgesic properties of the opiod, and also inhibits abuse, since taking more than the prescribed dose would create a risk of liver damage due to acetaminophen overdose.

The list of over the counter (OTC) analgesics includes Asprin (acetylsalicylic acid), Tylenol (acetaminophen), Aleve (naproxen sodium), Advil (ibuprofen), and Actron Orudis (ketoprofen) to name a few.

I know that combining regular Asprin with ibuprofen would be a bad idea, as both can cause stomach problems including bleeding and ulcers. Can they safely be combined if the Asprin has an enteric coating so that it passes through the stomach before dissolving? Are they mutually synergistic as pain relievers? What OTC pain meds do boost each others effectiveness and yet present little or no added risk of complications or unwanted side effects?

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37 Answers

Coloma's avatar

Happy Brownies are a safe compliment to any OTC analgesics. ;-)
Otherwise it’s probably best to consult with a doctor or pharmacist to be on the safe side.

Rarebear's avatar

I’ll answer this bit: “Can they safely be combined if the Asprin has an enteric coating so that it passes through the stomach before dissolving?” No.

Generally you can take acetaminophen and a nonsteroidal together safely.

Lightlyseared's avatar

So the reason why aspirin and NSAID’s like ibuprofen, diclofenac, and naproxen cause stomach problems like bleeding and uclers is because they interfere with the bodies ability to protect itself from the acid the stomach produces. Even if you have them injected into you as an IV you would still end up with stomach problems as it’s not the physical pressence of the tablet in the stomach that causes the problems.

Salem88's avatar

Wow…learned a lot. Tylenol makes my ears ring and no pain relief so I’m an Advil-person. Dr. Said I could take up to 4 at a time when I had broken leg – stupid dirt bike cause Percodan from hospital made me hurl. I would not mix and match any of them

lloydbird's avatar

@ETpro Serrapeptase might be worth checking out.

JLeslie's avatar

@Lightlyseared Do you have a link for that? I don’t think that is right. The photos I have of huge ulcers in my esophagis were from ibuprofen not going down well, and laying in my esophogus all night. I take ibuprofen all the time still, and never have a problem, I just make sure I drink water with it and eat something, I make sure it goes down and is buffered a little in my tummy, but it is still in my bloodstream.

I have combined aceitomenophine and ibuprofen when trying to control a very high fever under medical advice, but generally I would say taking any pain relievers in high doses for a prolonged time, or in combination is a bad idea. Some of them tax your liver, some your kidney more. I do take advil usually at 600mg doses when I take it, which is higher than the recommended OTC dose, but a common dosage when it is prescribed. I am not a doctor as you know, so this is not advice, just how I look at it. I think you should read up on how the different drugs affect the liver or kidneys, and read the package inserts (or the PDR write up, same thing) if you have not already for warnings against drug interactions.

Salem88's avatar

I never took 4 at a time…just said Dr. Told me I could. Have never taken more than 2 at a time. Usually have no need. Walking seems to help if your pain is a headache. Don’t box me in.

ETpro's avatar

@Coloma Ya think I have a case for medical Mary Jane?

@Rarebear Thanks. So the problem pertains to NSAIDs in general. Any combination of them would be a problem, right?

@Lightlyseared I must have a cast iron stomach because I’ve fought arthritis for nearly 40 years now, and taken Asprin daily, and I’ve never had any problem—knock on wood.

@Salem88 You have some strange reactions to various pain meds, and so do I. I have a script to Percocet for osteoarthritis in my neck. The messed up disks sometimes cause the bone to pinch a nerve, and it touches off a syndrome, tensing the back muscles, which makes the pinching worse… Percocet works great for me and no nausea, but I can’t sleep when I take it. I feel drowsy, but it makes my head feel wooden; and I get stuck thinking about that odd sensation instead of drifting off to sleep.

@lloydbird Have you tried Serrapeptase?

@JLeslie I’m interested in verifying that as well. What’s the point of enteric coatins if that’s the case? A way to make relief take longer?

@Salem88 No boxes here. My concern isn’t headaches. Excedrin is my go-to cure for headaches, but because I’m a cheapskate, I actually take generic Aspirin and Acetaminophen in the giant size bottles from Costco, and a cup of coffee for the caffeine.

What’s aching lately is my right toe. Almost 50 years ago, I got hit on the toe by a falling steel and concrete stanchion weighing several hundred pounds. The steel flange on top of it sliced through the bone and narrowly missed cutting my whole toe off. It happened in Corfu Greece and they took me to a little country clinic where a Greek GO did what he could to set the bone and stitch the toe back together. Arthritis has taken hold of that joint with a vengeance. I don’t want to use Percocet every day. And this think now hurts like the dickens every time I walk a few blocks. That’s what led me to ask.

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Seaofclouds's avatar

[mod says]: Please remember: This question is in the General Section. Responses must be helpful and on-topic. Thanks!

Lightlyseared's avatar

@JLeslie any tablet you like will cause a giant ulcer in your oesphagus if it gets stuck there as will a food bolus for that.

You may have heard of COX-2 inhibitors, a type of NSAID. Most NSAID’s inhibit both the COX-1 and the COX-2 pathway. The COX-2 pathway is responsible for for inflammation and pain while the COX-1 pathway promotes production of the mucous that protects stomach. COX-2 NSAID’s were designed to get round this problem effecting only the pain pathway and leaving everything else alone. Sadly they had much more severe side effects while having being no more effective at pain releif howver some have been repurposed as anticancer drugs so that’s nice.
Sune K. Bergström, Bengt I. Samuelsson and John R. Vane were awarded a Noble prize in 1971 for proving that aspirin-like drugs could inhibit the synthesis of prostaglandins.

JLeslie's avatar

@Lightlyseared Why would food cause an ulcer there? I can see if it was a food like a chili pepper, but a pill size of jello or meat? Just asking, I don’t know the answer.

From what I remember Cox-2’s reduced stomach ulcers by 20–50% depending on the studies, compared to other NSAID’s like ibuprofen and naproxen. I don’t disagree with your information about prostaglandins, but I wonder how much that actually plays into the ulcer development. I really don’t know what studies specifically have been done concerning that, so I am simply ignorant there. I would guess that some people are genetically much more likely to get ulcers, and they would be the most sensitive to cox-1 inhibitors. My knowledge is very limited on this. I actually had a friend who was a pharm rep for Vioxx and he had told me when it hit the market why it was so great, and then not long after were the cardiovascular scares. Since my family gets heart disease very young, I scratched those off my list, and never learned very much more about them, or the mechanism that makes them effective. It seems to me there must be some irritation caused by the actual pill in the stomach, because as @ETpro said, why else is aspirin buffered with a coating on the pill?

Rarebear's avatar

@ETpro ”@Rarebear Thanks. So the problem pertains to NSAIDs in general. Any combination of them would be a problem, right?”

Generally mixing NSAIDS isn’t a good idea. Every once in awhile is probably okay, but it’s a question of your sensitivity, the chronicity of how much you’re taking it, and the dose.

Lightlyseared's avatar

@JLeslie pressure and friction. A food bulus pressing and rubbing against the delicate mucosa of the oesphugaus will cause problems.

Aspirin is enteric coated because it irritates the stomach and often causes pretty much every stomach related problem in the book but that is in addition to the fact that once it is in the system it switches off the stomachs defences. Remember that aspirin is an incredibly weak NSAID. Compare with diclofenac which is stronger. It is still often enteric coated but has a signifiacntly higher incidence of GI bleeds. It is almost always prescribed with a PPI like omeprazole to protect the stomach and still the most common reason for having to discontinue treatment is GI complaints.

Now @ETpro describes having taken aspirin regularly for years without any problems which brings us to our most interesting point. How do you know whether the NSAID is causing you a stomach problem? Researchers is Norway perfomed gastroscopies on every single inhabitant of a large town (no idea how they convinced them to do it but hey), none of whom had any previous diagnosis of gastic problems or had reported any gastric symptoms. They did not find a single “normal” stomach. Everyone had something wrong, be it gastritis, hiatus hernia, erosions etc that would have resulted in further treatment had they gone to see a gastroenterologist. In the case of @ETpro the aspirn may very well be causing a bit of gastritis or what ever but becasue it’s not causing any symptoms that @ETpro is aware of it’s not worth worrying about.

JLeslie's avatar

@Lightlyseared Thanks for all the explanation. I do know that in double blind tests a percentage of people report gastric problems even while on placebo, which indicates some of the complaints while taking the medication could easily not be related to the medication. Of course this is true for almost every med and every type of side effect during testing, the question is if the symptoms are occuring more often in the test group in a statistically significant way.

Your study in the town in Norway is interesting. Not a single normal stomach? Wow! When you think about all the things that can mean it is mind boggling. How we perceive pain. How the medical community diagnosis what might be a cause of symtpims we are having. How or how to treat. Very interesting.

Salem88's avatar

Yes, it is mind boggling, isn’t it?

lloydbird's avatar

@ETpro
No. I’ve not had the need.
But if I did have, I would.
Jus recommendin.

ETpro's avatar

@Rarebear, @Lightlyseared & @JLeslie Thanks for diving deeply into this. You have truly increased my understanding.

@Lightlyseared That study seems to beg the question, “What is a normal stomach?”

@Salem88 Definitely mind boggling.

@lloydbird Thanks. Just exercising due diligence to avoid the snake-oil salesmen. There are a bunch of them when it comes to pain management. There are two good tip-offs that a site is selling snake oil. Fists it it claims to be good for a very long and frightening list of disorders. Second is that it requires that you take things that would never have been in a typical hunter-gatherer’s diet, or that you take a dose thousands or tens of thousands of times stronger than the diet we evolved consuming. This site raised both of those red flags.

Lightlyseared's avatar

So I just opened a tube of topical ibuprofen gel (you apply directly to the back and it gets rid of pain – pretty effective too). The listed side effects incluude heart burn and indigestion (as well as all the other lovely side effects of NSAID’s) even though it is applied to the skin.

JLeslie's avatar

@Lightlyseared Very interesting. I never heard of that product, are you in America?

ETpro's avatar

@Lightlyseared Well, that pretty definitively says it does its dirty work on the stomach lining from within the bloodstream. Still, I asked this because of some rather severe pain from an arthritic big right tow. I wouldn’t need to spread much cream on that to get some effect. It sounds with a try.

JLeslie's avatar

@ETpro Are you sure it isn’t gout?

Lightlyseared's avatar

Isn’t gout a type of arthritis? ;)

JLeslie's avatar

@Lightlyseared Yes, but it is treated differently than say osteoarthritis. Certain diets can help prevent gout flair ups.

Lightlyseared's avatar

hence the wink

ETpro's avatar

@JLeslie I’ve already had it diagnosed by my GP and a podiatrist. They are going to get me into Mass General for more definitive tests in the near future. But the fact that I got that toe severly broken and almost severed from my foot almost 50 years ago, and that was on a small Greek idland where medical care was in a local doctor’s one-room clinic and rudimentary even for mid 1960s standards suggests to the doctors that it’s just a severe case of osteoarthritis. Also, I show no symptoms of gout anywhere eles, and my bloodwork shows normal values for uric acid.

JLeslie's avatar

@ETpro It does sound like the accident is the culprit. Is the toe swollen?

ETpro's avatar

@JLeslie The whole foot is puffy. The toe just hurts like all get out when I walk any distance.

JLeslie's avatar

@ETpro That sounds a lot like gout to me. I am not a doctor as you know. And, of course I am not looking at your foot. And, I could be completely wrong, that goes without saying.

My BIL gets horrible gout and his blood tests don’t come back with the elevated levels they look for, but when he uses gout medicine it is effective. He also follows a gout diet now, and has not had a flair up in a long time. His episodes would last weeks, sometimes months of pain.

Did you see a rheumotologist for it?

ETpro's avatar

@JLeslie No, I haven’t seen a rheumotologist. The flare up happened right after a minor surgery that included some anesthesia I was allergic to. It’s been slowly going away since. The right foot just seems to be recovering slower due to the arthritic toe. It’s only one of the two joints in the toe—the same one that was sliced nearly in two decades ago. Gout normally attacks all the joints.

JLeslie's avatar

@ETpro It isn’t unusual for gout to flair up after some sort of trauma. It very often only occurs in one joint, which is most likely to be the big toe, but not necessarily.

But, I agree it also could be something else with what you have been through. Some sort of combination of osteoarthritis and the allergy.

ETpro's avatar

@JLeslie It seems to be going away, but if it persists, I will seek specific tests to see if that’s what’s going on. T Hanks for the tips.

JLeslie's avatar

@ETpro I’m glad you are feeling better. I hope it isn’t gout. This is the pubmed for gout if you want to read over the information, it was the first thing that popped up in a google search.

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