Which OTC Painkillers Can You Take Together?

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If you already have a headache and navigate your way to the pain relief shelf at your pharmacy the headache is likely to get worse. That's because there are a bazillion names on the bottles. Very complicated. But this is only because the manufacturers of analgesics want it that way. In reality, it is very simple. There are only four drugs to choose from despite all the different names (1). So people are perpetually confused about what painkiller they're looking at.

And many are also unaware that some of these drugs can be combined while others cannot. First, let's look at the four drugs that are available OTC in the US and some alternate names they are known by. The first three all belong to a class of drugs called NSAIDs (non-steroidal anti-inflammatory drugs). Tylenol does not. It works (but not very well - See Tylenol Isn't So Safe, But At Least It Works, Right?) by blocking pain signals to the brain. 

OTC PAIN RELIEVERS

1. Aspirin:

  • Acetylsalicylic acid
  • ASA
  • Excedrin (with acetaminophen and caffeine)
  • Anicin (with caffeine)
  • Bufferin (with an antacid)
  • Alka-Seltzer (with various other drugs depending on use)

2. Ibuprofen:

  • Advil
  • Motrin
  •  IBU
  • Midol IB
  • Genpril 

3. Naproxen:

  • Aleve
  • Naprosyn
  • Anaprox
  • Sodium Naproxen

4. Acetaminophen:

  • Tylenol
  • APAP
  • Paracetamol
  • Panadol

So, why does the OTC pain relief counter at CVS look like this?

Analgesic hell. Photo: New York Times

It's because drug companies have combined the analgesics with other drugs, for example, antihistamines, to help with sleep or allergies, something that I think is pretty scummy and have written about in the past (See Combining Pain, Cold, Cough, And Sleep Meds - Great For Drug Companies, But Unethical)

WHICH DRUGS CAN BE COMBINED SAFELY?

So, despite all the noise, it's very simple. There are four OTC pain medications. It is safe, even helpful, to take some of them together, but not others. A new article in Medical News Today helps sort this out. Although the article speaks only about Aleve and Tylenol it also applies to Tylenol plus the other NSAIDs - aspirin, and ibuprofen. 

NSAIDs are generally safe to take with Tylenol, and the two together work better than either one alone. There are three ways to do this:

  1. Taking the NSAID and Tylenol on alternate days, especially for chronic pain, is easier on your stomach and liver than taking either or both drugs daily, but the degree of pain relief may be insufficient. 
  2. Taking the NSAID and Tylenol at the same time will give better superior pain relief than in scenario #1 but may wear off before it's time for the next dose in 4-6 hours.
  3. Alternating the two drugs, for example, the NSAID at 0,4, and 8 hours plus the Tylenol at 2,6, and 10 hours will produce a more sustained level of pain relief.

WHICH DRUGS CANNOT BE COMBINED SAFELY?

This is also simple. Aspirin, Advil, and Aleve are all NSAIDs and control pain and inflammation by a common mechanism. But they also produce side effects, most commonly heartburn, gastric bleeding, and ulcers by a common mechanism. So taking Advil plus Aleve is going to mess up your stomach or cause bleeding about the same as taking double the dose or either drug. For this reason, it is not safe to combine NSAIDs (2)

American Council friend Dr. Aric Hausknecht, a neurologist and pain management physician explains:

"OTC oral pain meds basically fall into two categories, Tylenol and NSAIDs. All NSAIDs will have a ceiling effect, i.e. taking more of that particular NSAID, or combining with a different NSAID once you have taken the maximum dose, will not produce any further analgesic effect (and will increase the likelihood of side effects). So, if one takes the maximum dose of ibuprofen, taking another NSAID or aspirin would not provide any therapeutic benefit and would increase the likelihood of ulcers. Tylenol could be taken simultaneously with a full dose of NSAID and would possibly provide synergistic pain relief."

WHAT ABOUT TOPICAL NSAIDs?

A number of creams and patches are applied directly to the skin (3) at the affected area. Since they do not go through the stomach or result in high blood levels they are safer than using two different NSAID pills. Dr. Hausknecht says:

Other OTCs include the topical compounds and patches and those could be taken in combination with a maximal dose of Tylenol or NSAIDs.

Feel better.

NOTES:

(1) There used to be five. Ketoprofen (Orudis) was sold OTC but is now by prescription only.

(2) Kidney damage is also a side effect of NSAIDS. Heart attacks are also linked to NSAID use, but less so for the OTC NSAIDs.

(3) Voltaren (diclofenac) is commonly used in a patch.