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Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are two types of over-the-counter medications taken to help relieve minor pain and lower fever. Acetaminophen, while effective as a mild analgesic and anti-pyretic, does not have the anti-inflammatory properties of the NSAIDs.1

The relative ease of access and widespread use of these medications lead many to assume that they are relatively safe drugs. However, like any medication, there are some significant associated health risks—especially when they are misused. Taking these medications with alcohol can result in significant harm.1,2

Nonsteroidal Anti-Inflammatory Drugs vs. Acetaminophen

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce pain and inflammation.Many NSAIDs are available as over the counter remedies, but some require a prescription.1

There are many different NSAIDs, but some examples include:3,4

  • Acetylsalicylic acid (i.e., aspirin).
  • Ibuprofen (Motrin, Advil).
  • Naproxen (Aleve).
  • Ketorolac (Toradol).
  • Meloxicam (Mobic).
  • Celecoxib (Celebrex).

Acetaminophen, a commonly used pain reliever and fever reducer, is not an NSAID. Commonly confused with NSAIDs because they are both indicated for similar uses, acetaminophen works via a different mechanism to relieve aches and pains as well as fever.5

Acetaminophen is available in generic form or as an ingredient in a number of brand formulations, including several Tylenol products.6 It may be purchased as several over-the-counter varieties, but it is also commonly combined with other prescription medications, many of them opioids (e.g., hydrocodone, oxycodone, codeine).

Both NSAIDs and acetaminophen are common components of combination remedies, such as cold or flu medicines. At one point, there were more than 600 medicines available that contained acetaminophen as an active ingredient.5 It is important to be aware of the active ingredients in all medications you may be taking to avoid accidental acetaminophen toxicity, which can result in severe liver damage.5

Over-the-counter medications that contain acetaminophen include:6

  • Alka-Seltzer Plus Cold & Sinus.
  • Excedrin.
  • DayQuil/NyQuil.
  • Midol PMS.
  • Robitussin Cold Cough and Flu.
  • Sudafed PE Sinus Headache.
  • Theraflu.

The generic or store-name equivalents of each of these brand-name medicines also contain acetaminophen. As mentioned, many prescription painkillers (such as Norco, Percocet, and Tylenol No. 3) also contain acetaminophen.6

Acetaminophen toxicity can result in acute liver injury.

When misused, both over-the-counter and prescription-strength acetaminophen-containing medications may easily exceed the recommended maximum dose. Acetaminophen toxicity can result in acute liver injury, which may be more likely to occur should more than one medication containing acetaminophen be taken or when the acetaminophen-containing product is consumed with alcohol.

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Side Effects of Pain Relievers

When used as directed, NSAIDs and acetaminophen are considered to be relatively safe. As with any drug use, however, there is always a risk of experiencing negative side effects. Side effects range in severity from slight upset stomach to severe liver damage.

Potential side effects of the various NSAIDs include:

  • Gastrointestinal distress.
  • GERD.
  • Stomach pain.
  • Gastric/duodenal ulcers.
  • GI bleeds.
  • Impaired renal function.
  • Increased risk of certain cardiovascular events (e.g., heart attack, stroke).
  • Elevated blood pressure.
  • Tinnitus.
  • Headache.
  • Dizziness.
  • Lightheadedness.
  • Impaired balance.

NSAIDs have also been associated with more severe problems in some individuals. For example, NSAIDs have been shown to increase the risk of gastrointestinal bleeding (more likely in regular NSAID users).7

Additionally, the use of NSAIDs (with the exception of aspirin) is linked to a greater risk of heart attack and stroke. The risk increases the longer the NSAID is used.7

NSAIDs also reduce blood flow to the kidneys and should not be used by those with decreased renal function. They may also harm healthy kidneys if they are taken in high enough doses or for a prolonged period of time.8

Beyond the risk of liver damage, acetaminophen has a remarkably minimal side effect profile. Some studies support the fact that, at prescribed doses, few serious side effects have arisen in conjunction with acetaminophen use beyond potential allergic skin reactions.

Because of its near-ubiquitous use in both home and clinical settings, Tylenol may seem like a completely benign medication; however, users should exercise caution when taking it, especially when taking more than one medicine. Because acetaminophen is in so many medications, you may take more than recommended without even realizing it, for example by popping a Tylenol and then taking some DayQuil. Exceeding the recommended dose of acetaminophen can result in severe liver injury.9 Alcohol increases this risk (see more below).

Acetaminophen overdose is the most common cause of acute liver failure in the United States. Over 30,000 people each year are sent to the hospital due to liver failure caused by acetaminophen toxicity.10

Interactions When Mixing with Alcohol

 Any misuse of acetaminophen or NSAIDs can be harmful. When you add alcohol to the mix, it only increases the potential dangers.9

For example, NSAIDs are already associated with some risk of internal bleeding in the stomach. Drinking heavily may cause additional gut irritation and increase this risk.11 The potential for aspirin-related ulcers is also increased when alcohol is consumed.12

Additionally, as NSAIDs are linked to impaired renal function, people with kidney disease should take care not to drink alcohol when taking an NSAID, as doing so may exacerbate this risk.13 The National Kidney Foundation advises avoiding alcohol when taking any pain medications.13

Alcohol also increases the risk of liver damage from acetaminophen. Even having just 3 alcoholic drinks during the day while taking acetaminophen could result in severe liver injury.14 If you drink heavily and are unable to cut back, talk to your doctor before taking any acetaminophen.9

When you are taking acetaminophen or an NSAID in combination with other drugs, different risks are introduced. For example, acetaminophen and certain NSAIDs are often combined with opioids in prescription painkillers. If you drink alcohol while using opioid-containing drugs, you risk extremely slowed breathing, coma, and death.15

Though people who consume very little alcohol and only use NSAIDs or acetaminophen occasionally are not likely to experience these potentially serious complications, certain medical conditions (e.g., renal insufficiency, inflammatory bowel disease) or excessive alcohol consumption may make medical emergencies more likely.

It’s important to discuss the risks with your doctor if you suffer from a condition such as kidney disease. And always read the labels on any medications you take and avoid drinking alcohol if the drug advises as much. Finally, avoid mixing medications that contain the same analgesic component, as the combined dose could be problematic.

References:

  1. Harvard Medical School. (2018). 10 things you should know about common pain relievers.
  2. Miller, K, MD. (2010). Alcohol and NSAIDs Increase Risk for Upper GI Bleeding. American Family Physician, 61(9), 2863-2864.
  3. Marks, J., MD. (n.d.) Nonsteroidal Anti-inflammatory Drugs (NSAIDs).
  4. U.S. National Library of Medicine, Medline Plus. (2018). Aspirin.
  5. U.S. Food and Drug Administration. (2009). A Guide to Safe Use of Pain Medicine.
  6. U.S. National Library of Medicine, Medline Plus. (2018). Acetaminophen.
  7. U.S. Food and Drug Administration. (2018). The Benefits and Risks of Pain Relievers: Q & A on NSAIDs with Sharon Hertz, M.D.
  8. National Kidney Foundation. (n.d.). Pain Medicine (Analgesics).
  9. Centers for Disease Control and Prevention. (2009). Acetaminophen: Avoiding Liver Injury.
  10. Yoon, E., Babar, A., Choudhary, M., Kutner, M., & Pyrsopoulos, N. (2016). Acetaminophen-Induced Hepatotoxicity: a Comprehensive UpdateJournal of clinical and translational hepatology4(2), 131-42.
  11. Carter, A. (2017). Everything you need to know about NSAIDs. Medical News Today.
  12. Williams College Health Center. (n.d.). Alcohol and Tylenol (or other pain relievers) don’t mix.
  13. National Kidney Foundation. (n.d.). What out for Your Kidneys When You Use Medicines for Pain.
  14. U.S. National Library of Medicine. (2015). Label: Acetaminophen 325 MG-acetaminophen tablet.
  15. University of Michigan University Health Service. (n.d.). The Effects of Combining Alcohol with Other Drugs.