Ask Dr. Etingin: Side effects of OTC pain relievers; New medications for migraine

What are the most common side effects associated with OTC pain relievers?

The most common over-the-counter (OTC) pain relievers are nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin), naproxen (Aleve), and salicylic acid (aspirin), and acetaminophen (Tylenol).

Taking NSAIDs is associated with an increased risk of cardiovascular disease (CVD) and events, including heart attack, stroke, and heart failure, especially in people who already have heart disease or are at high risk of heart disease. Taking higher doses of NSAIDs and/ or taking them for longer periods of time further increase the risks.

NSAIDs may also cause bleeding in the gastrointestinal (GI) tract. This risk is higher for patients who take blood thinners (warfarin or any of the newer anticoagulants, including Eliquis, Pradaxa, Xarelto, Plavix, and Brilinta) or who are at increased risk of GI bleeding for other reasons, such as having a peptic ulcer, an inflamed esophagus, or intestinal disease.

Possible consequences of GI bleeding include significant blood loss, which can lead to anemia. If GI bleeding is sudden and severe, it can cause shock, unconsciousness, and even death.

Aspirin is also an NSAID. It carries a similar risk of GI bleeding as the other NSAIDs, but it does not carry the same risks of CVD.

A low-dose daily aspirin is recommended for people with CVD who have had a heart attack or stroke, bypass surgery, or a procedure to open narrowed or blocked arteries. And millions of people who don’t have CVD take aspirin in hopes of preventing a cardiovascular event. But we now know that the benefit of a daily aspirin is offset by the risk of internal bleeding, especially for people age 70 and older, and the American Heart Association advises against this practice.

Acetaminophen relieves pain by a different mechanism than NSAIDs. It is usually recommended as the first choice for people with cardiovascular disease who take blood thinners and daily aspirin.

Your body clears safe doses of acetaminophen without a problem, but high doses can cause liver damage. You’re also at higher risk of liver toxicity if you take acetaminophen and you have more than three alcoholic drinks every day.

And you may be taking more acetaminophen than you realize: Hundreds of combination medications contain acetaminophen. Be sure to check the labels of all OTC products, especially cough, cold, and flu medicines, for acetaminophen. If you take any prescription medications, ask your pharmacist if any of them contain acetaminophen.

Bottom line: Choose your OTC pain reliever carefully depending on your doctor’s recommendations, and always use the smallest amount for the shortest period of time possible. If you have chronic pain, talk with your doctor about the many other strategies and treatments that may reduce your pain.

What new medications are available for migraines?

Several new drug options for migraine have been approved by the U.S. Food and Drug Administration in the past few years. New medications for preventing migraine include erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy), and epitenezumab (Vyepti). These medications are delivered by injection every one to three months.

New oral medications include ubrogepant (Ubrelvy) and rimegepant (Nurtec). These medications are taken when migraine symptoms begin; for many patients, they decrease or eliminate symptoms within one to two hours. These drugs were initially approved for treating migraine symptoms, but recent clinical trials have shown that they may also be used for migraine prevention.

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