Dr. Lee: Bill, how does one go about choosing an OTC pain reliever?

Dr. Shiel: Different people respond differently to pain relievers. Therefore, choosing the right pain reliever can be somewhat of a trial and error process. I recommend that patients use the pain reliever that has worked for them in the past. This will increase the likelihood of effectiveness and decrease the risk of any side effects.

Dr. Lee: For a healthy adult, like myself, is it safe to use over-the-counter pain relievers for toothache or muscle pain, fever or occasional aches and pains?

Dr. Shiel: Over-the-counter pain relievers have been shown to be safe and effective for short-term relief of pain when used properly according to the label instructions. By short-term I mean no more than ten days. Anybody with persisting or severe pain ought to consult a doctor for proper evaluation and accurate diagnosis.

Dr. Lee: Any special precautions while using acetaminophen?

Dr. Shiel: Even though acetaminophen is safe and well tolerated, it can cause severe liver damage and liver failure in high (toxic) doses. You and I have both taken care of patients with liver failure as a result of acetaminophen overdose in suicide attempts. Acetaminophen can also damage the kidneys when taken in high amounts. Therefore, it is crucial that acetaminophen not be taken more frequently or in higher quantities than recommended on the label of the bottle or container.

I also do not recommend acetaminophen to patients with existing liver disease, and in those who regularly consume moderate to heavy quantities of alcohol.

Dr. Lee: You brought up a very important issue. Even though most of us know that acetaminophen can cause serious liver damage in toxic doses, not many people realize that even non-toxic doses of acetaminophen can cause liver damage in people who regularly drink alcohol in moderate to heavy amounts.

Ten years ago, I took care of a 30 year old gentlemen who mysteriously developed acute liver failure and coma after taking multiple doses of acetaminophen for "flu" symptoms over the weekend. Fortunately, the doctors at a nearby liver transplant center were able to perform emergency liver transplantation. He is doing very well now. While the exact cause of his liver failure remains a mystery, I strongly suspect it was caused by the combination of moderate alcohol use along with excessive though non-toxic amounts of acetaminophen intake.

Let me make another important point. Many over-the-counter cold and flu remedies contain either aspirin or acetaminophen along with other active ingredients. Always study the active ingredients or consult the pharmacist before using them, especially if you drink alcohol regularly or have existing heart, liver, or kidney diseases.

Any special precautions while using aspirin?

Dr. Shiel: Yes, aspirin should especially be avoided by children and teenagers with chickenpox and "flu" because of risk of Reye Syndrome, a potentially serious medical condition.

Aspirin should be avoided by patients who are taking blood-thinning medications such as Coumadin because it can increase the risk of bleeding. I also do not recommend aspirin for patients with active ulcers of the stomach or bowels because it can impair ulcer healing, aggravate ulcers, and also increase the risk of ulcer bleeding.

I also do not recommend aspirin to patients who have a history of balance disorders or hearing difficulties because aspirin potentially can aggravate these conditions.

Dr. Lee: Any special precautions while using non-aspirin OTC NSAIDs?

Dr. Shiel: Patients taking blood thinners, such as Coumadin, should not take OTC NSAIDs without doctor supervision. NSAIDs can increase the risk of bleeding.

Patients with active ulcers should not take OTC NSAIDs because NSAIDs can impair ulcer healing, aggravate ulcers, and also increase the risk of ulcer bleeding.

Dr. Lee: As a gastroenterologist taking care of patients with liver disease, I also do not recommend NSAIDs to my patients with advanced liver disease. Patients with advanced liver disease also have impaired kidney function. I'm concerned about the effect of NSAIDs on the kidneys in these patients. Any worsening of kidney function in these patients can cause rapid and life-threatening deterioration of their liver disease.

Are there any other conditions you can think of that should lead to cautious use of NSAIDs?

Dr. Shiel: Yes Dennis, you bring up an excellent point. I recommend that patients with underlying heart disease, kidney disease and the elderly consult their doctors prior to using any over-the-counter medication.

Dr. Lee: Let's now go to the areas of prescription use of pain relievers and NSAIDs. Firstly, Bill, what are the NSAIDs that are available by prescription only?

Dr. Shiel: There are more than twenty prescription NSAIDs currently available in the United States, and the number is growing as new NSAIDs are added to the market yearly. Examples of traditional prescription NSAIDs include Feldene, Naprosyn, Indocin, Tolectin, Clinoril, Relafin, and Voltaren. Then, there are the newer selective NSAIDs called COX-2 inhibitors such celecoxib (Celebrex.)

Dr. Lee: What are the selective COX-2 inhibitors?

Dr. Shiel: COX-2 inhibitors are different from the traditional NSAIDs. Traditional NSAIDs reduce pain and inflammation but they also reduce prostaglandins in the stomach. A decrease in stomach prostaglandins increases the risk of stomach ulceration. COX-2 inhibitors such as Vioox and Celebrex reduce pain and inflammation without reducing the prostaglandins in the stomach. Patients who take COX-2 inhibitors have been shown to have less bleeding from ulceration than those who take traditional NSAIDs.