Q: My 88-year old mother often complains of various aches and pains. What is the safest over-the-counter painkiller for her to take? Aren’t some of them bad for your liver and kidneys?
A: Frequent aches and pains are a common problem for older adults.
If your mother has been complaining, you’ll want to make sure she gets a careful evaluation from her doctor. After all, frequent pain can be a sign of an important underlying health problem that needs attention. You’re also more likely to help your mom reduce her pain if you can help her doctors identify the underlying causes of her pain.
That said, it’s a good idea to ask what over-the-counter (OTC) pain relievers are safest for older people.
That’s because improper use of OTC painkiller tablets is actually a major cause of harm to older adults.
So let me tell you what OTC pain relievers geriatricians usually consider the safest, and which very common group of painkillers can cause serious side-effects in aging adults.
What’s the safest OTC painkiller for an aging parent?
For most older adults, the safest oral OTC painkiller for daily or frequent use is acetaminophen (brand name Tylenol), provided you are careful to not exceed a total dose of 3,000mg per day.
Acetaminophen is usually called paracetamol outside the U.S.
It is processed by the liver and in high doses can cause serious — sometimes even life-threatening — liver injury. So if an older person has a history of alcohol abuse or chronic liver disease, then an even lower daily limit will be needed, and I would strongly advise you to talk to a doctor about what daily limit might be suitable.
The tricky thing with acetaminophen is that it’s actually included in lots of different over-the-counter medications (e.g. Nyquil, Theraflu) and prescription medications (e.g. Percocet). So people can easily end up taking more daily acetaminophen than they realize. This can indeed be dangerous; research suggests that 40% of acetaminophen overdose cases are accidental.
But when taken at recommended doses, acetaminophen has surprisingly few serious side effects and rarely harms older adults. Unlike non-steroidal anti-inflammatory drugs (NSAIDs, see below), it does not put older adults at risk of internal bleeding, and it seems to have minimal impacts on kidney function and cardiovascular risk.
Be careful or avoid this common class of painkillers
At the drugstore, the most common alternatives to acetaminophen are painkiller tablets such as ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve, Naprosyn, and Anaprox).
Both of these are part of a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Many people are familiar with these medications. But in fact, older adults should be very careful before using NSAIDs often or regularly.
Unlike acetaminophen, which usually doesn’t become much riskier as people get older, NSAIDs cause side effects that are especially likely to become dangerous as people get older. These include:
- Increased risk of bleeding in the stomach, small bowel, or colon. Seniors who take a daily aspirin or a blood thinner are at especially high risk.
- Problems with the stomach lining, which can cause stomach pain or even peptic ulcer disease.
- Decreased kidney function. This can be especially problematic for those many older adults who have already experienced a chronic decline in kidney function.
- Interference with high blood pressure medications.
- Fluid retention and increased risk of heart failure.
Experts have estimated that NSAIDs cause 41,00 hospitalizations and 3,300 deaths among older adults every year.
Recent research has also suggested that NSAIDs cause a small but real increase in the risk of cardiovascular events (e.g. heart attacks and strokes).
Because of these well-known serious side effects of NSAIDs in older adults, in 2009 the American Geriatrics Society recommended that older adults avoid using NSAIDS for the treatment of chronic persistent pain. Today, oral NSAIDs remain on the Beer’s List of medications that older adults should avoid or use with caution. (For more on the Beer’s list, see this article: Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria 2019 Update.)
Now, it’s important to know NSAIDs can also be prescribed as creams or gels. These topical forms are much safer, and can be effective for pain relief.
Despite this fact, NSAID painkiller tablets are often bought by seniors at the drugstore. Perhaps even worse, NSAIDs are often prescribed to older adults by physicians, because the anti-inflammatory effect can provide relief from arthritis pain, gout, and other common health ailments.
(Commonly prescribed NSAIDs include indomethacin, diclofenac, sulindac, meloxicam, and celecoxib. These tend to be stronger than the NSAIDs available without a prescription. However, stronger NSAIDs are associated with higher risks of serious side effects, unless they are used as a cream or gel, in which case the risks are much less.)
Now let me share a true story. Many years ago, a man in his 70s transferred to my patient panel. He had been taking a daily NSAID for several months, prescribed by the previous doctor, to treat his chronic shoulder arthritis.
I cautioned him about continuing this medication, explaining that it could cause serious internal bleeding. He seemed dubious, and said his previous doctor had never mentioned bleeding. He wanted to continue it. I decided to let it slide for the time being.
A few weeks later, he was hospitalized for internal bleeding from his stomach. Naturally, I felt terrible about it.
This is not to say that older adults should never use NSAIDs. They are often more effective pain relievers than acetaminophen, especially for conditions such as arthritis. So even in geriatrics, we sometimes conclude that the likely benefits seem to outweigh the likely risks.
But this conclusion really should be reached in partnership with the patient and family; only they can tell us how much that pain relief means to them, and how concerned they are about the risk of bleeding and other dangerous side effects. (It’s also possible to reduce the risk of bleeding by having a patient take a medication to reduce stomach acid.)
Unfortunately, far too many older adults are never informed of the risks associated with NSAIDs. And in the drugstore, they sometimes choose ibuprofen over acetaminophen, because they’ve heard that Tylenol can cause liver failure.
Yes, acetaminophen has risks as well. But every year, NSAIDs cause far more hospitalizations among older adults than acetaminophen does.
Aspirin: a special NSAID we no longer use for pain
Aspirin is another analgesic available over-the-counter.
It’s technically also an NSAID, but its chemical structure is a bit different from the other NSAIDs. This is what allows it to be effective in reducing strokes and heart attacks. It is also less likely to affect the kidneys than other NSAIDs are.
(For more on the risks and benefits of aspirin, see this MayoClinic.com article.)
Aspirin is no longer used as an analgesic by the medical community. But many older adults still reach for aspirin to treat their aches and pains, because they are used to thinking of it as a painkiller. Aspirin is also included in certain over-the-counter medications, such as Excedrin.
Taking a very occasional aspirin for a headache or other pain is not terribly risky for most aging adults. But using aspirin more often increases the risk of internal bleeding. So, I discourage my older patients from using aspirin for pain.
Tips on safer use of OTC painkillers
In short, the safest oral OTC painkiller for older adults is usually acetaminophen, provided you don’t exceed 3,000 mg per day.
If you have any concerns about liver function or alcohol use, plan to use the medication daily on an ongoing basis, or otherwise want to err on the safer side, try to not exceed 2,000 mg per day, and seek medical input as soon as possible.
You should also be sure to bring up any chronic pain with your parent’s doctor. It’s important to get help identifying the underlying causes of the pain. The doctor can then help you develop a plan to manage the pain.
And don’t forget to ask about non-drug treatments for pain; they are often safer for older adults, but busy doctors may not bring them up unless you ask. For example, chronic pain self-management programs can be very helpful to some people. Physical therapy, massage, and certain forms of exercise can play an important role in pain relief, especially when it comes to chronic pain.
Now if your older parent is taking acetaminophen often or every day, you’ll want to be sure you’ve accounted for all acetaminophen she might be taking. Remember, acetaminophen is often included in medications for cough and cold, and in prescription painkillers. So you need to look at the ingredients list for all medications of this type. Experts believe that half of acetaminophen overdoses are unintentional, and result from people either making mistakes with their doses or not realizing they are taking other medications containing acetaminophen.
Last but not least: be sure to avoid the “PM” version of any OTC painkiller. The “PM” part means a mild sedative has been included, and such drugs — usually diphenhydramine, which is the main ingredient in Benadryl — are anticholinergic and known to be bad for brain health. (See 7 Common Brain-Toxic Drugs Older Adults Should Use With Caution for more about the risks of anticholinergic drugs.)
My own approach, when I do house calls, is to check the older person’s medicine cabinet. If I find any NSAIDs or over-the-counter anticholinergic medications (e.g. antihistamines, sleep aids, etc), I discuss them with my older patient and usually remove them from the house unless there’s a good reason to leave them.
If acetaminophen isn’t providing enough pain relief
If acetaminophen doesn’t provide enough relief for your mom’s pains, then it may be reasonable to consider over-the-counter (or sometimes prescription) NSAIDs, preferably for a limited period of time. But be sure to discuss the risks and alternatives with the doctor first, and be sure to discuss possible non-drug approaches to lessen pain.
You may also want to ask about topical painkillers, such as gels, creams, and patches. These are generally safer than oral medications, because less of the body is exposed to side effects.
For severe pain, it may also be reasonable to discuss other prescription drug options. Depending on the type of pain, in some cases it can be reasonable to consider using very small doses of opioids, or other types of painkillers. That said, bear in mind that all prescription pain relievers come with risks and can cause serious side effects. In older adults, most will affect brain function and balance.
The truth is that it’s often not possible to treat pain effectively and 100% safely, when it comes to using oral painkiller tablets. But by being informed and proactive, your family can help your mom get better care for her pain, while minimizing the risk of harm from pain relievers.
Good luck!
This article was reviewed & updated in March 2023.
[As we are approaching 200 comments, comments have been closed.]
Thomas E Hamilton says
I have an aspirin allergy and but I’buprofen is usually okay I’ve never tried naproxen but heard from Caltech professors that the prescription version of naproxen has fewer side effects and is safer than the over-the-counter version. they think that difference is due to the chirality purity. prescription has to be about twice as good as the over-the-counter and that opposite chirality causes a lot of the side effects.
Nicole Didyk, MD says
Your question raises a few interesting points, probably beyond what I can discuss as a Geriatrician (and not a clinical pharmacist).
There can definitely be differences in formulation and effectiveness between OTC and prescription types of drugs, and between generic and brand name drugs for that matter. This is permissible by most regulatory agencies, as long as the variation in the actual amount of active compound is within a certain range. There may even be variation between batches of mediation, even when produced at the same factory with the same ingredients. In some cases, this can affect how well the drug works (or clinical effectiveness).
In terms of chirality, this is a property of certain chemical compounds, which have different forms or enantiomers. You’re right that some enantiomers are much more effective than their opposite form, and are usually marketed as such (the antidepressant citalopram and s-citalopram for example).
From what I was able to find in a quick search about enantiomers of ibuprofen or naproxen, there hasn’t been much study since the mid 1990’s about whether the different enantiomers are more effective or more toxic, but the folks at Cal Tech may be more up to date than I am!
Joe Sawyer says
I have mild headaches and I cut a 500 mg
Tablet in half. 250mg gets rid of my headaches. The only prescription medication i take is phenytoin. Is it safe to cut the tablet in half, and does phenytoin have acetaminophen in it.
Nicole Didyk, MD says
Most of the time, cutting a tablet in half is safe to do, but for some preparations, it may affect the effectiveness of the medication. For example, if the tablet has a special coating on it to make it a slow release or extended release formulation, then cutting into the coating might prevent that slower release. Acetaminophen usually comes in 325 mg strength as a regular Tylenol so that is an option for those who want a lower dose of acetaminophen.
Phenytoin (also known as Dilantin) is a medication used to treat seizure disorder and does not contain acetaminophen.
Linda A. says
I have osteoarthritis in my spine. Unfortunately, there are no prescription medications for osteoarthritis, and I do not want to take anything potentially addictive. For my aches and pains, which can, at times, be considerable, I’ve been taking a combination of acetaminophen and naproxen. However, for whatever reason, acetaminophen has become all but impossible to find in these days of COVID-19, so I’m considering switching to ibuprofen, at least until acetaminophen once again becomes readily available.
Nicole Didyk, MD says
Hi Linda and sorry to hear that you’re living with pain. For many older adults, the occasional use of ibuprofen can be safe but over the long term ew prefer not to use it, for the reasons Dr. Kernisan mentions in the article.
Don’t forget that the management of osteoarthritis includes more than just medications. Weight management, exercise, physiotherapy, even mindfulness or meditation can help with OA pain.
Cat rosing says
Thank you for the very informative article. I always find myself standing in the pain relief aisle not quite sure which pain relief medicine to choose. My doctor recommends Tylenol but I have always been an aspirin fan, but now through your article I understand and I will be making the move too Tylenol.
Nicole Didyk, MD says
I know what you mean about all of the choices for pain relievers at the pharmacy! I’m glad the article was helpful to you in making a choice. There are definitely therapeutic reasons for some to use aspirin (for example if you have had a heart attack or stroke), but for pain relief acetaminophen (Tylenol) has a lower risk of stomach irritation and bleeding.
william Offen says
I’m 73, apparently fit and healthy, except for some prostate-related discomforts. I don’t like the side effects of the normal drugs (Tansulosina etc) for prostate relief as they build up in the body and lead to low energy and attitude.
I find that 400mg of ibuprofen, taken as I retire, helps me sleep, dramatically reduces the nocturnal toilet visits and there is no sign now of the foggy brain and tiredness that `I had become used to?.
Is this a feasible and safe treatment?
Nicole Didyk, MD says
I found this response from Dr. K. to a related question a few months ago. She rightly points out that we use NSAIDs like ibuprofen with caution in older adults, and usually not on a chronic or ongoing basis. I would suggest you speak to your doctor about whether this is the right way to use ibuprofen for you.
Linda Benskin says
Please comment about the possibility of alternating NSAIDs and acetaminophen when acetaminophen alone does not provide enough pain relief to allow a person to be functional, particularly for short-term “flares” of arthritis, wound pain, etc.
I found that taking 400 mg ibuprofen every 6 hours or 400 mg naproxen sodium every 12 hours with food, alternating with 500 mg acetaminophen every 6 hours (taken 3 hours after the ibuprofen, for example), provides amazing pain relief with very low doses. Because acetaminophen is primarily metabolized by the liver and NSAIDs primarily by the kidneys, toxicity is less of an issue than it would be with higher doses of acetaminophen. And, the anti-inflammatory action of NSAIDs can be very helpful to calm down pain from arthritis.
Nicole Didyk, MD says
Hi Linda
I am not a clinical pharmacologist, and most of what I have read about alternating acetaminophen with ibuprofen is in regards to treating a child with a fever. Here is a little review article about that. Now these authors mention that there is a theoretical risk of increased toxicity to the kidney or liver as a result of the NSAID contributing to the production of a toxic compound when the acetaminophen is metabolized (I am simplifying, here!).
A study of combined ibuprofen and paracetamol (British for acetaminophen), for pain management after a hip replacement (the PANSAID randomized clinical trial), found that the combination was better than acetaminophen alone, but not better than ibuprofen alone. They didn’t find an increase in the risk of serious adverse events. So that would seem to suggest that using ibuprofen alone is the way to go.
So, after just looking into it briefly, I’m not sure that I would recommend the regimen you describe, but there isn’t a large body of good evidence to guide us in the matter.
John says
Thank you for your post about NSAIDs. I share your cautions about them. But could you please share other ways of reducing inflammation? I have osteoarthritis, piriformis-sciatica, and bursitis, all of which have inflammation as a component. Thank you ? .
Nicole Didyk, MD says
Well, that’s a big question, John! One of the hot topics in strategies to reduce inflammation is the gut microbiome: the type of bacteria in a person’s gastrointestinal tract.
Many studies about the link between frail health in older persons and their gut microbes are ongoing, and I have also read a few research papers looking at how a modified diet can help to treat inflammatory conditions like rheumatoid arthritis. Most “anti-inflammatory” diets are low in salt, eggs, most dairy products, red meat, gluten and sugar and higher in yogurt, enzymatic fruits (like pineapple, mango, papaya), green tea, and turmeric, among other things.
Most physicians would also advise that adequate sleep, being a non-smoker, and avoiding stress is a good way to keep inflammation at bay as well.
Bruce of Australia says
Having just read your latest blog about OTC pain killers (“safest-otc-painkiller-aging-risks-of-nsaids”); I find it very useful.
Many years ago (in my 50s) my GP recommended that I try glucosamine for very sore knees and my hips were becoming more painful. While it took a several weeks to relive the joint pain I have never had a recurrence. I have continued taking glucosomine daily (3000 mg) ever since. I am in my 70s and I would consider myself much more spy than the average male my age.
Nicole Didyk, MD says
Hi Bruce. We have been hearing about glucosamine (a component of joint cartliage), taken with or without chondroitin for years, usually as a treatment for knee osteoarthritis. I recently read a meta-analysis of studies looking at glucosamine for knees osteoarthritis, and the authors concluded that it was better than a placebo for pain (Effects of glucosamine in patients with osteoarthritis of the knee: a systematic review and meta-analysis, Toru Ogata, et.al., CLin, Rheumatol. 2018; 37(9): 2479–2487.). The effect size was very small, however, so in the amalgamation of the 18 articles the authors analyzed, it was not MUCH better than placebo. I’m glad you are getting some results and feeling spry, though!
Bart Windrim says
Rather than read through the voluminous # of comments before posing this question…
If one is going to use ibu occasionally or short term, what daily dosage limit ought one observe? If it matters, this one is a 180lb 67yo male.
Nicole Didyk, MD says
Hi Bart. A ballpark for a daily recommended dose is usually printed on the side of the package for most OTC’s, but I would advise anyone to consult with their doctor, or with a pharmacist. Safe ibuprofen dosing depends on a person’s health history and what other medications they are taking, among other things.
CB Nelson says
Hi Bart, it’s Carla. I don’t know about you, but the standard wisdom on this topic as above drives me nuts, as much as I love Leslie and have for years. Too many draconian choices in which I have no choice but to ignore Leslie and the Beers list.
Tylenol is worthless for me, only Advil works. Meditation is a joke with my kind of mind and CBD oil did zippola too. Magnesium creams and spray help a bit once in awhile. But my chronic muscle pain is such (even as a statin refusenik) that Id have constant insomnia otherwise. So I take the risks,
Happy to hear there are are prescription NSAID creams, Will ask about that next.
Nicole Didyk, MD says
Hi Carla and thanks for taking the time to leave a comment.
It’s true that the Beers list is a guideline, but not one that needs to be followed to the letter in every case. Every medication decision can involve a trade off, and it sounds like you know yourself and your body very well. If you understand the risks and make an informed choice, that’s a reasonable way to go.
Hope the topical NSAID creams work for you.
Rick Schulte says
I just read that the government is considering putting a warning on acetaminophen due to it’s possible dangers. Does this change your opinion of it or is it still related to how much is taken?
Nicole Didyk, MD says
You make a good point, which I think is clearly covered in the article, that acetaminophen (or paracetamol) can need very careful use in those with liver disease, or who may be getting acetaminophen from other sources (i.e. in other OTC medications).