Dosage is based on a 70 kg adult with normal hepatic and renal function. Food decreases the rate of absorption and may delay the time to peak levels. Caution : Allergy, renal or liver impairment, combination with anticoagulant or antiplatelet medications. Common side effects : Dyspepsia, nausea, abdominal pain, headache, dizziness, somnolence, rash, elevated liver enzymes, constipation, fluid retention, peripheral edema, tinnitus, ecchymosis. OTC : Over-the-counter (nonprescription). Rx : Prescription required for certain strengths. * Ketorolac (Toradol) is approved for moderate to severe pain. Oral tablets only recommended as continuation following IM or IV dosing. ** Acetaminophen is included in multiple prescription and OTC products for treatment of pain, cough, cold, flu, migraine, insomnia, etc., increasing the risk for accidental overdosage; the FDA is asking drug manufacturers to limit the amount of acetaminophen in prescription products to 325 mg and perhaps reduce the maximum recommended dose to < 3,250 mg. Note . Adapted from “Clinical Drug Information,” 2020, by Lexicomp. Retrieved from http://webstore.lexi.com/ONLINE-Software-for-Dentists; and “Treatment Guidelines from The Medical Letter: Nonopioid Drugs for Pain,” 2018, The Medical Letter, 60 (1544), 57-64.
The additive effects of acetaminophen and an NSAID have been repeatedly shown to offer an analgesic effect superior to either drug alone, and they have a better side effect profile and less potential for abuse compared to opioids (Becker, 2010; Aminoshariae et al., 2017; American Dental Association, 2020; Hersch et al., 2020). Use of NSAIDs has also been shown to reduce the incidence of postoperative nausea and vomiting by 30% compared to narcotics (Elia, Lysakowski, & Tramer, 2005). Strong familiarity with individual maximum recommended doses cannot be stressed enough. The most effective dose for the shortest period of time will provide the greatest pain relief balanced against patient safety. For simplicity, many practitioners rely on the “2-4-24” mnemonic as the postoperative prescription of choice for acute nociceptive orofacial pain. This memory aid stands for “2 drugs, 4 doses, for 24 hours”: a combination of ibuprofen 600 mg plus acetaminophen 650 mg administered every 6 hours for 24 hours (Figure 3; Donaldson & Goodchild, 2010). This dosing mnemonic is especially useful since it is both effective and safe (the maximum recommended dose per 24 hours for the treatment of acute pain for either drug is not exceeded: 2,400 mg and 4,000 mg, respectively). Understanding the inflammatory process and the pharmacokinetics of these medications and routine dosing during the initial 24-hour postoperative period is required. In most cases, if a patient is compliant with these four doses of two different medications, he or she will not require any further analgesic medication beyond the first 24 hours. These doses can be administered every 6 hours, either together or in a staggered fashion based on physician and patient preference (e.g., 650 mg of acetaminophen now, then 600 mg of ibuprofen 3 hours later, then 650 mg of acetaminophen 3 hours later, and so on for the first 24-hour postoperative period). The staggered approach is sometimes valuable for patients who are “clock watchers” or for whom more frequent medication administration may be more psychologically beneficial following dental surgery. These two medications work by different mechanisms of action, and compliance is the key to the success of this analgesic regimen, which may require that patients set alarms so that they do not miss the prescribed doses during the initial 24-hour postoperative period. After the initial 24-hour postoperative period, patients can reduce their regimen to an “as needed” basis of either drug alone or in combination. However, if patients still require routine pain medication after the initial 48 hours following the dental procedure despite excellent compliance, re- examination by the dental practitioner should be strongly considered. Given all of this evidence, then, the question typically arises, “why is there not a commercially available product which contains both acetaminophen and ibuprofen?” This was
answered in March 2020 when the FDA approved the first ibuprofen-acetaminophen drug (Garvin, 2020). Unfortunately, this fixed dose combination tablet contains 250mg of acetaminophen with 125mg of ibuprofen, which means that in order to get the greatest analgesic effect of the ibuprofen (600mg four times a day), you would inadvertently be overdosing on 4800mg of acetaminophen (Lexicomp, 2021). It is curious that Pfizer and the FDA did not stick with the currently approved, over-the-counter dose of ibuprofen which is 200mg, in which case this product would have solved an unmet need. As such, this is a missed opportunity. Figure 3: The “Perfect” Prescription for Postoperative Dental Pain*
*For those patients currently on an anticoagulant such as warfarin, dabigatran, rivaroxaban, apixaban, betrixaban, or edoxaban, a COX-2 inhibitor such as celecoxib could replace the ibuprofen prescription above as 400 mg given once then 200mg every 12 hours for the initial 24-hour postoperative period.
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