View Full Version : Practical guide to OTC NSAIDs

2003-07-12, 00:22
Practical Guide to OTC Painkillers for Hikers
Bryan Clardy MD

Disclaimer: While I am a physician, this article is meant to supplement your own knowledge and support decision making between you and your personal physician. This should not be construed as specific medical advice for any specific person. Having said this, what you do with this information is up to you, I will not be held liable for any undesirable outcomes. As I said, specifics should be addressed between you and YOUR physician.

The options for OTC painkillers on the trail are fairly numerous and the reasons for selecting one over the other will depend on a persons specific needs and desires. As such I intend to provide an overview of the many options available and what they will or will not do. I will also give the Prescriptive doses for these meds in their over the counter formulations. If you canít remember what I have presented here then I strongly suggest you read the box and follow the directions rather than guessing. I also recommend that you purchase generic meds rather than name brand, in my experience there is very little difference between the two and the savings can be substantial.
There are for all practical purposes 3 classes of painkillers available to the general public, with somewhat different mechanisms of action. Tylenol is in a class by itself. NSAIDS, or non-steroidal anti-inflammatories include ibuprofen, naproxen and ketoprofen. Salicylates like aspirin are technically NSAIDs but because of some different side effects I have elected to place them in the third category. All of these meds will reduce fever. Therefore if you are going to pick an NSAID, it is unnecessary to carry Tylenol for the exclusive purpose of reducing fever. Tylenol has some other uses we will be discussing momentarily.

Specfic Medicines

Tylenol : Tylenol is a centrally acting pain reducer and centrally acting fever reducer. It has no anti-inflammatory properties, so while it will treat pain associated with musculoskeletal injuries common to hikers, it will not treat the actual cause of the pain, inflammation. The dose for Tylenol is between 325 mg to 1000 mg every 6 hours. The maximum dose in a 24 hour period is 4 grams, or 4000 mg. It is commonly available in 325 mg caplets and 500 mg caplets (and others). 3 325 mg caplets is 975 mg, and is essentially equivalent to 2 extra strength caplets, which would be 1000 mg.
For long distance hikers, the volume required would be in my opinion prohibitive. Using a typical dosing schedule with 500 mg tabs, 2 tabs X 4 times a day = 8 tabs/day = a lot of extra stuff to carry. However, if you have a history of reflux, ulcer or GI bleeding, Tylenol would likely be your best bet from a side effect standpoint. Other uses for Tylenol is adjunctive therapy with an NSAID. It is safe to use Tylenol with NSAIDS as they are metabolized differently. Mild to moderate pain may be successfully managed with a Tylenol Ibuprofen combination. More specifically, one could use Tylenol added to an NSAID for pain not controlled by an NSAID alone. This is what I do. I do not carry enough Tylenol for prolonged use, however, a small tube of caplets do grace my first aid kit to augment my NSAID of choice. Ultralighters may be willing to forgoe this option, and I really could not offer an argument against that, as I donít feel that a lack of Tylenol is unsafe.

Ibuprofen : Ibuprofen, or Advil/Motrin is an NSAID with anti-inflammatory properties that acts as a pain reliever both centrally (brain) and at the site of inflammation. It has the additional property of acting as a fever reducer. The mechanism of action for fever reduction is different than that of Tylenol. Therefore Tylenol may be used to augment the fever reducing properties of ibuprofen. The dose for Ibuprofen is 200-800 mg every 6 to 8 hours for a daily maximum of 3600 mg or 3.6 grams. Ibuprofen is available commonly as elixirs (kind of pointless for backpacking) and in 200 mg tabs. These are pretty cheap, with 500 200 mg tabs running between 10 and 15 dollars in the generic formulations.
The weight and volume issue becomes more of an issue here as well. The dosing is such that when you achieve your theoretical max dose, you would be consuming (and carrying) 16 pills a day. This means that the 500 pill stock bottle is about 30 days worth.
While weight and volume are disadvantages, Ibuprofen has an advantage in terms of onset of action. It begins working in about 20 minutes, with maximal effect achieved in about 40 minutes. Therefore it represents a good choice when dealing with acute injuries to provide rapid relief. The flip side of this is the very short half life 5-8 hours which increases the frequency of dosing.
The last caveat regarding Ibuprofen is in long term side effects. The two side effects I see the most frequently in my practice is gastric pain proceeding to ulcers, and kidney damage. The most dangerous feature of ulcers is the propensity to bleed, and this can be life threatening. The kidney damage can accumulate over many years of chronic use. These warnings apply to all NSAIDS.

Aleve or Naproxen: Generally naproxen is about the same as ibuprofen with several notable distinctions. Onset of action is about 30 to 60 minutes, and it lasts about 12 hours. Naproxen will also reduce fevers. The available form of Naproxen is 220 mg tablets. The dosage is 1-2 tabs every 12 hours. This translates to about 4 tabs a day giving naproxen a distinct advantage in the weight and bulk department. The side effects of aleve/naproxen are the same as ibuprofen. This is my painkiller of choice when I am restocking my first aid kit.

Orudis/Ketoprofen: Just like Ibuprofen in terms of side effects, and onset and duration of action. I donít use and generally donít recommend Orudis. It is dosed 25-75 mg every 4-6 hours, this is just to frequent for me to find useful. Your experience may be different.

ASA /Aspirin: ASA is another NSAID and could be described as the grandfather of them all. ASA acts just like any other NSAID with one notable exception: It irreversibly binds to platelets and thereby interferes with clotting mechanisms. This means if you are cut or injured you will bleed a lot longer if you are on aspirin. Any one with a coagulation disorder should probably avoid this unless directed to do so by their physician. The dosing is coincidentally exactly the same as for Tylenol. 650 to 1000 mg every 6 hours. Toxicity however is more serious. Over dosing can result in acid base disorders, coma and death. For people taking aspirin for prevention of heart attack and stroke my advice is to continue your routine in the backcountry.

To Summarize: My personal choice is to use Naproxen exclusively for fever, inflammation and pain. I typically do not carry Tylenol in any substantial quantity unless I am expected to provide and attend to more than just myself. I generally avoid Aspirin due to its side effect profile, but recognize its utility in prevention. When taking children along it is imperative that Aspirin NOT be administered to them due to the risk of Reyeís syndrome. I would also advise people to pick meds based both on utility and familiarity, meaning that if you are used to taking Ibuprofen, by all means keep using it. You are less likely to make errors in dosing with medicines you are familiar with.

I hope this article was helpful. I can be reached from Sgt Rocks hiking site, www.hikinghq.net I would encourage you to direct specific questions to your personal physician.

2003-07-12, 01:12
Thanks Sundog for the excellent article!! I agree with you on the generic meds!! I save alot on generic antibiotics whenever I go to the dentist(cant even sit in the chair unless ive been premedicated) And also on Ibuprofen for my arthritis which was made alot worse by lyme disease!! Watch for the ticks!!!!! Streamweaver

2003-07-15, 15:48
Anyone ever had experiences, good or bad, with the headache powders (e.g. Goody's)? I frequently see them advertised (as in the Goody's Headache Powder Hopme Run Inning during Braves games) but have no experience with them. They are reputed to act very quickly, but I'm not sure what the active ingredient is (suppose it may vary from product to product).

2003-07-15, 16:32
These headach powders are either aspirin free (read tylenol) or Aspirin, or a salicylate(i.e. just like aspirin). They work "quick" because being a powder they dissolve almost immediately and are absorbed quickly as well. tablets do not work as quickly because it takes a lot longer for them to dissolve. Powders taste simply awful. yuck. and if they get wet, they become a nasty paste. again, yuck.


2003-07-16, 05:01

I read recently of a British study (published in Lancet, I believe) that recommended powdered salicylates for the onset of migraine pain. The key factor was the rapid aborption.


2003-07-16, 20:09
thats is a reasonable approach, but I assumed that anyone with migraines would already have a realationship with a physician for the purposes of this article. (by this I mean that they would already have a strategy in place) I don't like powders because I find them to be cumbersome, and as I said earlier taste nasty. Plus you end up with alot of waste packaging. However, as I said earlier, people should use what they are comfortable with. I was not aware of that particular study, but it makes sense.