June 4, 2023

Dr. Judith Beizer, a tenured Clinical Professor at St. John’s University College of Pharmacy and Health Sciences in Queens, NY and pharmacist, joins the Patient Pulse to discuss how to safely use pain-relieving medication while taking an anticoagulant (blood thinner).

Hello everyone and welcome to the patient pulse this month we’re thrilled to welcome dr judith biser to discuss how to safely use pain relievers while taking anticoagulation which are sometimes called blood thinners dr biser is a tenured clinical professor at st john’s university college of pharmacy and health sciences in queens new york and as part of her duties

She practices as a clinical pharmacist at the stern family center for rehabilitation in the northwell health system and she precepts pharmacy students and residents on rotation dr advisor is a board certified geriatric pharmacist and a past president of the american society of consultant pharmacists she is currently an active member of the american geriatrics

Society and serves on their board of directors and education committee so welcome dr biaser please take it away well thank you for inviting me to talk about this really important topic a lot of people who are taking anticoagulation want to know what type of pain relievers are safe for them to take so that’s what we’re going to talk about today so these are my

Disclosures so today i’m going to talk about the different classes of analgesics also known as pain relievers and then discuss which medications pose a risk to patients on anticoagulants and other blood thinning medications we’re going to talk about the safe use of acetaminophen also known as tylenol and then i’ll talk about some topical analgesics that can be

Very useful if you have joint or muscle pain so these are the various classes of analgesics there’s the non-steroidal anti-inflammatory drugs known as nsaids there’s acetaminophen as i said that’s tylenol and then there are opioids things like morphine and oxycodone steroids can also be used for pain relief things like prednisone and dexamethasone and then

There are additional types of medications that are used for neuropathic or nerve pain things like gabapentin pregabalin things like even amitriptyline and noretripuline which are used as antidepressants and duloxetine so these are specific types of medications just for neuropathic pain let’s start off with talking about the non-steroidal anti-inflammatory

Drugs these are things like aspirin naproxen ibuprofen celecoxib and meloxicam and there are others as well so they’re known as the nsaids they’re available orally and topically and they’re available by prescription and some are prescription and over-the-counter so these agents have analgesic or pain relieving properties anti-inflammatory and antipyretic

Or fever lowering properties and what i mean by anti-inflammatory is sometimes you pull a muscle or you strain an ankle and you’ve got swelling so these agents do help with decreasing swelling but they do come with serious side effects there’s serious risk of gastrointestinal bleeding in the stomach or in the intestines can also even cause heart attacks and

Strokes they can cause kidney damage particularly in patients who already have some kidney damage to begin with for kidney disease and then cause edema or retention of fluid and cause swelling in the legs so there are certain times when we don’t want to use these in patients with certain heart diseases as well but for people on anticoagulants they do have an

Increased risk of bleeding and they can interfere with platelet aggregation and platelets are cells in our blood that clump together and help us to stop bleeding if we get cut so these agents interfere with the platelet aggregation and they can also cause local irritation in the stomach and cause ulcers and if you do have bleeding from these ulcers and you’re

On an anticoagulant you’re at an increased risk for severe bleeding so we tell patients to avoid using non-steroidal anti-inflammatory drugs while they’re on an anticoagulant and if you must take one to consult your physician about using an occasional dose say you pull a muscle you sprain your ankle ask your doctor or your prescriber if it’s okay to take an

Occasional low dose of one of these agents and we’ll talk about each of these individually let’s talk a little bit about aspirin aspirin is rarely used for pain anymore it’s generally used now as low dose to prevent heart attacks and strokes because remember it said they decrease the clumping of those platelets so that can prevent any clots in your heart and in

Your brain so under your prescriber your healthcare provider’s direction a low dose is safe to use with anticoagulants and depending on your medical conditions it may be recommended that you do take a low dose of aspirin along with your other blood thinning medication your other anticoagulant warfarin or eliquis or one of the other ones some of the common side

Effects of aspirin even with the low dose are stomach upset which could include gastric or duodenal ulcers in the intestine and easy bruising so you do want to make sure that you take these with food to prevent any stomach irritation and if you are taking a low dose aspirin to get the one that’s enterocoated to protect the stomach just as a note this low dose

Is not effective for pain relief so it really only has that anti-platelet or anti-thrombotic effect to prevent clotting i want to talk about the over-the-counter oral non-steroidal anti-inflammatory drugs that’s the proxima and ibuprofen and you can find these in your local pharmacy they’re indicated for mild to moderate pain muscle aches fever and headache

And as i said you want to talk with your prescriber about whether an occasional dose of one of these would be okay for you to take while you’re taking your anticoagulant so naproxen is also known by the brand name aleve metaproxin naproxen is the prescription only version of it and the higher dose and over the counter it’s available as a tablet a capsule or

A liquid and the tablets come as 220 milligrams so the dose is one tablet every eight to 12 hours no more than three tablets a day and again to talk with your doctor about an occasional dose ibuprofen is known as advil or motrin iv plain motrin is the prescription strength and it’s available as a tablet capsule or liquid over the counter and the dosing is

200 to 400 milligrams or one to two tablets every four to six hours and once again talk with your doctor about whether an occasional dose is safe for you to take now new on the market is the over-the-counter diclofenac gel or voltaren and it was recently approved for over-the-counter use for arthritis pain so this offers a safer alternative for patients who

Are on anticoagulants it’s applied four times a day and the dose depends on which joint you’re applying it to but they do recommend not to use it longer than 21 days and if you need it longer than that you need to talk with your doctor about some alternative for your arthritis pain because it’s topical because it’s applied to the skin there’s less risk for

Any kind of stomach or intestinal irritation or any ulcers and as i said it’s safer to use in patients who are taking anticoagulants just as a note diclofenac is also available orally as a topical patch and as an eye drop but these are all prescription only there are a number of different prescription nsaids but some of the most common ones are a maloxicam

Sometimes these are used short term after surgery so you would talk with your surgeon and your physician about how long to be taking it and making sure they know that you’re on an anticoagulant and selects it because of the way it works may have less risk of stomach bleeding gi bleeding than some of the other nsaids and as i said there are a number of other

Ones on the market as well so now let’s talk about acetaminophen commonly known as tylenol sometimes abbreviated as apap or apap and also just so you know that acetaminophen is known as paracetamol outside of the united states so if you’re in europe and you go into a pharmacy you would be asking for paracetamol the good news about acetaminophen is that it

Does not affect coagulation so it’s safe to use when you’re on an anticoagulant or other blood thinning medications it does have analgesic and antipyretic effects so it works for pain and for fever but it doesn’t have anti-inflammatory effects so if you pull them us it’ll help with the pain but it’s not going to decrease any swelling or inflammation that you

Have there over the counter acetaminophen is available in many different dosage forms tablets capsules liquids even as suppositories for children but what’s important to note is that you don’t want to go above the maximum daily dose three thousand to thirty to fifty milligrams a day and the reason for that is that in higher doses you can see severe liver

Toxicity liver damage if you’re taking consistent doses greater than 4 000 milligrams a day so that’s why we recommend that you stick with the no more than 250 milligrams a day to keep you away from that 4 000 milligrams also very important to note is that acetaminophen is found in many over-the-counter cough and cold prod so if you’re taking acetaminophen

For pain and now you’re going to buy an over-the-counter cough or cold product make sure you read the label so that you avoid any kind of overdose so this is just a couple examples of some over-the-counter products that do contain acetaminophen an example of a label so that you can read the label and look for that acetaminophen and how much is in each dose

To make sure that you’re not taking too much a day let’s talk a little bit about the opioids or narcotics they’re used for severe pain though we do try to avoid chronic use because of our concern about dependence and addiction and misuse of these agents there’s no significant interaction with anticoagulants so they are safe to use if you need them while you’re

Taking an anticoagulant but do note that the side effects include things like sedation confusion particularly in older adults and constipation and so we generally recommend that when someone starts one of these opioids like morphine codeine oxycodone then we also recommend that they start a laxative regimen to prevent the constipation and also opioid products

There are a number of combination products that contain acetaminophen so once again to try to make sure that you’re not taking in too much acetaminophen look at how many milligrams are in each tablet sometimes a doctor after surgery will recommend you well you can take plain acetaminophen or you could take something like percocet which contains oxycodone plus

Acetaminophen so you want to make sure that you’re not taking too much over the course of the day and some of these products are fiora set tylenol with codeine vicodin and ultraset and then just for muscle or joint pain you can think about using a topical analgesic these are things that just give you some local relief from the pain and they’re safe to use while

You’re taking an anticoagulant so there’s lidocaine which comes in a patch a cream or a lotion this capsaicin cream which comes also as a gel or a patch and then even things like methyl salicylate plus menthol which would commonly known as something like bengay also comes as a cream a patch or a spray and they can be used for local pain particularly if you’ve

Like pulled a muscle or something like that so i’ve given you a lot of information today what’s the bottom line acetaminophen is the safest pain reliever while taking an anticoagulant but make sure not to exceed the recommended daily dose avoid oral nonsteroidal anti-inflammatory drugs and discuss with your doctor your prescriber if you can take an occasional

Dose if it’s just muscle or joint pain consider whether a topical analgesic will be able to relieve your pain and most importantly when in doubt about choosing an over-the-counter product consult your pharmacist talk to the pharmacist where you get your prescriptions filled they can help you choose a safe over-the-counter product that won’t interfere with your

Anticoagulant and won’t interfere with even any of your other prescription medications we’re here to help you thank you thank you so much for that wonderful overview dr bizer you’ve really helped clarify the do’s and don’ts so to speak of taking both over-the-counter and prescription pain relievers while taking anticoagulation so thank you again and thank you

To all of our listeners for tuning in and join us next month for another episode of patient pulse you

Transcribed from video
Pain Relievers and Anticoagulation: What's the Story? By NAThrombosisForum