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Ibuprofen and acetaminophen: Pediatric drug information

Ibuprofen and acetaminophen: Pediatric drug information
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For additional information see "Ibuprofen and acetaminophen: Drug information" and "Ibuprofen and acetaminophen: Patient drug information"

For abbreviations, symbols, and age group definitions show table
ALERT: US Boxed Warning
Risk of medication errors (injection):

Take care when prescribing, preparing, and administering ibuprofen/acetaminophen injection to avoid dosing errors which could result in accidental overdose and death.

Hepatotoxicity:

Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death. Most of the cases of liver injury are associated with doses of acetaminophen that exceed 4 g/day, and often involve more than 1 acetaminophen-containing product.

Cardiovascular risk:

Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use.

Ibuprofen/acetaminophen is contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft surgery.

Gastrointestinal risk:

Injection: NSAIDs cause an increased risk of serious GI adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious GI events.

Oral (Rx): NSAIDs cause an increased risk of serious GI adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events.

Brand Names: US
  • Acetaminophen-Ibuprofen [OTC];
  • Advil Dual Action [OTC];
  • Combogesic;
  • FT Dual Action [OTC];
  • Motrin Dual Action [OTC]
Therapeutic Category
  • Analgesic, Nonopioid;
  • Nonsteroidal Anti-inflammatory Drug (NSAID), Oral
Dosing: Pediatric
Analgesic

Analgesic: Children ≥12 years and Adolescents: Acetaminophen 250 mg/ibuprofen 125 mg per tablet: Oral: Two tablets every 8 hours as needed; maximum daily dose: 6 tablets/24 hours.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling; however, clearance may be reduced; active metabolites may accumulate. Use with caution; initiate at lower doses or longer dosing intervals followed by careful titration. See individual monographs for specific adjustments.

KDIGO 2012 guidelines provide the following recommendations for nonsteroidal anti-inflammatory drugs (Ref):

eGFR 30 to <60 mL/minute/1.73 m2: Avoid use in patients with intercurrent disease that increases risk of acute kidney injury.

eGFR <30 mL/minute/1.73 m2: Avoid use.

Dosing: Liver Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling; however, product contains acetaminophen; use with caution. Cases of hepatotoxicity at daily acetaminophen dosages <4,000 mg/day have been reported. See individual monographs.

Dosing: Adult

(For additional information see "Ibuprofen and acetaminophen: Drug information")

Pain

Pain:

IV:

Note: Combogesic IV (acetaminophen and ibuprofen) is a combination product; each 100 mL vial contains 1 g acetaminophen and 300 mg ibuprofen.

<50 kg : Acetaminophen 15 mg/kg (in combination with ibuprofen 4.5 mg/kg) every 6 hours as needed (maximum: acetaminophen 750 mg/ibuprofen 225 mg as single dose or acetaminophen 3 g/ibuprofen 900 mg per 24 hours).

≥50 kg: Acetaminophen 1 g (in combination with ibuprofen 300 mg) every 6 hours as needed (maximum: acetaminophen 4 g/ibuprofen 1.2 g per 24 hours).

Oral:

Rx: Acetaminophen 325 mg/ibuprofen 97.5 mg per tablet: Three tablets every 6 hours as needed (maximum: 12 tablets [acetaminophen 3.9 g/ibuprofen 1.17 g] per 24 hours).

OTC: Acetaminophen 250 mg/ibuprofen 125 mg per tablet: Two tablets every 8 hours as needed (maximum: 6 tablets [acetaminophen 1.5 g/ibuprofen 750 mg] per 24 hours).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); use with caution. Use of Rx products are not recommended. Also refer to individual agents.

KDIGO 2012 guidelines provide the following recommendations for nonsteroidal anti-inflammatory drugs:

eGFR 30 to <60 mL/minute/1.73 m2: Avoid use in patients with intercurrent disease that increases risk of acute kidney injury.

eGFR <30 mL/minute/1.73 m2: Avoid use.

Dosing: Liver Impairment: Adult

IV:

Hepatic impairment prior to treatment:

Mild to moderate impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); use not recommended. Also refer to individual agents.

Severe impairment or severe active liver disease: Use is contraindicated.

Hepatic impairment during treatment: If signs and symptoms consistent with liver disease or systemic manifestations (eg, eosinophilia, rash) occur, discontinue treatment immediately and clinically evaluate the patient.

Oral:

Rx:

Hepatic impairment prior to treatment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); use not recommended. Also refer to individual agents.

Hepatic impairment during treatment: If signs and symptoms consistent with liver disease or systemic manifestations (eg, eosinophilia, rash) occur, discontinue treatment immediately and clinically evaluate the patient.

OTC: There are no dosage adjustments provided in the manufacturer's labeling; use with caution to avoid adverse effects and discontinue if hepatic function worsens. Also refer to individual agents.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for injectable formulation in adults, unless otherwise noted. Also see individual agents.

>10%: Local: Infusion-site pain (18%)

1% to 10%:

Dermatologic: Hyperhidrosis (2% to 3%), pruritus (2% to 3%)

Gastrointestinal: Vomiting (6%)

Nervous system: Drowsiness (tablet: 2%)

Frequency not defined (any formulation):

Cardiovascular: Thrombosis (including acute myocardial infarction, cerebrovascular accident)

Gastrointestinal: Gastrointestinal signs and symptoms (including gastrointestinal hemorrhage, gastrointestinal perforation [intestinal perforation, stomach], gastrointestinal ulcer)

Hepatic: Acute hepatic failure

Postmarketing: Dermatologic: Exfoliative dermatitis, fixed drug eruption, Stevens-Johnson syndrome, toxic epidermal necrolysis

Contraindications

Hypersensitivity (eg, anaphylactic reactions, serious skin reactions) to acetaminophen, ibuprofen, other nonsteroidal anti-inflammatory drug (NSAIDs), or any component of the formulation; history of asthma, urticaria, or allergic-type reaction to aspirin or other NSAIDs; use in the setting of coronary artery bypass graft surgery; severe hepatic impairment or severe active liver disease (IV only).

OTC labeling: When used for self-medication, do not use if previous allergic reaction to any other pain reliever/fever reducer; do not use with other drug products containing acetaminophen; prior to or following cardiac surgery.

Warnings/Precautions

Concerns related to adverse effects:

• Anaphylactoid reactions/hypersensitivity: Even in patients without prior exposure to ibuprofen, anaphylactoid reactions may occur; patients with "aspirin triad" (bronchial asthma, aspirin intolerance, rhinitis) may be at increased risk. Hypersensitivity and anaphylactic reactions have also been reported with acetaminophen.

• Cardiovascular events: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious (and potentially fatal) adverse cardiovascular thrombotic events, including fatal myocardial infarction (MI) and stroke. Risk may occur early during treatment and may increase with dose and duration of use. Avoid use in patients with a recent MI unless benefits outweigh risk of cardiovascular thrombotic events. Use the lowest effective dose for the shortest duration of time, consistent with individual patient goals, to reduce risk of cardiovascular events; alternate therapies should be considered for patients at high risk (ACC/AHA [Amsterdam 2014]). Avoid use in patients undergoing revascularization procedures. New-onset hypertension or exacerbation of hypertension may occur. NSAIDs may also impair response to antihypertensive agents; monitor BP; use with caution in patients with hypertension. May cause sodium and fluid retention; use with caution in patients with edema. Avoid use in heart failure (FDA 2015).

• CNS effects: May cause drowsiness, dizziness, blurred vision, and other neurologic effects that may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery, driving).

• Drug reaction with eosinophilia and systemic symptoms: Potentially serious, sometimes fatal, drug reaction with eosinophilia and systemic symptoms (DRESS), also known as multiorgan hypersensitivity reactions, has been reported with NSAIDs. Monitor for signs and symptoms (eg, fever, rash, lymphadenopathy, eosinophilia) in association with other organ system involvement (eg, hepatitis, nephritis, hematological abnormalities, myocarditis, myositis). Early symptoms of hypersensitivity reaction (eg, lymphadenopathy, fever) may occur without rash; discontinue therapy and further evaluate if DRESS is suspected.

• GI events: Use with caution in patients on concurrent therapy known to increase the risk of GI bleeding (eg, aspirin, anticoagulants and/or corticosteroids), advanced hepatic disease, coagulopathy, use of alcohol, or in elderly patients. Use the lowest effective dose for the shortest duration of time, consistent with individual patient goals, to reduce risk of GI adverse events. In patients with a history of GI ulcer bleeding requiring NSAID therapy, a COX-2 inhibitor in combination with a proton pump inhibitor is recommended to reduce the risk of recurrent bleeding (Barkun 2019). Discontinue use if GI bleeding occurs.

• Hematologic effects: Platelet adhesion and aggregation may be decreased; may prolong bleeding time; patients with coagulation disorders or who are receiving anticoagulants should be monitored closely. Rarely, NSAID use has been associated with potentially severe blood dyscrasias.

• Hepatotoxicity: Acetaminophen has been associated with acute liver failure, at times resulting in liver transplant and death. Hepatotoxicity is usually associated with excessive acetaminophen intake and often involves >1 product that contains acetaminophen. Do not exceed the maximum recommended daily dose (>4 g daily in adults) (Lancaster 2015). Hepatotoxicity has been reported with therapeutic doses of acetaminophen in patients with alcohol use disorder. In addition, chronic daily dosing may also result in liver damage in some patients (Bolesta 2002). Rare (sometimes fatal) severe hepatic reactions (eg, fulminant hepatitis, liver necrosis, hepatic failure) have occurred with NSAID use.

• Hyperkalemia: NSAID use may increase the risk of hyperkalemia, particularly in the elderly, diabetics, renal disease, and with concomitant use of other agents capable of inducing hyperkalemia (eg, angiotensin-converting enzyme [ACE]-inhibitors). Monitor potassium closely.

• Infection: May mask signs and symptoms of infection (eg, pain, fever, inflammation) resulting in delayed diagnosis.

• Ophthalmic events: Ophthalmologic adverse effects have been reported with NSAID use. Discontinue therapy and refer for ophthalmologic evaluation if symptoms occur.

• Renal effects: NSAID use may compromise existing renal function; dose-dependent decreases in prostaglandin synthesis may result from NSAID use, reducing renal blood flow which may cause renal decompensation (usually reversible). Patients with impaired renal function, dehydration, hypovolemia, heart failure, hepatic impairment, those taking diuretics and ACE inhibitors or angiotensin II receptor blockers, and the elderly are at greater risk of renal toxicity. Rehydrate patient before starting therapy; monitor renal function closely. Long-term NSAID use may result in renal papillary necrosis and other renal injury.

• Skin reactions: May cause serious skin adverse events (sometimes fatal), including acute generalized exanthematous pustulosis, exfoliative dermatitis, fixed drug eruption (including generalized bullous fixed drug eruption), Stevens-Johnson syndrome, and toxic epidermal necrolysis; may occur without warning. Discontinue use at first sign of skin rash (or any other hypersensitivity).

Disease-related concerns:

• Aseptic meningitis: NSAIDs may increase the risk of aseptic meningitis, especially in patients with systemic lupus erythematosus and mixed connective tissue disorders.

• Asthma: Use with caution in patients with asthma. Use of ibuprofen is contraindicated in patients with aspirin-sensitive asthma; severe and potentially fatal bronchospasm may occur.

• Coronary artery bypass graft surgery: Avoid ibuprofen use in the setting of coronary artery bypass graft (CABG) surgery. Risk of MI and stroke may be increased with use following CABG surgery.

• Coronavirus disease 2019 (COVID-19): Clinical or population-based data regarding the risks of NSAIDs in the setting of COVID-19 are limited (FDA Safety Communication 2020; Kim 2020). Some experts recommend the use of acetaminophen as the preferred antipyretic agent, when possible, and if NSAIDs are needed, to use the lowest effective dose and shortest duration (EMA 2020; Kim 2020). In general, for patients already taking an NSAID for a comorbid condition, it is recommended to continue the NSAID as directed by their health care provider (EMA 2020; NIH 2020; WHO 2020).

• Ethanol use: Use acetaminophen with caution in patients with alcoholic liver disease; consuming ≥3 alcoholic drinks/day may increase the risk of liver damage. Patients should avoid ethanol or limit to <3 drinks/day.

• Hepatic impairment: Use with caution in patients with hepatic impairment; reduced doses may be required due to extensive hepatic metabolism. Patients with advanced hepatic disease are at an increased risk of GI bleeding and kidney failure with NSAIDs (AASLD [Biggins 2021]; AASLD [Runyon 2013]).

Special populations:

• Older adult: Older adult patients are at increased risk for adverse effects (especially peptic ulceration, CNS effects, renal toxicity) from NSAIDs even at low doses; use with caution.

Other warnings/precautions:

• Self-medication (OTC use): Should not be used with other products containing acetaminophen. Patients should be instructed to contact health care provider if new symptoms occur, if redness or swelling occurs in the painful area, or for pain lasting >10 days. Consuming ≥3 alcoholic beverages/day or taking longer than recommended may increase the risk of GI bleeding. Also see individual agents.

Warnings: Additional Pediatric Considerations

Hepatoxicity has been reported in patients using acetaminophen. In pediatric patients, this is most commonly associated with supratherapeutic dosing, more frequent administration than recommended, and use of multiple acetaminophen-containing products; however, hepatotoxicity has been rarely reported with recommended dosages (AAP [Sullivan 2011]; Heard 2014). All sources of acetaminophen (eg, prescription, OTC, combination) should be considered when evaluating a patient's maximum daily dose. To lower the risk for hepatotoxicity, the maximum daily acetaminophen dose should be limited to ≤75 mg/kg/day (maximum of 5 daily doses), not to exceed 4,000 mg/day (AAP [Sullivan 2011]; Heard 2014; Krenzelok 2012; Lavonas 2010). Acetaminophen avoidance or a lower total daily dose (2,000 to 3,000 mg/day) has been suggested for adults with increased risk for acetaminophen hepatotoxicity (eg, malnutrition, certain liver diseases, use of drugs that interact with acetaminophen metabolism); similar data are unavailable in pediatric patients (Hayward 2016; Larson 2007; Worriax 2007).

A single-center, 10-year, retrospective review of pediatric patients diagnosed with acute kidney injury (AKI) (n=1,015; ages ≤18 years) reported nonsteroidal anti-inflammatory drugs (NSAIDs) as a potential cause of AKI in 2.7% of patients (n=27); a higher incidence (6.6%) was reported when additional exclusion factors were included in the data analysis. Dosing information was available for 74% of the NSAID-associated AKI cases (n=20); dosing was within the recommended range in 75% (n=15) of these cases. The median age of children with NSAID-associated AKI was 14.7 years (range: 0.5 to 17.7 years) and 15% of patients were <5 years and more likely to require dialysis than the older patients. Some experts suggest the incidence of NSAID-associated AKI found in this study is conservative due to aggressive exclusion criteria (eg, concurrent aminoglycoside or other nephrotoxic therapy) and the actual incidence may be higher (Brophy 2013; Misurac 2013).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous [preservative free]:

Combogesic: Acetaminophen 1,000 mg and ibuprofen 300 mg/100 mL (100 mL)

Tablet, Oral:

Acetaminophen-Ibuprofen: Acetaminophen 250 mg and ibuprofen 125 mg

Advil Dual Action: Acetaminophen 250 mg and ibuprofen 125 mg

Combogesic: Acetaminophen 325 mg and ibuprofen 97.5 mg

FT Dual Action: Acetaminophen 250 mg and ibuprofen 125 mg [contains corn starch]

Motrin Dual Action: Acetaminophen 250 mg and ibuprofen 125 mg [contains corn starch]

Generic Equivalent Available: US

May be product dependent

Pricing: US

Solution (Combogesic Intravenous)

1000-300 mg/100 mL (per mL): $0.28

Tablets (Advil Dual Action Oral)

125-250 mg (per each): $0.36

Tablets (Combogesic Oral)

325-97.5 mg (per each): $3.59

Tablets (Motrin Dual Action Oral)

125-250 mg (per each): $0.17

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Administration: Pediatric

Oral: Administer without regard to meals. May be administered with food or milk if GI upset occurs.

Administration: Adult

IV: For IV infusion only. Administer undiluted over 15 minutes. Attach an administration set in accordance with the manufacturer's recommendations. If dose to be administered is less than acetaminophen 1g/ibuprofen 300 mg, withdraw appropriate dose and place into separate empty, sterile container (eg, glass bottle, plastic IV container, syringe) for administration. Do not mix with other diluents or other medications.

Oral: May be administered with food or milk if stomach upset occurs.

Storage/Stability

IV: Store in original container at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Do not refrigerate or freeze. Protect from heat and light.

Oral:

Rx: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from light and moisture.

OTC: Store at 20°C to 25°C (68°F to 77°F); avoid excessive heat (40°C [104°F]).

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and at the following website, must be dispensed with this medication:

Combogesic: https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/209471s001lbl.pdf#page=28

Use

Oral: Temporary relief of minor aches and pains due to headache, backache, toothache, menstrual cramps, muscular aches, and minor pain of arthritis (OTC product: FDA approved in ages ≥12 years and adults).

Parenteral: Temporary relief of mild to moderate pain; management of moderate to severe pain as an adjunct to opioid analgesics (FDA approved in adults). Only indicated for short-term use of ≤5 days.

Medication Safety Issues
Older Adult: High-Risk Medication:

Beers Criteria: Ibuprofen is identified in the Beers Criteria as a potentially inappropriate medication to be avoided for chronic use in patients 65 years and older (unless alternative agents are ineffective and patient can receive concomitant gastroprotective agent) due to increased risk of GI bleeding and peptic ulcer disease in older adults in a high-risk category (eg, older than 75 years of age or receiving concomitant oral/parenteral corticosteroids, anticoagulants, or antiplatelet agents). In addition, avoid for short-term scheduled use in combination with oral/parenteral corticosteroids, anticoagulants, or antiplatelet agents unless alternatives are ineffective and patient can receive concomitant gastroprotective agent (Beers Criteria [AGS 2023]).

International issues:

Maxigesic brand name for ibuprofen/acetaminophen [Australia, New Zealand, Singapore] but also brand name for diclofenac sodium/paracetamol [India].

Other safety concerns:

Duplicate therapy issues: This product contains acetaminophen, which may be a component of other combination products. Do not exceed the maximum recommended daily dose of acetaminophen.

Metabolism/Transport Effects

Refer to individual components.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program

5-Aminosalicylic Acid Derivatives: Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of 5-Aminosalicylic Acid Derivatives. Risk C: Monitor

Abciximab: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Abrocitinib: Agents with Antiplatelet Effects may increase antiplatelet effects of Abrocitinib. Risk X: Avoid

Acalabrutinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Acemetacin: May increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Risk X: Avoid

Alcohol (Ethyl): May increase hepatotoxic effects of Acetaminophen. Risk C: Monitor

Aliskiren: Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of Aliskiren. Nonsteroidal Anti-Inflammatory Agents may decrease antihypertensive effects of Aliskiren. Risk C: Monitor

Aminoglycosides: Nonsteroidal Anti-Inflammatory Agents may decrease excretion of Aminoglycosides. Data only in premature infants. Risk C: Monitor

Aminolevulinic Acid (Systemic): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Systemic). Risk X: Avoid

Aminolevulinic Acid (Topical): Photosensitizing Agents may increase photosensitizing effects of Aminolevulinic Acid (Topical). Risk C: Monitor

Anagrelide: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Angiotensin II Receptor Blockers: Nonsteroidal Anti-Inflammatory Agents may decrease therapeutic effects of Angiotensin II Receptor Blockers. The combination of these two agents may also significantly decrease glomerular filtration and renal function. Angiotensin II Receptor Blockers may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Risk C: Monitor

Angiotensin-Converting Enzyme Inhibitors: Nonsteroidal Anti-Inflammatory Agents may decrease antihypertensive effects of Angiotensin-Converting Enzyme Inhibitors. Angiotensin-Converting Enzyme Inhibitors may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Risk C: Monitor

Anticoagulants (Miscellaneous Agents): Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Anticoagulants (Miscellaneous Agents). Risk C: Monitor

Antiplatelet Agents (P2Y12 Inhibitors): Agents with Antiplatelet Effects may increase antiplatelet effects of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor

Aspirin: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may decrease therapeutic effects of Aspirin. Aspirin may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Specifically, the risk for bleeding may be increased. Aspirin may decrease serum concentration of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Management: In general, avoid regular, frequent use of NSAIDs with aspirin whenever possible. If combined, monitor for increased bleeding and a reduced cardioprotective effect of aspirin. Risk D: Consider Therapy Modification

Atazanavir: May increase serum concentration of UGT1A1 Substrates. Management: Do not use UGT1A1 substrates for which small increases in exposure can cause serious adverse effects together with atazanavir, and use caution with any UGT1A1 substrate, even when small changes in exposure are less likely to cause serious adverse effects. Risk D: Consider Therapy Modification

Belumosudil: May increase serum concentration of UGT1A1 Substrates. Management: Avoid coadministration of belumosudil with substrates of UGT1A1 for which minimal concentration increases can cause serious adverse effects. If coadministration is required, dose reductions of the UGT1A1 substrate may be required. Risk D: Consider Therapy Modification

Bemiparin: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Bemiparin. Management: Avoid this combination if possible, due to an increased risk of bleeding. If coadministration cannot be avoided, monitor patients closely for clinical and laboratory evidence of bleeding. Risk D: Consider Therapy Modification

Beta-Blockers: Nonsteroidal Anti-Inflammatory Agents may decrease antihypertensive effects of Beta-Blockers. Risk C: Monitor

Bile Acid Sequestrants: May decrease absorption of Nonsteroidal Anti-Inflammatory Agents. Risk C: Monitor

Bisphosphonate Derivatives: Nonsteroidal Anti-Inflammatory Agents may increase adverse/toxic effects of Bisphosphonate Derivatives. Both an increased risk of gastrointestinal ulceration and an increased risk of nephrotoxicity are of concern. Risk C: Monitor

Busulfan: Acetaminophen may increase serum concentration of Busulfan. Risk C: Monitor

Caplacizumab: Agents with Antiplatelet Effects may increase adverse/toxic effects of Caplacizumab. Specifically, the risk of bleeding may be increased. Risk C: Monitor

CarBAMazepine: May increase metabolism of Acetaminophen. This may 1) diminish the effect of acetaminophen; and 2) increase the risk of liver damage. Risk C: Monitor

Cardiac Glycosides: Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of Cardiac Glycosides. Risk C: Monitor

Clofarabine: OAT1/3 Inhibitors may increase serum concentration of Clofarabine. Risk C: Monitor

Collagenase (Systemic): Agents with Antiplatelet Effects may increase adverse/toxic effects of Collagenase (Systemic). Specifically, the risk of injection site bruising and or bleeding may be increased. Risk C: Monitor

Corticosteroids (Systemic): May increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Risk C: Monitor

CycloSPORINE (Systemic): Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of CycloSPORINE (Systemic). Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of CycloSPORINE (Systemic). CycloSPORINE (Systemic) may increase serum concentration of Nonsteroidal Anti-Inflammatory Agents. Management: Consider alternatives to nonsteroidal anti-inflammatory agents (NSAIDs). Monitor for evidence of nephrotoxicity, as well as increased serum cyclosporine concentrations and systemic effects (eg, hypertension) during concomitant therapy with NSAIDs. Risk D: Consider Therapy Modification

Dapsone (Topical): May increase adverse/toxic effects of Methemoglobinemia Associated Agents. Risk C: Monitor

Dasatinib: Acetaminophen may increase hepatotoxic effects of Dasatinib. Dasatinib may increase serum concentration of Acetaminophen. Management: Avoid coadministration of acetaminophen and dasatinib if possible. If coadministration is unavoidable, monitor for signs/symptoms of hepatotoxicity, particularly in patients with greater acetaminophen exposure. Risk D: Consider Therapy Modification

Deferasirox: Nonsteroidal Anti-Inflammatory Agents may increase adverse/toxic effects of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Risk C: Monitor

Deoxycholic Acid: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Desirudin: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Desirudin. Risk C: Monitor

Desmopressin: Nonsteroidal Anti-Inflammatory Agents may increase hyponatremic effects of Desmopressin. Risk C: Monitor

Dichlorphenamide: OAT1/3 Inhibitors may increase serum concentration of Dichlorphenamide. Risk C: Monitor

Direct Oral Anticoagulants (DOACs): Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Direct Oral Anticoagulants (DOACs). Risk C: Monitor

Drospirenone-Containing Products: May increase hyperkalemic effects of Nonsteroidal Anti-Inflammatory Agents. Risk C: Monitor

Enoxaparin: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Enoxaparin. Management: Discontinue nonselective NSAIDs prior to initiation of enoxaparin whenever possible. If coadministration cannot be avoided, monitor patients closely for clinical and laboratory evidence of bleeding. Risk D: Consider Therapy Modification

Eplerenone: Nonsteroidal Anti-Inflammatory Agents may decrease antihypertensive effects of Eplerenone. Nonsteroidal Anti-Inflammatory Agents may increase hyperkalemic effects of Eplerenone. Risk C: Monitor

Flucloxacillin: May increase adverse/toxic effects of Acetaminophen. Specifically, the risk for high anion gap metabolic acidosis may be increased. Risk C: Monitor

Fluconazole: May increase serum concentration of Ibuprofen. Risk C: Monitor

Fondaparinux: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Fondaparinux. Management: Discontinue nonselective nonsteroidal anti-inflammatory agents prior to the initiation of fondaparinux, if possible. If coadministration is required, monitor patients closely for signs and symptoms of bleeding. Risk D: Consider Therapy Modification

Fosphenytoin-Phenytoin: May decrease serum concentration of Acetaminophen. Specifically, serum concentrations of acetaminophen may be decreased (leading to decreased efficacy), but the formation of the toxic N-acetyl-p-benzoquinone imine (NAPQI) metabolite may be increased (leading to increased hepatotoxicity). Risk C: Monitor

Glycoprotein IIb/IIIa Inhibitors: Agents with Antiplatelet Effects may increase antiplatelet effects of Glycoprotein IIb/IIIa Inhibitors. Risk C: Monitor

Heparin: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Heparin. Risk C: Monitor

Heparins (Low Molecular Weight): Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Heparins (Low Molecular Weight). Risk C: Monitor

Herbal Products with Anticoagulant/Antiplatelet Effects: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

HydrALAZINE: Nonsteroidal Anti-Inflammatory Agents may decrease antihypertensive effects of HydrALAZINE. Risk C: Monitor

Ibritumomab Tiuxetan: Agents with Antiplatelet Effects may increase antiplatelet effects of Ibritumomab Tiuxetan. Risk C: Monitor

Ibrutinib: Agents with Antiplatelet Effects may increase adverse/toxic effects of Ibrutinib. Specifically, the risk of bleeding and hemorrhage may be increased. Risk C: Monitor

Imatinib: Ibuprofen may decrease serum concentration of Imatinib. Specifically, ibuprofen may decrease intracellular concentrations of imatinib, leading to decreased clinical response. Management: Consider using an alternative to ibuprofen in patients who are being treated with imatinib. Available evidence suggests other NSAIDs do not interact in a similar manner. Risk D: Consider Therapy Modification

Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Acetaminophen may decrease therapeutic effects of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Risk C: Monitor

Inotersen: Agents with Antiplatelet Effects may increase adverse/toxic effects of Inotersen. Specifically, the risk of bleeding may be increased. Risk C: Monitor

Isoniazid: May increase hepatotoxic effects of Acetaminophen. Isoniazid may increase metabolism of Acetaminophen. Specifically, formation of the hepatotoxic NAPQI metabolite may be increased. Risk C: Monitor

Ketorolac (Nasal): May increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Risk X: Avoid

Ketorolac (Systemic): Nonsteroidal Anti-Inflammatory Agents may increase adverse/toxic effects of Ketorolac (Systemic). Risk X: Avoid

LamoTRIgine: Acetaminophen may decrease serum concentration of LamoTRIgine. Risk C: Monitor

Limaprost: May increase adverse/toxic effects of Agents with Antiplatelet Effects. Specifically, the risk of bleeding may be increased. Risk C: Monitor

Lithium: Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of Lithium. Management: Consider reducing the lithium dose when initiating a NSAID. Monitor for increased lithium therapeutic/toxic effects if a NSAID is initiated/dose increased, or decreased effects if a NSAID is discontinued/dose decreased. Risk D: Consider Therapy Modification

Local Anesthetics: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Local Anesthetics. Specifically, the risk for methemoglobinemia may be increased. Risk C: Monitor

Loop Diuretics: Nonsteroidal Anti-Inflammatory Agents may decrease diuretic effects of Loop Diuretics. Loop Diuretics may increase nephrotoxic effects of Nonsteroidal Anti-Inflammatory Agents. Management: Monitor for evidence of kidney injury or decreased therapeutic effects of loop diuretics with concurrent use of an NSAID. Consider avoiding concurrent use in CHF or cirrhosis. Concomitant use of bumetanide with indomethacin is not recommended. Risk D: Consider Therapy Modification

Lorlatinib: May decrease serum concentration of Acetaminophen. Risk C: Monitor

Lumacaftor and Ivacaftor: May decrease serum concentration of Ibuprofen. Risk C: Monitor

Macimorelin: Coadministration of Nonsteroidal Anti-Inflammatory Agents and Macimorelin may alter diagnostic results. Risk X: Avoid

MetFORMIN: Nonsteroidal Anti-Inflammatory Agents may increase adverse/toxic effects of MetFORMIN. Risk C: Monitor

Methotrexate: Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of Methotrexate. Management: Avoid coadministration of higher dose methotrexate (such as that used for the treatment of oncologic conditions) and NSAIDs. Use caution if coadministering lower dose methotrexate and NSAIDs. Risk D: Consider Therapy Modification

Methoxsalen (Systemic): Photosensitizing Agents may increase photosensitizing effects of Methoxsalen (Systemic). Risk C: Monitor

Methoxyflurane: Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of Methoxyflurane. Risk X: Avoid

MetyraPONE: May increase serum concentration of Acetaminophen. More importantly, by inhibiting the conjugative metabolism of acetaminophen, metyrapone may shift the metabolism towards the oxidative route that produces a hepatotoxic metabolite. Risk X: Avoid

Mifamurtide: Nonsteroidal Anti-Inflammatory Agents may decrease therapeutic effects of Mifamurtide. Risk X: Avoid

Miscellaneous Antiplatelets: Agents with Antiplatelet Effects may increase antiplatelet effects of Miscellaneous Antiplatelets. Risk C: Monitor

Mitapivat: May decrease serum concentration of UGT1A1 Substrates. Risk C: Monitor

Nadroparin: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Nadroparin. Management: Coadministration of NSAIDs and nadroparin is not recommended due to an increased risk of bleeding. If coadministration is required, monitor patients closely for clinical and laboratory signs of bleeding. Risk D: Consider Therapy Modification

Naftazone: May increase antiplatelet effects of Nonsteroidal Anti-Inflammatory Agents. Risk C: Monitor

Nitric Oxide: May increase adverse/toxic effects of Methemoglobinemia Associated Agents. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents (Topical): Nonsteroidal Anti-Inflammatory Agents (Topical) may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk of gastrointestinal (GI) toxicity is increased. Management: Coadministration of systemic nonsteroidal anti-inflammatory drugs (NSAIDs) and topical NSAIDs is not recommended. If systemic NSAIDs and topical NSAIDs, ensure the benefits outweigh the risks and monitor for increased NSAID toxicities. Risk D: Consider Therapy Modification

Nonsteroidal Anti-Inflammatory Agents: May increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk for gastrointestinal toxicity is increased. Risk X: Avoid

Obinutuzumab: Agents with Antiplatelet Effects may increase adverse/toxic effects of Obinutuzumab. Specifically, the risk of bleeding may be increased. Management: Consider avoiding coadministration of obinutuzumab and agents with antiplatelet effects, especially during the first cycle of obinutuzumab therapy. Risk D: Consider Therapy Modification

Omacetaxine: Nonsteroidal Anti-Inflammatory Agents may increase adverse/toxic effects of Omacetaxine. Specifically, the risk for bleeding-related events may be increased. Risk C: Monitor

PEMEtrexed: Ibuprofen may increase serum concentration of PEMEtrexed. Management: In patients with an estimated creatinine clearance of 45 to 79 mL/min, avoid ibuprofen for 2 days before, the day of, and 2 days following the administration of pemetrexed. Monitor for increased pemetrexed toxicities if combined. Risk D: Consider Therapy Modification

Pentosan Polysulfate Sodium: Agents with Antiplatelet Effects may increase adverse/toxic effects of Pentosan Polysulfate Sodium. Specifically, the risk of hemorrhage may be increased. Risk C: Monitor

PHENobarbital: May increase metabolism of Acetaminophen. Specifically, formation of the hepatotoxic NAPQI metabolite may be increased. Risk C: Monitor

Phenylbutazone: May increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Risk X: Avoid

Phenylephrine (Systemic): Acetaminophen may increase serum concentration of Phenylephrine (Systemic). Risk C: Monitor

Pirtobrutinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Polyethylene Glycol-Electrolyte Solution: Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of Polyethylene Glycol-Electrolyte Solution. Risk C: Monitor

Porfimer: Photosensitizing Agents may increase photosensitizing effects of Porfimer. Risk X: Avoid

Potassium Salts: Nonsteroidal Anti-Inflammatory Agents may increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

Potassium-Sparing Diuretics: Nonsteroidal Anti-Inflammatory Agents may increase hyperkalemic effects of Potassium-Sparing Diuretics. Nonsteroidal Anti-Inflammatory Agents may decrease antihypertensive effects of Potassium-Sparing Diuretics. Risk C: Monitor

PRALAtrexate: Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of PRALAtrexate. More specifically, NSAIDS may decrease the renal excretion of pralatrexate. Management: Avoid coadministration of pralatrexate with nonsteroidal anti-inflammatory drugs (NSAIDs). If coadministration cannot be avoided, closely monitor for increased pralatrexate serum levels or toxicity. Risk D: Consider Therapy Modification

Prilocaine: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Prilocaine. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Management: Monitor for signs of methemoglobinemia when prilocaine is used in combination with other agents associated with development of methemoglobinemia. Avoid use of these agents with prilocaine/lidocaine cream in infants less than 12 months of age. Risk C: Monitor

Primaquine: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Primaquine. Specifically, the risk for methemoglobinemia may be increased. Management: Avoid concomitant use of primaquine and other drugs that are associated with methemoglobinemia when possible. If combined, monitor methemoglobin levels closely. Risk D: Consider Therapy Modification

Primidone: May increase metabolism of Acetaminophen. Specifically, formation of the hepatotoxic NAPQI metabolite may be increased. Risk C: Monitor

Probenecid: May increase serum concentration of Acetaminophen. Probenecid may also limit the formation of at least one major non-toxic metabolite, possibly increasing the potential for formation of the toxic NAPQI metabolite. Management: Consider limiting acetaminophen use in combination with probenecid. Probenecid may reduce clearance of acetaminophen to one of its non-toxic metabolities, increasing the risk for acetaminophen toxicity, even a lower doses. Risk D: Consider Therapy Modification

Prostaglandins (Ophthalmic): Nonsteroidal Anti-Inflammatory Agents may decrease therapeutic effects of Prostaglandins (Ophthalmic). Nonsteroidal Anti-Inflammatory Agents may also enhance the therapeutic effects of Prostaglandins (Ophthalmic). Risk C: Monitor

Quinolones: Nonsteroidal Anti-Inflammatory Agents may increase neuroexcitatory and/or seizure-potentiating effects of Quinolones. Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of Quinolones. Risk C: Monitor

RifAMPin: May increase hepatotoxic effects of Acetaminophen. RifAMPin may decrease serum concentration of Acetaminophen. Risk C: Monitor

Salicylates: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase adverse/toxic effects of Salicylates. An increased risk of bleeding may be associated with use of this combination. Risk X: Avoid

Seladelpar: OAT1/3 Inhibitors may increase serum concentration of Seladelpar. Risk X: Avoid

Selective Serotonin Reuptake Inhibitor: May increase antiplatelet effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Nonsteroidal Anti-Inflammatory Agents (Nonselective) may decrease therapeutic effects of Selective Serotonin Reuptake Inhibitor. Management: Consider alternatives to NSAIDs. Monitor for evidence of bleeding and diminished antidepressant effects. It is unclear whether COX-2-selective NSAIDs reduce risk. Risk D: Consider Therapy Modification

Selumetinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Serotonin/Norepinephrine Reuptake Inhibitor: May increase antiplatelet effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Risk C: Monitor

Sincalide: Drugs that Affect Gallbladder Function may decrease therapeutic effects of Sincalide. Management: Consider discontinuing drugs that may affect gallbladder motility prior to the use of sincalide to stimulate gallbladder contraction. Risk D: Consider Therapy Modification

Sodium Nitrite: Methemoglobinemia Associated Agents may increase adverse/toxic effects of Sodium Nitrite. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Risk C: Monitor

Sodium Phosphates: May increase nephrotoxic effects of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk of acute phosphate nephropathy may be enhanced. Risk C: Monitor

SORAfenib: Acetaminophen may increase hepatotoxic effects of SORAfenib. SORAfenib may increase serum concentration of Acetaminophen. Management: Avoid coadministration of acetaminophen and sorafenib if possible. If coadministration is unavoidable, monitor for signs/symptoms of hepatotoxicity, particularly in patients with greater acetaminophen exposure. Risk D: Consider Therapy Modification

Sulopenem Etzadroxil: OAT1/3 Inhibitors may increase serum concentration of Sulopenem Etzadroxil. Risk C: Monitor

Sulprostone: Nonsteroidal Anti-Inflammatory Agents may decrease therapeutic effects of Sulprostone. Risk X: Avoid

Tacrolimus (Systemic): Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of Tacrolimus (Systemic). Risk C: Monitor

Tenofovir Products: Nonsteroidal Anti-Inflammatory Agents may increase nephrotoxic effects of Tenofovir Products. Management: Seek alternatives to these combinations whenever possible. Avoid use of tenofovir with multiple NSAIDs or any NSAID given at a high dose due to a potential risk of acute renal failure. Diclofenac appears to confer the most risk. Risk D: Consider Therapy Modification

Tenoxicam: May increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Risk X: Avoid

Thiazide and Thiazide-Like Diuretics: Nonsteroidal Anti-Inflammatory Agents may decrease therapeutic effects of Thiazide and Thiazide-Like Diuretics. Thiazide and Thiazide-Like Diuretics may increase nephrotoxic effects of Nonsteroidal Anti-Inflammatory Agents. Risk C: Monitor

Thrombolytic Agents: Agents with Antiplatelet Effects may increase adverse/toxic effects of Thrombolytic Agents. Specifically, the risk of bleeding may be increased. Risk C: Monitor

Tipranavir: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Tolperisone: Nonsteroidal Anti-Inflammatory Agents may increase adverse/toxic effects of Tolperisone. Specifically, the risk of hypersensitivity reactions may be increased. Tolperisone may increase therapeutic effects of Nonsteroidal Anti-Inflammatory Agents. Risk C: Monitor

Tricyclic Antidepressants: May increase antiplatelet effects of Nonsteroidal Anti-Inflammatory Agents. Tricyclic Antidepressants may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk of major adverse cardiac events (MACE), hemorrhagic stroke, ischemic stroke, and heart failure may be increased. Risk C: Monitor

Vaccines: Acetaminophen may decrease therapeutic effects of Vaccines. Management: Consider avoiding routine prophylactic use of acetaminophen before or during vaccine administration when possible. Acetaminophen is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider Therapy Modification

Vadadustat: OAT1/3 Inhibitors may increase serum concentration of Vadadustat. Risk C: Monitor

Valproic Acid and Derivatives: Ibuprofen may decrease serum concentration of Valproic Acid and Derivatives. Risk C: Monitor

Vancomycin: Nonsteroidal Anti-Inflammatory Agents may increase serum concentration of Vancomycin. Risk C: Monitor

Verteporfin: Photosensitizing Agents may increase photosensitizing effects of Verteporfin. Risk C: Monitor

Vitamin E (Systemic): May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Vitamin K Antagonists: Nonsteroidal Anti-Inflammatory Agents (Nonselective) may increase anticoagulant effects of Vitamin K Antagonists. Management: Consider alternatives to this combination when possible. If the combination must be used, monitor coagulation status closely and advise patients to promptly report any evidence of bleeding or bruising. Risk D: Consider Therapy Modification

Volanesorsen: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Voriconazole: May increase serum concentration of Ibuprofen. Specifically, concentrations of the S-(+)-ibuprofen enantiomer may be increased. Risk C: Monitor

Zanubrutinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor

Reproductive Considerations

Refer to individual monographs.

Pregnancy Considerations

Acetaminophen crosses the placenta (Naga Rani 1989).

Refer to individual monographs for additional information.

Monitoring Parameters

Short-term use: Relief of pain.

Long-term use: Relief of pain, occult blood loss, liver enzymes; urine output, BUN, and creatinine (in patients at risk for kidney impairment), acetaminophen concentrations (in patients with hepatic disease).

Suspected overdose: Serum acetaminophen concentrations, hepatic function, kidney function.

Mechanism of Action

Acetaminophen: The mechanism of acetaminophen is not fully elucidated; it produces analgesia by increasing the pain threshold.

Ibuprofen: Ibuprofen reversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, which results in decreased formation of prostaglandin precursors; has antipyretic, analgesic, and anti-inflammatory properties.

Pharmacokinetics (Adult Data Unless Noted)

Refer to individual agents.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Maxigesic;
  • (AR) Argentina: Bengue caps | Causalon gesic | Duomax | Duomax vl | Tafirol duo | Tafirol flex;
  • (AU) Australia: Advilduo paracetamol+ibuprofen | Amcal Paracetamol & Ibuprofen | Apohealth ibuprofen plus paracetamol | Avallon paracetamol and ibuprofen | Blooms the chemist ibuprofen plus paracetamol | Bpa paracetafen | Bpa paracetamol + ibuprofen | Chemists own ibuprofen + paracetamol duo | Chemists' own ibuprofen + paracetamol duo | Combigesic | Combimol ibuprofen + paracetamol | David craig paracetamol and ibuprofen | Dymafen | Gesicomb | Ibumol double action pain relief | Ibupane | Maxigesic | Maxofen | Medreich paracetamol and ibuprofen | Mersynofen | Nuromol | Nuromol dual action pain relief | Paracetamol & Ibuprofen | Pharmacist formula ibuprofamol | Pharmacy action paracetamol & Ibuprofen | Pharmacy Choice Ibuprofen & Paracetamol | Pharmacy health paracetamol & ibuprofen | Pharmacy health paracetamol and ibuprofen | Pharmacy plus moverex | Priceline pharmacy paracetamol & ibuprofen | Priceline pharmacy paracetamol and ibuprofen | Soul pattinson paracetamol and ibuprofen | Spiro lifecare ibuprofen + paracetamol | Terrywhite chemmart paracetamol + ibuprofen | Terrywhite chemmart paracetamol and ibuprofen | Trust fenmol;
  • (BE) Belgium: Combophen | Nuralgan;
  • (BF) Burkina Faso: Asmoflam | Ibumol | Lexofen plus | Paraflam | Parofen;
  • (BG) Bulgaria: Combogesic | Lekadol complex | Metafen max | Nurulin duo | Syafen duo;
  • (BR) Brazil: Algi-danilon | Algi-itamanil | Luftafem | Nuromol | Reuplex;
  • (CH) Switzerland: Paraconica plus;
  • (CI) Côte d'Ivoire: Asmoflam | Brupal forte | Genforte | Ibutamol | Kilmol | Lytamol plus | Parofen | Supafen;
  • (CL) Chile: Adona | Artri tapsin | Dolo octirona | Gedol | Ibupirac compuesto | Kitadol duo | Lumdol | Midol | Predual Di | Tapsin duo;
  • (CN) China: Bao shi tai | Brustan | Compound ibuprofen;
  • (CZ) Czech Republic: Brufen combi | Cetalgen;
  • (DE) Germany: Duoval | Paracetamol/Ibuprofen Acino | Paracetamol/Ibuprofen ratiopharm;
  • (DO) Dominican Republic: Algimax | Doloxin plus | Ibumol | Natrafen Plus | Subridon;
  • (EC) Ecuador: Algitrin | Beralfeno | Dolo octirona | Dolorpan forte | Efficol plus | Finalin artritis | Finalin fem | Finalin mujer | Ibumedica | Ibupar forte | Paraconica plus | Paralgen plus | Paralgen plus forte | Rufen forte;
  • (EE) Estonia: Combogesic;
  • (EG) Egypt: Cetafen | Megafen | Parofen;
  • (ES) Spain: Dolostop plus | Paracetamol/ibuprofeno;
  • (GB) United Kingdom: Combogesic | Combogesic iv | Nuromol | Nuromol double action;
  • (GH) Ghana: Combipar;
  • (GR) Greece: Gopain | Ibutomol | Unitek;
  • (HK) Hong Kong: Maxigesic;
  • (HR) Croatia: Lekofen | Neofen combo;
  • (HU) Hungary: Brufen plus | Dolowill duo;
  • (ID) Indonesia: Aknil | Axalan | Bimacyl | Exedra rema | Iremax | Limasip | Linugo | Neo rheumacyl | Oskadon sp | Parafen | Paramex nyeri otot | Prafenta;
  • (IE) Ireland: Easolief duo;
  • (IL) Israel: Combodex;
  • (IN) India: Acegesic | Actimol f | Adiflam plus | Anaflam | Answell | Antiflam | Arcure | Arden plus | Arfen comp | Arfen-p | Arpibru | Artifen plus | Artigesic | Bestofen | Bestogesic plus old | Biobru plus | Bren plus | Bruace | Brucet | Bruceta | Brufamol | Brufamol plus | Brufen p | Bruforte | Brugesic p | Brupal | Brustan | Brustin | Bufex | Cadotryl | Calpol plus | Combiflam | Combiforex | Corflam | Credol-a | Creflam | Crofen | Curegesic | Curiflam forte | Deflam | Dip | Dolgesic | Dolomed | Doloprofen | Dolosans | Dt ibuflam | Duoflam | Eldoflam-old | Embru plus | Emflam-plus | Eucrafen | Extragesic | Fenceta | Fenmol | Fenomol | Fentrex plus | Flexon | Flyon | Geeflam | Gexofen | Iben | Iben plus | Ibu-p libra | Ibubid plus | Ibuclin | Ibucon plus | Ibudex | Ibudol-A Kid | Ibufen plus | Ibuflamar-p | Ibugesic plus | Ibumag plus | Ibumet-p | Ibumol | Ibunij a tab. | Ibunol | Ibupar | Ibupil | Ibuplus | Iburic plus | Ibusaan | Ibuspan-p | Ibustal Plus | Ibusule | Ibuter | Ibuwin | Imol | Inflake | Inflazen | Inflazen-m | Inpane | Intaflam | Itnil | Jk flam | Lederflam plus | Lupiflam | Magadol | Maxofen | Maxofen plus | Medomol plus | Mexipar | Multigon | Neurophen forte | New artifen plus | Nivafen | Norswel plus | Nostafen | Orthogesic | Osofen plus | Osyfen | Osyfen plus | P fen | Pabuflam | Pacitab | Parbudol | Pd flam | Pinkin plus | Prenovil | Prestigin plus | Procider ef | Profentol | Pyreflam | Pyremol-ib | Redflam | Reduc-a | Reducin-a | Regaflam | Relifen plus | Relpa | Renofen | Rubigesic-p | Safeaid | Stifnil | Tolfen | Torynal | Tribusynth | Triflam | Tylofen | Velcomb | Windol | Xeroflam | Zupar;
  • (IT) Italy: Tabumol | Tachifene;
  • (JO) Jordan: Bigesic | Ibumol | Taskine pain;
  • (JP) Japan: Norshin ai;
  • (KE) Kenya: Abumol | Artifen plus | Betafen plus | Brupal forte | Brupal kid | Brustan | Cetafen | Combisun | Fenpar | Fenplus | Finmol | Flexon | Ibuflam plus | Ibulab | Ibupar | Ibuplus | Nauma plus | Paraconica plus | Paraflam | Relievo | Relpa;
  • (LB) Lebanon: Maxifen;
  • (LT) Lithuania: Ibuclin | Metafenex;
  • (LU) Luxembourg: Combophen | Nuralgan;
  • (LV) Latvia: Combogesic | Ibuclin | Metafenex;
  • (MX) Mexico: Acciogen | Algitrin | Dualgos | Proxego;
  • (MY) Malaysia: Maxigesic;
  • (NG) Nigeria: Dyofen | Lotemp plus | Zedfen plus;
  • (NL) Netherlands: Nuralgan;
  • (NO) Norway: Dolerin;
  • (NZ) New Zealand: Brufen extra | Maxigesic | Nuromol | Paracare paracetamol + ibuprofen | Paracetamol + ibuprofen | Paracetamol and ibuprofen | Pharmacy health paracetamol & ibuprofen;
  • (PE) Peru: Calmiren | Dolamine extra forte | Dolmacaf plus | Dolmigran | Dolo octirona lch | Dolo teralgex plus | Dolofrenar | Dolomarket plus | Dolomax plus | Dolomolargesico | Luxor aprol extra forte | Panaflam forte | Thermoflam;
  • (PH) Philippines: Alaxan | Aldrinex | Brustan | Cortal pain | Cortal Sqr | Femol | Fenpar | Mulax | Muskelax | Parabufen | Parafen | Paramax | Proflex | Relaxid | Restolax | Scheelax | Selxan;
  • (PK) Pakistan: Provas duo;
  • (PL) Poland: Apap intense | Inflanor plus | Nurofen Ultima;
  • (PR) Puerto Rico: Advil dual action | Combogesic iv | Motrin dual action;
  • (PT) Portugal: Brufenon | Dolostop duo | Duodix | Trifeduo;
  • (PY) Paraguay: Dolo feminal | Duomax | Kitadol plus | Libredol plus;
  • (QA) Qatar: Maxigesic | Maxigesic IV;
  • (RO) Romania: Analgex | Biofen extra | Combifexin | Combogesic | Inflanor plus | Paduden duo | Synocam;
  • (RU) Russian Federation: Brustan | Hirumat | Ibamol intensive | Ibuclin | Next | Nuralgon | Nurofen long | Nurofen multisymptom | Temponet plus;
  • (SE) Sweden: Dolerin;
  • (SG) Singapore: Maxigesic | Nuromol;
  • (SI) Slovenia: Adobil | Ibuprofen/paracetamol belupo | Lekofusin | Metafen;
  • (SK) Slovakia: Brufen combi | Cetalgen | Combogesic;
  • (TH) Thailand: Alaxan pi tab | Bruno | Brustan | Dologen | Ibucet | Ibuman plus | Ibutamol | Kintal-b | Lofen | Ostemed | Panofen | Parafen | Setargin 525 | Skelan | Torrafen | Torrafen forte;
  • (UA) Ukraine: Affida plus | Brustan | Darfen long | Ibuclin | Inflagesik Plus | Lekadol long | Noxapan | Nurofen intensive | Nurofen long | Tarafol;
  • (UG) Uganda: Astraflam | Brumax plus | Brustan | Combifen | Ibumol | Ibupar | Ibuplus | Paraconica plus | Primafen | Prop plus;
  • (UY) Uruguay: Doblon | Dolo octirona | Perifar Plus;
  • (VN) Viet Nam: Agiparofen | Alecizan | Doaxan s | Dolanol | Fencedol | Feparac | Medialeczan | Paralmax pain | Partamol extra | Protamol | Richaxan | Taxanzan;
  • (ZA) South Africa: Ibumol | Maxigesic | Mypaid | Nocomypro;
  • (ZM) Zambia: Adiflam plus | Brupal | Brustan | Ibugesic plus | Ibun | Panado plus
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