Credit: Vaughn Fritts
Acetaminophen (Tylenol) and ibuprofen (Advil) rank first and second, respectively, on the list of most commonly used over-the-counter (OTC) drugs in the United States. They are great for mild to moderate pain control and fever reduction, and are considered generally safe if used correctly.
But some Americans take OTC medications less seriously than prescriptives, disregarding label directions and downing any dose that suits them. As a result, nearly one in five ibuprofen users in the U.S. admit to regularly exceeding the maximum daily dose of 1,200 milligrams; one in 13 acetaminophen users surpass the daily 4,000 mg limit. Many continue dosing for weeks, months, even years, ignoring the three–day maximum spelled out on the labels.
Understanding the difference between the two meds and how to manage them can help you avoid dangerous consequences.
Tylenol
Used by 60 million Americans, acetaminophen is still something of a mystery: No one knows how this 75-year-old drug works. Experts believe it targets the brain and spinal column to alleviate fever and curtail pain. Acetaminophen is popularly used for fever, headache, chronic arthritis and backache. It’s not an anti-inflammatory like ibuprofen, so it isn’t as effective for the acute swelling of sprains or strains; the trade-off is that it’s easier on the stomach.
Acetaminophen was once considered a mild drug with few side effects, but its overuse has led to 2,000 cases of liver failure annually in the U.S., making it the leading cause of liver transplants. Acetaminophen has a narrow window of safety—small differences in dosage can quickly reach toxic levels—making it easy to take too much. Of the 500 annual American deaths from acetaminophen overdose, half are unintentional.
Many users consume high doses for too long; some don’t realize they’re getting additional acetaminophen in OTC allergy or cold medications, such as Alka-Seltzer Plus, NyQuil and Theraflu. People with liver disease are at highest risk; so are heavy drinkers. The common habit of popping a few Tylenol to prevent a hangover is a perilous practice. Acetaminophen was recently found to elevate blood pressure in people with hypertension—a 5-point rise in as little as two weeks. (Its impact on healthy individuals’ blood pressure is being studied.)
Advil
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). It works by blocking the body’s production of prostaglandin, a hormone-like chemical with a wide range of effects, including inflammation. More than 30 million Americans use Ibuprofen for muscle injuries, arthritis, menstrual cramps and fever; side effects include nausea, vomiting or dizziness. It can cause gastric ulcers and gastrointestinal bleeding even if used correctly. This is especially true for seniors, whose stomach linings have thinned with age, as well as people who take anticoagulants such as warfarin or clopidogrel.
Long-term use of ibuprofen may lead to salt and water retention, increasing the risk of kidney damage, high blood pressure and heart failure. The U.S. Food & Drug Administration (FDA) added a warning in 2015 to all NSAID labels: Standard doses can significantly increase the risk of heart attack and stroke for those with pre-existing heart disease—in as early as the first few weeks of use. There’s a small risk (2%) for healthy individuals, too.
Surgeons often recommend a mix of ibuprofen and acetaminophen for post-op pain. The combination is more effective than taking either drug alone, and it can work as well as narcotics. The FDA approved a “dual-action” product in 2020; it contains both drugs in one tablet. (Risks and side effects for both medications apply.)
What to do
Ibuprofen and acetaminophen are meant for occasional use at minimal doses. Read the labels and follow directions. Speak to your medical provider if pain or fever lasts more than three days. If taking acetaminophen, check the ingredients of any cold or allergy remedies you’re using to avoid accidental overdose. Protect your stomach by taking ibuprofen with food. Ask your pharmacist about possible drug interactions with any of your prescription meds. Try alternative treatments for pain and fever if approved by your medical provider: warm or cold packs, massage, topical creams or gels.
Mary Jenkins recently retired after nearly 40 years as a family practice physician in New York state.