Q: My 88-year old mother often complains of various aches and pains. What is the safest over-the-counter painkiller for her to take? Aren’t some of them bad for your liver and kidneys?
A: Frequent aches and pains are a common problem for older adults.
If your mother has been complaining, you’ll want to make sure she gets a careful evaluation from her doctor. After all, frequent pain can be a sign of an important underlying health problem that needs attention. You’re also more likely to help your mom reduce her pain if you can help her doctors identify the underlying causes of her pain.
That said, it’s a good idea to ask what over-the-counter (OTC) pain relievers are safest for older people.
That’s because improper use of OTC painkiller tablets is actually a major cause of harm to older adults.
So let me tell you what OTC pain relievers geriatricians usually consider the safest, and which very common group of painkillers can cause serious side-effects in aging adults.
What’s the safest OTC painkiller for an aging parent?
For most older adults, the safest oral OTC analgesic drug for daily or frequent use is acetaminophen (brand name Tylenol), provided you are careful to not exceed a total dose of 3,000mg per day.
Acetaminophen is usually called paracetamol outside the U.S.
It is processed by the liver and in high doses can cause serious — sometimes even life-threatening — liver injury. So if an older person has a history of alcohol abuse or chronic liver disease, then an even lower daily limit will be needed, and I would strongly advise you to talk to a doctor about what daily limit might be suitable.
The tricky thing with acetaminophen is that it’s actually included in lots of different over-the-counter medications (e.g. Nyquil, Theraflu) and prescription medications (e.g. Percocet). So people can easily end up taking more daily acetaminophen than they realize. This can indeed be dangerous; research suggests that 40% of acetaminophen overdose cases are accidental.
But when taken at recommended doses, acetaminophen has surprisingly few serious side effects and rarely harms older adults. Unlike non-steroidal anti-inflammatory drugs (NSAIDs, see below), it does not put older adults at risk of internal bleeding, and it seems to have minimal impacts on kidney function and cardiovascular risk.
Also safe for pain relief in aging: over-the-counter topical analgesics
Another option to consider are topical analgesics creams; a variety of them are available over-the-counter. I generally recommend trying a few different ones, to see which one seems to provide better relief for a particular person.
Be careful or avoid oral over-the-counter anti-inflammatory drugs
At the drugstore, the most common alternatives to acetaminophen are painkiller tablets such as ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve, Naprosyn, and Anaprox).
Both of these are part of a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Many people are familiar with these medications. But in fact, older adults should be very careful before using NSAIDs often or regularly.
Unlike acetaminophen, which usually doesn’t become much riskier as people get older, NSAIDs cause side effects that are especially likely to become dangerous as people get older. These include:
- Increased risk of bleeding in the stomach, small bowel, or colon. Older adults who take a daily aspirin or a blood thinner are at especially high risk.
- Problems with the stomach lining, which can cause stomach pain or even peptic ulcer disease.
- Decreased kidney function. This can be especially problematic for those many older adults who have already experienced a chronic decline in kidney function.
- Interference with high blood pressure medications.
- Fluid retention and increased risk of heart failure.
Experts have estimated that NSAIDs cause 41,00 hospitalizations and 3,300 deaths among older adults every year.
Recent research has also suggested that NSAIDs cause a small but real increase in the risk of cardiovascular events (e.g. heart attacks and strokes).
Because of these well-known serious side effects of NSAIDs in older adults, in 2009 the American Geriatrics Society recommended that older adults avoid using NSAIDS for the treatment of chronic persistent pain. Today, oral NSAIDs remain on the Beer’s List of medications that older adults should avoid or use with caution. (For more on the Beer’s list, see this article: Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria 2023 Update.)
Now, it’s important to know NSAIDs can also be prescribed as creams or gels. These topical forms are much safer, and can be effective for pain relief. (In fact, as of 2020, the topical NSAID Voltaren gel is now available without a prescription.)
Despite the well-established risks of oral NSAIDs, NSAID painkiller tablets are often bought by seniors at the drugstore. Perhaps even worse, NSAIDs are often prescribed to older adults by physicians, because the anti-inflammatory effect can provide relief from arthritis pain, gout, and other common health ailments.
(Commonly prescribed NSAIDs include indomethacin, diclofenac, sulindac, meloxicam, and celecoxib. These tend to be stronger than the NSAIDs available without a prescription. However, stronger NSAIDs are associated with higher risks of serious side effects, unless they are used as a cream or gel, in which case the risks are much less.)
Now let me share a true story. Many years ago, a man in his 70s transferred to my patient panel. He had been taking a daily NSAID for several months, prescribed by the previous doctor, to treat his chronic shoulder arthritis.
I cautioned him about continuing this medication, explaining that it could cause serious internal bleeding. He seemed dubious, and said his previous doctor had never mentioned bleeding. He wanted to continue it. I decided to let it slide for the time being.
A few weeks later, he was hospitalized for internal bleeding from his stomach. Naturally, I felt terrible about it.
This is not to say that older adults should never use NSAIDs. They are often more effective pain relievers than acetaminophen, especially for conditions such as arthritis. So even in geriatrics, we sometimes conclude that the likely benefits seem to outweigh the likely risks.
But this conclusion really should be reached in partnership with the patient and family; only they can tell us how much that pain relief means to them, and how concerned they are about the risk of bleeding and other dangerous side effects. (It’s also possible to reduce the risk of bleeding by having a patient take a medication to reduce stomach acid.)
Unfortunately, far too many older adults are never informed of the risks associated with NSAIDs. And in the drugstore, they sometimes choose ibuprofen over acetaminophen, because they’ve heard that Tylenol can cause liver failure.
Yes, acetaminophen has risks as well. But every year, NSAIDs cause far more hospitalizations among older adults than acetaminophen does.
Aspirin: a special NSAID we no longer use for pain
Aspirin is another analgesic drug available over-the-counter.
It’s technically also an NSAID, but its chemical structure is a bit different from the other NSAIDs. This is what allows it to be effective in reducing strokes and heart attacks. It is also less likely to affect the kidneys than other NSAIDs are.
(For more on the risks and benefits of aspirin, see this MayoClinic.com article.)
Aspirin is no longer used as an analgesic by the medical community. But many older adults still reach for aspirin to treat their aches and pains, because they are used to thinking of it as a painkiller. Aspirin is also included in certain over-the-counter medications, such as Excedrin.
Taking a very occasional aspirin for a headache or other pain is not terribly risky for most aging adults. But using aspirin more often increases the risk of internal bleeding. So, I discourage my older patients from using aspirin for pain.
Note: A daily baby aspirin also used to be recommended for the primary prevention of heart disease. However, because research showed that in older adults, the risk of bleeding was often higher than the expected protection of a baby aspirin, the US Preventive Services Task Force no longer recommends a daily aspirin for primary prevention in older adults. (A daily aspirin is still however often recommended for those older adults who have already had a heart attack or stroke.)
FAQ: What’s the strongest OTC painkiller?
I’m also sometimes asked what is the “strongest” available over-the-counter analgesic drug.
To be honest, for many aches and pains, most people seem to find anti-inflammatory analgesic drugs (also known as NSAIDs) more effective for pain relief than acetaminophen. This can be especially true if one takes a higher dose, such as 600mg of ibuprofen.
The problem, of course, is that higher doses (and more frequent doses) of NSAIDs create higher risks for older adults.
For this reason, I discourage older adults and their families from trying to get the “strongest” oral OTC pain reliever.
Tips on safer use of OTC painkillers
In short, the safest oral OTC painkiller for older adults is usually acetaminophen, provided you don’t exceed 3,000 mg per day.
If you have any concerns about liver function or alcohol use, plan to use the medication daily on an ongoing basis, or otherwise want to err on the safer side, try to not exceed 2,000 mg per day, and seek medical input as soon as possible.
It is also generally safe to treat pain with over-the-counter topical analgesics. Although oral anti-inflammatory drugs such as ibuprofen are risky in older adults, an OTC topical NSAID such as Voltaren is usually safe.
You should also be sure to bring up any chronic pain with your parent’s doctor. It’s important to get help identifying the underlying causes of the pain. The doctor can then help you develop a plan to manage the pain.
And don’t forget to ask about non-drug treatments for pain; they are often safer for older adults, but busy doctors may not bring them up unless you ask. For example, chronic pain self-management programs can be very helpful to some people. Physical therapy, massage, and certain forms of exercise can play an important role in pain relief, especially when it comes to chronic pain.
Now if your older parent is taking acetaminophen often or every day, you’ll want to be sure you’ve accounted for all acetaminophen she might be taking. Remember, acetaminophen is often included in medications for cough and cold, and in prescription painkillers. So you need to look at the ingredients list for all medications of this type. Experts believe that half of acetaminophen overdoses are unintentional, and result from people either making mistakes with their doses or not realizing they are taking other medications containing acetaminophen.
Last but not least: be sure to avoid the “PM” version of any OTC painkiller. The “PM” part means a mild sedative has been included, and such drugs — usually diphenhydramine, which is the main ingredient in Benadryl — are anticholinergic and known to be bad for brain health. (See 7 Common Brain-Toxic Drugs Older Adults Should Use With Caution for more about the risks of anticholinergic drugs.)
My own approach, when I do house calls, is to check the older person’s medicine cabinet. If I find any NSAIDs or over-the-counter anticholinergic medications (e.g. antihistamines, sleep aids, etc), I discuss them with my older patient and usually remove them from the house unless there’s a good reason to leave them.
If acetaminophen isn’t providing enough pain relief
If acetaminophen doesn’t provide enough relief for your mom’s pains, then it may be reasonable to consider over-the-counter (or sometimes prescription) NSAIDs, preferably for a limited period of time. But be sure to discuss the risks and alternatives with the doctor first, and be sure to discuss possible non-drug approaches to lessen pain.
You may also want to ask about prescription topical painkillers, such as gels, creams, and patches. These are generally safer than oral medications, because less of the body is exposed to side effects.
For severe pain, it may also be reasonable to discuss other prescription drug options. Depending on the type of pain, in some cases it can be reasonable to consider using very small doses of opioids, or other types of painkillers. That said, bear in mind that all prescription pain relievers come with risks and can cause serious side effects. In older adults, most will affect brain function and balance.
The truth is that it’s often not possible to treat pain effectively and 100% safely, when it comes to using oral painkiller tablets. But by being informed and proactive, your family can help your mom get better care for her pain, while minimizing the risk of harm from pain relievers.
Good luck!
This article was reviewed & updated in August of 2024.
[As we are approaching 200 comments, comments have been closed.]
Mike P says
Thank you for an informative article. The warnings about not using aspirin as an analgesic and the PM” versions of OTC meds. I read some of it to my wife and she responded with an, “Oh oh!” A half hour later she came out with an amazing assortment of “PM” bottles to be disposed of.
Appreciate the help in “spring-cleaning” our medicine cabinets
Nicole Didyk, MD says
Hooray! Good job cleaning out the medicine cupboard. Thanks for sharing your success story with us and for reading the article!
Linda Haering says
Many insulin dependent diabetics use a CGM (continuous glucose monitor) in conjunction with their insulin pumps. One manufacturer whose previous model came with the caution that acetamenaphrin would cause inacurate readings supposedly corrected that problem in its latest model. However, if I take 500 mg of Tylenol it causes significant reading errors or even sensor failure after about 4 hours. I need something at night to add to my regular non-chemical pain relief routine and my cold packs. Can you suggest something? Dr. suggested OTC lidocaine patches but they are not effective for me. Thank you for your work.
Nicole Didyk, MD says
Hi Linda and thanks for sharing your story.
I didn’t know about the effect of acetaminophen on CGM’s, so I’m not sure what to suggest. Depending a person’s age and other medical issues, aspirin might be reasonable, and I’ve used duloxetine for pain in those with diabetes and nerve-related pain. Duloxetine is an anti-depressant but does have pain relieving properties too.
I hope you find a solution!
Margaret Zondo says
Thank you so much for the most informative articles.
I am allergic to aspirin. Is there an alternative drug for persons like me especially when we often hear that aspirin can save lives in the event of a stroke?
Nicole Didyk, MD says
I’m so glad you found the article helpful!
If a person has an ASA (acetylsalicylic acid, which is the chemical name for aspirin), then there are options. Most commonly, if a person is at risk of stroke, we use clopidogrel . This medication is similar to aspirin in that it affects platelets and makes the blood less likely to clot, so bleeding can be a side effect. Clopidogrel is only available by prescription.
Imtiyaz Yusuf says
I am.63 years old male having muscular pain of left side lower ribs. I am taking Panadol Extend 2 tabs 1330 mg 2-3:times a day but not much relief. I added M Myonal 50 mg to it but no relief.
I cannot take Ibuprofen, Diclofenac because they raise my BP.
Or should I take Aspirin?
Nicole Didyk, MD says
Aspirin (or ASA) is considered an NSAID, just like ibuprofen, so it may not be right for you if you avoid drugs like ibuprofen. With ASA at any dose, the main side effect we worry about is gastrointestinal irritation and bleeding.
debbie says
My doctor wants to put me on celecoxib for
rheumatoid arthritis and osteoarthritis but I am afraid to take this medication because of all of the side effects. I am 67 years old, I also have diverticulitis and this medicine is supposed to also cause stomach issues.
Nicole Didyk, MD says
Celecoxib is a COX-2 inhibitor, similar to an NSAID (like ibuprofen) but less likely to cause stomach and small intestine irritation and bleeding, but as far as I know it does not affect diverticulosis (which usually affects the colon or large intestine) in any way.
Dorothy says
I dislocated my left shoulder 3 years ago. They put it back in place however there are 3major torn tendons with massive tears. Injections are not for me do to the risk that all involved and surgery is not an option because they cannot repair torn tendons. I have chronic pain. I’ve had a EMG and there isn’t any signs of nerve damage. It’s the torn tendons that are killing me. I cannot sleep due to my condition and Aleve and OTC medicines are useless. I’ve tryed all kinds of creams that promise pain relief to no avail. Any suggestions?
Nicole Didyk, MD says
I’m so sorry to hear about your shoulder injury. If I was seeing someone in your situation, I would recommend physical therapy that focuses on stabilizing and strengthening the shoulder and then getting the function back. A physical therapist might be able to suggest a brace or something that could help at nighttime.
Bruce says
I’m a 66-yr.-old male who recently suffered an eye
stroke and am having a hard time with statin medications.
My cardiologist has tried two different ones, the first being Lipitor (35 mg) which caused much muscle and joint pain. After a month,
he then put me on Crestor (5 mg) which had the same effect making my whole body sore and weak.
He said I need some type of statin to prevent another stroke. he did, though, take me
off statins after a month on Crestor, for two weeks and wants to slowly reintroduce Crestor starting twice a week.
I’ve been very healthy person all my life, with low blood pressure and low cholesterol levels. Exercise has always been a daily regimen and have no weight issues.
I guess my question to you is what are the chances this (stroke) could happen to me again, especially if I chose to stop taking a
Statin medication, which really does raise havoc with my muscles and joints. Can you recommend a non-statin alternative?
I’m taking Tylenol (650 mg) daily to ease the discomfort. I had been
relying on ibuprofen until I came across your health columns.
Thank you for your “healthy” advice!
Nicole Didyk, MD says
I’m not sure exactly what you mean by “eye stroke” but, in general, after a stroke, taking a statin to lower the LDL-cholesterol can reduce the risk of having another stroke by about 2-5%., according to a recent meta-analysis (a systematic review of the existing literature about statins and stroke).
The other strategies that you mentioned can be helpful to reduce stroke risk as well (weight management, blood pressure control, exercise, and of course not smoking).
For those who can’t take a statin, there’s a medication called ezetimibe which can also lower risk of stroke and can be taken with or without a statin.
Thanks for letting us know about using tylenol in place of ibuprofen! This is a healthier choice for most older adults!
Bruce says
I’m sorry, i should have been more specific in regards to my mentioning the eye stroke I suffered in July of this year. It ‘s known as Retinal Artery Occlusion, which caused severe loss of vision.
MARY HILL says
I am a female 83 1/2 years old. Have been dealing with osteoarthritis of both knees but still working in yard doing more than I should in a not level lawn. My knees have got so bad swollen like elephant legs and so painful could not walk on right knee a few days. My surgeon doctor has scheduled TKR on right knee for September 8, 2020 which is very soon. He thinks a epidural would serve me better because of my age. I have osteoporosis in back for years not a problem so far and I have a horror of a needle in my spine or nerves. The same doctor did a complete hip replacement in 2015 with anesthesia with absolutely no problems. I did have C-dif after going home but had stayed in a bad rest home a few days was probable cause. Had no problem with hip and only used ice and low doses of tylenol. What is your thoughts on this? I am frightened of a needle in back since I have no back problems and I find this does have serious side effects later after use.
Thank you if you have time to email me. I receive your post and your inputs mean a lot for me. Thanks for your service. Mary
Nicole Didyk, MD says
I can understand being nervous about an upcoming surgery. As far as a I know, osteoporosis is not a reason to avoid a spinal anesthetic, but if you have a major spinal deformity, like spina bifida or have had back surgery before, you should let your doctor know.
Of course, no medical procedure is without risks, but the risk of nerve damage is extremely low, about 1.6 per 100,000 procedures. There can also be advantages to having spinal anesthesia instead of general, which can include better pain control and lower risk of lung-related complications. Here’s a video about the spinal anesthetic for knee surgery made by a couple of orthopedic surgeons (WARNING- it does include film of an actual spinal anesthetic being performed).
If you have a specific fear about the procedure, let your doctor know what exactly you’re most worried about. Your doctor might be able to provide you with information that will help you decide if it’s right for you, and what alternatives you have available. Good luck with your surgery!
John Ad Castillo says
Hi Dr Nicole, great insights as I read these threads. Am from the Philippines and currently suffering from back pain due to a bad fall. After self medicating with Mefenamic to Salonpas patches, it quite improves but the pain still there in my left back side. My doctor prescribed Arcoxia plus Lagaflex for 7 days but still there is pain. He switches Mobic and Myonal but pain still lingers. Patches works but momentarily only. I notice air fills my stomach which makes me fart. Am 65 yrs old and haven’t talked to my doctor yet that his medications isn’t working. Any comments? Thank you.
Nicole Didyk, MD says
I’m so glad that you find the discussion helpful!
I’m sorry to hear about your fall and your pain. I’m not familiar with many of the drugs that you mention, but it sounds like they are all common classes of meds that are used to treat musculoskeletal pain: NSAID,s, topical patches (which can contain methyl-salicylate or lidocaine), COX-2 inhibitors (like NSAIDs but less likely to bother the stomach), muscle relaxants, and ant-spasmodics. Each of these classes of medications can cause side effects, like stomach irritation, constipation, bloating, sleepiness and others (including flatulence!). When trying out different meds to treat pain (or any symptom, really), it’s important to keep careful track of whether the dosages and timing of the meds need to be optimized before trying something else. It can be tempting to give up after a few doses if it seems like it’s not working.
Along with the medications that you mention, non-medication strategies are usually recommended to help with acute back pain (like pain from an injury or fall). This can involve exercise, massage, heat and cold packs, and physiotherapy. And for some, other investigations can sometimes be needed, like an X-ray or ultrasound.
For most individuals with acute back pain, it is fully resolved by about 7 weeks, which can feel like a long time, especially when a person is suffering.
The other thing to look at is why a person is falling, and there’s a good article about that, which you can read here.
Jeri Todd says
I’m an active 85 year old woman. I have painful osteoarthritis in my knees and my back, along with scoliosis and disk herniation…all things that go with aging. I also have reflux disease with esophageal spasm, for which I take pantoprazole. For the last several years I’ve gotten by with taking 1 200 mg. ibuprofen daily for body pain. Several months ago the esophageal spasm got so bad I had to start on the pantoprazole. Now it’s to the point that I can’t find any NSAID that doesn’t increase that painful spasm. The problem is, without the ibuprofen I can’t do much more than walk around the house, and even that’s very painful. I normally walk at least a mile a day at a good clip, and need that exercise for my osteoarthritis. I’ve tried many prescription antiinflammatories, and they all aggravate the reflux problem. Is there any solution here?
Nicole Didyk, MD says
Congratulations on your commitment to exercise and I’m sorry to hear about your difficulties.
As a Geriatrician, we do try to avoid using NSAIDs over the long term, as Dr. Kernisan mentions, but the alternatives to them are not always other drugs. Osteoarthritis management can include things like weight loss, exercise, physiotherapy, meditation, and massage. Some people need surgery, or to use a gait aid or device to off load the painful joint.
Similarly, there can be dietary and other strategies to reduce the risk of esophageal reflux and spasm. A nutritionist might be able to offer advice.
I would advise someone in your shoes to not give up, and think about non-drug strategies in order to avoid more medication side effects.