Drugs & Aging

, Volume 21, Issue 8, pp 485–498

Over-the-Counter Analgesics in Older Adults

A Call for Improved Labelling and Consumer Education
Current Opinion


The use of analgesics increases with age and on any given day 20–30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.


  1. 1.
    Gabriel SE, Fehring RA. Trends in the utilization of non-steroidal anti-inflammatory drugs in the United States, 1986–1990. J Clin Epidemiol 1992; 45(9): 1041–4PubMedCrossRefGoogle Scholar
  2. 2.
    Barat I, Andreasen F, Damsgaard EM. The consumption of drugs by 75-year-old individuals living in their own homes. Eur J Clin Pharmacol 2000; 56(6–7): 501–9PubMedCrossRefGoogle Scholar
  3. 3.
    Stoehr GP, Ganguli M, Seaberg EC, et al. Over-the-counter medication use in an older rural community: the MoVIES Project. J Am Geriatr Soc 1997; 45(2): 158–65PubMedGoogle Scholar
  4. 4.
    McManus P, Primrose JG, Henry DA, et al. Pattern of non-steroidal anti-inflammatory drug use in Australia 1990–1994: a report from the Drug Utilization Sub-Committee of the Pharmaceutical Benefits Advisory Committee. Med J Aust 1996; 164(10): 589–92PubMedGoogle Scholar
  5. 5.
    Thomas J, Straus WL, Bloom BS. Over-the-counter non-steroidal anti-inflammatory drugs and risk of gastrointestinal symptoms. Am J Gastroenterol 2002; 97(9): 2215–9PubMedCrossRefGoogle Scholar
  6. 6.
    Sheen CL, Dillon JF, Bateman DN, et al. Paracetamol toxicity: epidemiology, prevention and costs to the health-care system. QJM 2002; 95(9): 609–19PubMedCrossRefGoogle Scholar
  7. 7.
    Blenkinsopp A, Bradley C. Patients, society, and the increase in self medication. BMJ 1996; 312(7031): 629–32PubMedCrossRefGoogle Scholar
  8. 8.
    Scheiman JM, Fendrick AM. NSAIDs without a prescription: over-the-counter access, under-counted risks. Am J Gastroenterol 2002; 97(9): 2159–61PubMedCrossRefGoogle Scholar
  9. 9.
    Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003; 289(9): 1107–16PubMedCrossRefGoogle Scholar
  10. 10.
    Physicians Desk Reference. 57th ed. Montvale (NJ): Medical Economics Co., 2003Google Scholar
  11. 11.
    Bradley JD, Katz BP, Brandt KD. Severity of knee pain does not predict a better response to an antiinflammatory dose of ibuprofen than to analgesic therapy in patients with osteoarthritis. J Rheumatol 2001; 28(5): 1073–6PubMedGoogle Scholar
  12. 12.
    Pincus T, Griffin M. Gastrointestinal disease associated with nonsteroidal anti-inflammatory drugs: new insights from observational studies and functional status questionnaires. Am J Med 1991; 91(3): 209–12PubMedCrossRefGoogle Scholar
  13. 13.
    Fries JF, Williams CA, Bloch DA, et al. Nonsteroidal anti-inflammatory drug-associated gastropathy: incidence and risk factor models. Am J Med 1991; 91(3): 213–22PubMedCrossRefGoogle Scholar
  14. 14.
    Fries JF, Williams CA, Bloch DA. The relative toxicity of nonsteroidal antiinflammatory drugs. Arthritis Rheum 1991; 34(11): 1353–60PubMedCrossRefGoogle Scholar
  15. 15.
    Dello Buono M, Urciuoli O, Marietta P, et al. Alternative medicine in a sample of 655 community-dwelling elderly. J Psychosom Res 2001; 50(3): 147–54CrossRefGoogle Scholar
  16. 16.
    Abebe W. Herbal medication: potential for adverse interactions with analgesic drugs. J Clin Pharm Ther 2002; 27(6): 391–401PubMedCrossRefGoogle Scholar
  17. 17.
    Motola G, Russo F, Mazzeo F, et al. Over-the-counter oral nonsteroidal anti-inflammatory drugs: a pharmacoepidemiologic study in southern Italy. Adv Ther 2001; 18(5): 216–22PubMedCrossRefGoogle Scholar
  18. 18.
    Bradley CP, Taylor RJ, Blenkinsopp A. Primary care: opportunities and threats: developing prescribing in primary care. BMJ 1997; 314(7082): 744–7PubMedCrossRefGoogle Scholar
  19. 19.
    Bradley C, Blenkinsopp A. Over the counter drugs: the future for self medication. BMJ 1996; 312(7034): 835–7PubMedCrossRefGoogle Scholar
  20. 20.
    Center for Drug Evaluation and Research. Over-the-counter drug products: consumer information: safe use of over-the-counter drug products [online]. Available from URL: http://www.fda.gov/cder/Offices/OTC/consumer.htm [Accessed 2004 May 11]
  21. 21.
    Ehrlich GE. Guidelines for antiinflammatory drug research. J Clin Pharmacol 1977; 17(11–12): 697–703PubMedGoogle Scholar
  22. 22.
    Advisory committees, OTC Drugs Advisory Committee: establishment, FDA: final rule. Fed Regist 1991; 56(185): 48103–4Google Scholar
  23. 23.
    MacDonald TM, Beard K, Bruppacher R, et al. The safety of drugs for OTC use: what evidence is required for an NSAID switch? Pharmacoepidemiol Drug Saf 2002; 11(7): 577–84PubMedCrossRefGoogle Scholar
  24. 24.
    Jain AK, Ryan JR, McMahon FG, et al. Analgesic efficacy of low-dose ibuprofen in dental extraction pain. Pharmacotherapy 1986; 6(6): 318–22PubMedGoogle Scholar
  25. 25.
    Sunshine A, Olson NZ, Marrero I, et al. Onset and duration of analgesia for low-dose ketoprofen in the treatment of postoperative dental pain. J Clin Pharmacol 1998; 38(12): 1155–64PubMedGoogle Scholar
  26. 26.
    Hyllested M, Jones S, Pedersen JL, et al. Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management: a qualitative review. Br J Anaesth 2002; 88(2): 199–214PubMedCrossRefGoogle Scholar
  27. 27.
    Eisenberg E, Berkey CS, Carr DB, et al. Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis. J Clin Oncol 1994; 12(12): 2756–65PubMedGoogle Scholar
  28. 28.
    Sunshine A, Olson NZ. Analgesic efficacy of ketoprofen in postpartum, general surgery, and chronic cancer pain. J Clin Pharmacol 1988; 28(12 Suppl.): S47–54PubMedGoogle Scholar
  29. 29.
    Shapiro SS. Treatment of dysmenorrhoea and premenstrual syndrome with non-steroidal anti-inflammatory drugs. Drugs 1988; 36(4): 475–90PubMedCrossRefGoogle Scholar
  30. 30.
    Brass EP. Changing the status of drugs from prescription to over-the-counter availability. N Engl J Med 2001; 345(11): 810–6PubMedCrossRefGoogle Scholar
  31. 31.
    Craine Jr RB. Role of the pharmaceutical industry in health care cost containment. Am J Cardiol 1985; 56(5): 43–6CCrossRefGoogle Scholar
  32. 32.
    Gurwitz JH. Suboptimal medication use in the elderly: the tip of the iceberg. JAMA 1994; 272(4): 316–7PubMedCrossRefGoogle Scholar
  33. 33.
    Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA 2002; 287(3): 337–44PubMedCrossRefGoogle Scholar
  34. 34.
    Curhan GC, Bullock AJ, Hankinson SE, et al. Frequency of use of acetaminophen, nonsteroidal anti-inflammatory drugs, and aspirin in US women. Pharmacoepidemiol Drug Saf 2002; 11(8): 687–93PubMedCrossRefGoogle Scholar
  35. 35.
    Cohen SM, Rousseau ME, Robinson EH. Therapeutic use of selected herbs. Holist Nurs Pract 2000; 14(3): 59–68PubMedGoogle Scholar
  36. 36.
    Williamson AT, Fletcher PC, Dawson KA. Complementary and alternative medicine: use in an older population. J Gerontol Nurs 2003; 29(5): 20–8PubMedGoogle Scholar
  37. 37.
    Ackman ML, Campbell JB, Buzak KA, et al. Use of nonprescription medications by patients with congestive heart failure. Ann Pharmacother 1999; 33(6): 674–9PubMedCrossRefGoogle Scholar
  38. 38.
    Consumer Healthcare Products Association. Self medication [online]. Available from URL: http://www.chpa-info.org/web/index.aspx [Accessed 2004 May 11]
  39. 39.
    National Council on Patient Information and Education. Attitudes and beliefs about the use of over-the-counter medications: a dose of reality: a national survey of consumers and health professionals [online]. Available from URL: http://www.bemedwise.com/survey/final_survey.pdf [Accessed 2004 May 11]
  40. 40.
    National Council on Patient Safety and Information. Be MedWise [online]. Available from URL: http://www.bemedwise.com [Accessed 2004 May 11]
  41. 41.
    Leong AL, Euller-Ziegler L. Patient advocacy and arthritis: moving forward. Bull World Health Organ 2004; 82(2): 115–20PubMedGoogle Scholar
  42. 42.
    Haug MR, Wykle ML, Namazi KH. Self-care among older adults. Soc Sci Med 1989; 29(2): 171–83PubMedCrossRefGoogle Scholar
  43. 43.
    Haug MR, Musil CM, Warner CD, et al. Elderly persons’ interpretation of a bodily change as an illness symptom. J Aging Health 1997; 9(4): 529–52PubMedCrossRefGoogle Scholar
  44. 44.
    Musil CM, Ahn S, Haug M, et al. Health problems and health actions among community-dwelling older adults: results of a health diary study. Appl Nurs Res 1998; 11(3): 138–47PubMedCrossRefGoogle Scholar
  45. 45.
    Ford AB, Haug MR, Stange KC, et al. Sustained personal autonomy: a measure of successful aging. J Aging Health 2000; 12(4): 470–89PubMedCrossRefGoogle Scholar
  46. 46.
    Ruoff G. Management of pain in patients with multiple health problems: a guide for the practicing physician. Am J Med 1998; 105(1B): 53–60SCrossRefGoogle Scholar
  47. 47.
    Colley CA, Lucas LM. Polypharmacy: the cure becomes the disease. J Gen Intern Med 1993; 8(5): 278–83PubMedCrossRefGoogle Scholar
  48. 48.
    Holden MD. Over-the-counter medications: do you know what your patients are taking? Postgrad Med 1992; 91(8): 191–4, 199-200PubMedGoogle Scholar
  49. 49.
    Honig PK, Gillespie BK. Drug interactions between prescribed and over-the-counter medication. Drug Saf 1995; 13(5): 296–303PubMedCrossRefGoogle Scholar
  50. 50.
    Honig PK, Gillespie BK. Clinical significance of pharmacokinetic drug interactions with over-the-counter (OTC) drugs. Clin Pharmacokinet 1998; 35(3): 167–71PubMedCrossRefGoogle Scholar
  51. 51.
    Sleath B, Rubin RH, Campbell W, et al. Physician-patient communication about over-the-counter medications. Soc Sci Med 2001; 53(3): 357–69PubMedCrossRefGoogle Scholar
  52. 52.
    Norris PT. Purchasing restricted medicines in New Zealand pharmacies: results from a “mystery shopper” study. Pharm World Sci 2002; 24(4): 149–53PubMedCrossRefGoogle Scholar
  53. 53.
    Wallsten SM, Sullivan Jr RJ, Hanlon JT, et al. Medication taking behaviors in the high- and low-functioning elderly: MacArthur field studies of successful aging. Ann Pharmacother 1995; 29(4): 359–64PubMedGoogle Scholar
  54. 54.
    Hersh EV, Moore PA, Ross GL. Over-the-counter analgesics and antipyretics: a critical assessment. Clin Ther 2000; 22(5): 500–48PubMedCrossRefGoogle Scholar
  55. 55.
    Hernandez-Diaz S, Garcia-Rodriguez LA. Epidemiologic assessment of the safety of conventional nonsteroidal anti-inflammatory drugs. Am J Med 2001; 110Suppl. 3A: 20–7SCrossRefGoogle Scholar
  56. 56.
    Beyth RJ, Shorr RI. Epidemiology of adverse drug reactions in the elderly by drug class. Drugs Aging 1999; 14(3): 231–9PubMedCrossRefGoogle Scholar
  57. 57.
    Blot WJ, McLaughlin JK. Over the counter non-steroidal anti-inflammatory drugs and risk of gastrointestinal bleeding. J Epidemiol Biostat 2000; 5(2): 137–42PubMedGoogle Scholar
  58. 58.
    Bjorkman DJ. One hundred years of NSAID gastropathy: are coxibs the answer? Rev Gastroenterol Disord 2001; 1(3): 121–7PubMedGoogle Scholar
  59. 59.
    Buffum M, Buffum JC. Nonsteroidal anti-inflammatory drugs in the elderly. Pain Manag Nurs 2000; 1(2): 40–50PubMedCrossRefGoogle Scholar
  60. 60.
    Smalley WE, Griffin MR. The risks and costs of upper gastrointestinal disease attributable to NSAIDs. Gastroenterol Clin North Am 1996; 25(2): 373–96PubMedCrossRefGoogle Scholar
  61. 61.
    Smalley WE, Griffin MR, Fought RL, et al. Excess costs from gastrointestinal disease associated with nonsteroidal anti-inflammatory drugs. J Gen Intern Med 1996; 11(8): 461–9PubMedCrossRefGoogle Scholar
  62. 62.
    Smalley WE, Ray WA, Daugherty JR, et al. Nonsteroidal anti-inflammatory drugs and the incidence of hospitalizations for peptic ulcer disease in elderly persons. Am J Epidemiol 1995; 141(6): 539–45PubMedGoogle Scholar
  63. 63.
    Singh G, Triadafilopoulos G. Epidemiology of NSAID induced gastrointestinal complications. J Rheumatol 1999; 26Suppl. 56: 18–24Google Scholar
  64. 64.
    Garcia Rodriguez LA, Walker AM, Perez Gutthann S, editor. Nonsteroidal antiinflammatory drugs and gastrointestinal hospitalizations in Saskatchewan: a cohort study. Epidemiology 1992; 3(4): 337–42Google Scholar
  65. 65.
    Garcia Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet 1994; 343(8900): 769–72PubMedCrossRefGoogle Scholar
  66. 66.
    Henry D, Lim LL, Garcia Rodriguez LA, et al. Variability in risk of gastrointestinal complications with individual nonsteroidal anti-inflammatory drugs: results of a collaborative meta-analysis. BMJ 1996; 312(7046): 1563–6PubMedCrossRefGoogle Scholar
  67. 67.
    Gutthann SP, Garcia Rodriguez LA, Raiford DS. Individual nonsteroidal antiinflammatory drugs and other risk factors for upper gastrointestinal bleeding and perforation. Epidemiology 1997; 8(1): 18–24PubMedCrossRefGoogle Scholar
  68. 68.
    Garcia Rodriguez LA. Nonsteroidal antiinflammatory drugs, ulcers and risk: a collaborative meta-analysis. Semin Arthritis Rheum 1997; 26 (6 Suppl. 1): 16–20PubMedCrossRefGoogle Scholar
  69. 69.
    Garcia Rodriguez LA, Cattaruzzi C, Troncon MG, et al. Risk of hospitalization for upper gastrointestinal tract bleeding associated with ketorolac, other nonsteroidal anti-inflammatory drugs, calcium antagonists, and other antihypertensive drugs. Arch Intern Med 1998; 158(1): 33–9PubMedCrossRefGoogle Scholar
  70. 70.
    Garcia Rodriguez LA. Variability in risk of gastrointestinal complications with different nonsteroidal anti-inflammatory drugs. Am J Med 1998; 104(3A): 30–4SCrossRefGoogle Scholar
  71. 71.
    Griffin MR, Piper JM, Daugherty JR, et al. Nonsteroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons. Ann Intern Med 1991; 114(4): 257–63PubMedGoogle Scholar
  72. 72.
    Perez-Gutthann S, Garcia-Rodriguez LA, Duque-Oliart A, et al. Low-dose diclofenac, naproxen, and ibuprofen cohort study. Pharmacotherapy 1999; 19(7): 854–9PubMedCrossRefGoogle Scholar
  73. 73.
    Henry D, Dobson A, Turner C. Variability in the risk of major gastrointestinal complications from nonaspirin nonsteroidal anti-inflammatory drugs. Gastroenterology 1993; 105(4): 1078–88PubMedGoogle Scholar
  74. 74.
    Henry D, McGettigan P. Epidemiology overview of gastrointestinal and renal toxicity of NSAIDs. Int J Clin Pract Suppl 2003; 135: 43–9PubMedGoogle Scholar
  75. 75.
    Strom BL, Schinnar R, Bilker WB, et al. Gastrointestinal tract bleeding associated with naproxen sodium vs ibuprofen. Arch Intern Med 1997; 157(22): 2626–31PubMedCrossRefGoogle Scholar
  76. 76.
    Doyle G, Jayawardena S, Ashraf E, et al. Efficacy and tolerability of nonprescription ibuprofen versus celecoxib for dental pain. J Clin Pharmacol 2002; 42(8): 912–9PubMedCrossRefGoogle Scholar
  77. 77.
    Doyle G, Furey S, Berlin R, et al. Gastrointestinal safety and tolerance of ibuprofen at maximum over-the-counter dose. Aliment Pharmacol Ther 1999; 13(7): 897–906PubMedCrossRefGoogle Scholar
  78. 78.
    Kellstein DE, Waksman JA, Furey SA, et al. The safety profile of nonprescription ibuprofen in multiple-dose use: a meta-analysis. J Clin Pharmacol 1999; 39(5): 520–32PubMedGoogle Scholar
  79. 79.
    Cebollero-Santamaria F, Smith J, Gioe S, et al. Selective outpatient management of upper gastrointestinal bleeding in the elderly. Am J Gastroenterol 1999; 94(5): 1242–7PubMedCrossRefGoogle Scholar
  80. 80.
    Lapane KL, Spooner JJ, Mucha L, et al. Effect of nonsteroidal anti-inflammatory drug use on the rate of gastrointestinal hospitalizations among people living in long-term care. J Am Geriatr Soc 2001; 49(5): 577–84PubMedCrossRefGoogle Scholar
  81. 81.
    Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995; 90(2): 206–10PubMedGoogle Scholar
  82. 82.
    Peura DA, Lanza FL, Gostout CJ, et al. The American College of Gastroenterology Bleeding Registry: preliminary findings. Am J Gastroenterol 1997; 92(6): 924–8PubMedGoogle Scholar
  83. 83.
    Hirschowitz BI, Lanas A. NSAID association with gastrointestinal bleeding and peptic ulcer. Agents Actions Suppl 1991; 35: 93–101PubMedGoogle Scholar
  84. 84.
    Guess HA, West R, Strand LM, et al. Fatal upper gastrointestinal hemorrhage or perforation among users and nonusers of nonsteroidal anti-inflammatory drugs in Saskatchewan, Canada 1983. J Clin Epidemiol 1988; 41(1): 35–45PubMedCrossRefGoogle Scholar
  85. 85.
    Maliekal J, Elboim CM. Gastrointestinal complications associated with intramuscular ketorolac tromethamine therapy in the elderly. Ann Pharmacother 1995; 29(7–8): 698–701PubMedGoogle Scholar
  86. 86.
    Silverstein FE, Gilbert DA, Tedesco FJ, et al. The national ASGE survey on upper gastrointestinal bleeding (II): clinical prognostic factors. Gastrointest Endosc 1981; 27(2): 80–93PubMedCrossRefGoogle Scholar
  87. 87.
    Dennis VC, Thomas BK, Hanlon JE. Potentiation of oral anticoagulation and hemarthrosis associated with nabumetone. Pharmacotherapy 2000; 20(2): 234–9PubMedCrossRefGoogle Scholar
  88. 88.
    Shorr RI, Ray WA, Daugherty JR, et al. Concurrent use of nonsteroidal anti-inflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorrhagic peptic ulcer disease. Arch Intern Med 1993; 153(14): 1665–70PubMedCrossRefGoogle Scholar
  89. 89.
    Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians’ fears often unfounded. Arch Intern Med 2003; 163(13): 1580–6PubMedCrossRefGoogle Scholar
  90. 90.
    Lanza FL. A guideline for the treatment and prevention of NSAID-induced ulcers. Members of the Ad Hoc Committee on Practice Parameters of the American College of Gastroenterology. Am J Gastroenterol 1998; 93(11): 2037–46PubMedCrossRefGoogle Scholar
  91. 91.
    Guidelines for monitoring drug therapy in rheumatoid arthritis. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39(5): 723–31Google Scholar
  92. 92.
    Tamblyn RM, McLeod PJ, Abrahamowicz M, et al. Questionable prescribing for elderly patients in Quebec. CMAJ 1994; 150(11): 1801–9PubMedGoogle Scholar
  93. 93.
    Tamblyn R, Berkson L, Dauphinee WD, et al. Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med 1997; 127(6): 429–38PubMedGoogle Scholar
  94. 94.
    Johnson AG, Nguyen TV, Owe-Young R, et al. Potential mechanisms by which nonsteroidal anti-inflammatory drugs elevate blood pressure: the role of endothelin-1. J Hum Hypertens 1996; 10(4): 257–61PubMedGoogle Scholar
  95. 95.
    Johnson AG. NSAIDs and increased blood pressure: what is the clinical significance? Drug Saf 1997; 17(5): 277–89PubMedCrossRefGoogle Scholar
  96. 96.
    Johnson AG. NSAIDs and blood pressure: clinical importance for older patients. Drugs Aging 1998; 12(1): 17–27PubMedCrossRefGoogle Scholar
  97. 97.
    Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure: a meta-analysis. Ann Intern Med 1994; 121(4): 289–300PubMedGoogle Scholar
  98. 98.
    Feenstra J, Heerdink ER, Grobbee DE, et al. Association of nonsteroidal anti-inflammatory drugs with first occurrence of heart failure and with relapsing heart failure: the Rotterdam Study. Arch Intern Med 2002; 162(3): 265–70PubMedCrossRefGoogle Scholar
  99. 99.
    Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an under-recognized public health problem. Arch Intern Med 2000; 160(6): 777–84PubMedCrossRefGoogle Scholar
  100. 100.
    Merlo J, Broms K, Lindblad U, et al. Association of outpatient utilisation of non-steroidal anti-inflammatory drugs and hospitalised heart failure in the entire Swedish population. Eur J Clin Pharmacol 2001; 57(1): 71–5PubMedCrossRefGoogle Scholar
  101. 101.
    Garcia Rodriguez LA, Hernandez-Diaz S. Nonsteroidal antiinflammatory drugs as a trigger of clinical heart failure. Epidemiology 2003; 14(2): 240–6PubMedGoogle Scholar
  102. 102.
    American Heart Association. 2002 heart and stroke statistical update. Dallas (TX): American Heart Association, 2001Google Scholar
  103. 103.
    Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001; 345(18): 1291–7PubMedCrossRefGoogle Scholar
  104. 104.
    Ruoff GE. The impact of nonsteroidal anti-inflammatory drugs on hypertension: alternative analgesics for patients at risk. Clin Ther 1998; 20(3): 376–87PubMedCrossRefGoogle Scholar
  105. 105.
    Houston MC. Nonsteroidal anti-inflammatory drugs and antihypertensives. Am J Med 1991; 90(5A): 42–7SCrossRefGoogle Scholar
  106. 106.
    Houston MC, Weir M, Gray J, et al. The effects of nonsteroidal anti-inflammatory drugs on blood pressures of patients with hypertension controlled by verapamil. Arch Intern Med 1995; 155(10): 1049–54PubMedCrossRefGoogle Scholar
  107. 107.
    Gurwitz JH, Avorn J, Bohn RL, et al. Initiation of antihypertensive treatment during nonsteroidal anti-inflammatory drug therapy. JAMA 1994; 272(10): 781–6PubMedCrossRefGoogle Scholar
  108. 108.
    Johnson AG, Simons LA, Simons J, et al. Non-steroidal antiinflammatory drugs and hypertension in the elderly: a community-based cross-sectional study. Br J Clin Pharmacol 1993; 35(5): 455–9PubMedCrossRefGoogle Scholar
  109. 109.
    Chrischilles EA, Wallace RB. Nonsteroidal anti-inflammatory drugs and blood pressure in an elderly population. J Gerontol 1993; 48(3): M91–6PubMedCrossRefGoogle Scholar
  110. 110.
    Pope JE, Anderson JJ, Felson DT. A meta-analysis of the effects of nonsteroidal anti-inflammatory drugs on blood pressure. Arch Intern Med 1993; 153(4): 477–84PubMedCrossRefGoogle Scholar
  111. 111.
    Oates JA, FitzGerald GA, Branch RA, et al. Clinical implications of prostaglandin and thromboxane A2 formation (1). N Engl J Med 1988; 319(11): 689–98PubMedCrossRefGoogle Scholar
  112. 112.
    Oates JA, FitzGerald GA, Branch RA, et al. Clinical implications of prostaglandin and thromboxane A2 formation (2). N Engl J Med 1988; 319(12): 761–7PubMedCrossRefGoogle Scholar
  113. 113.
    Jensen BL, Mann B, Skott O, et al. Differential regulation of renal prostaglandin receptor mRNAs by dietary salt intake in the rat. Kidney Int 1999; 56(2): 528–37PubMedCrossRefGoogle Scholar
  114. 114.
    Breyer MD, Jacobson HR, Hebert RL. Cellular mechanisms of prostaglandin E2 and vasopressin interactions in the collecting duct. Kidney Int 1990; 38(4): 618–24PubMedCrossRefGoogle Scholar
  115. 115.
    Patrono C, Dunn MJ. The clinical significance of inhibition of renal prostaglandin synthesis. Kidney Int 1987; 32(1): 1–12PubMedCrossRefGoogle Scholar
  116. 116.
    Whelton A, Hamilton CW. Nonsteroidal anti-inflammatory drugs: effects on kidney function. J Clin Pharmacol 1991; 31(7): 588–98PubMedGoogle Scholar
  117. 117.
    Whelton A, Schulman G, Wallemark C, et al. Effects of celecoxib and naproxen on renal function in the elderly. Arch Intern Med 2000; 160(10): 1465–70PubMedCrossRefGoogle Scholar
  118. 118.
    Perneger TV, Whelton PK, Klag MJ. Risk of kidney failure associated with the use of acetaminophen, aspirin, and nonsteroidal antiinflammatory drugs. N Engl J Med 1994; 331(25): 1675–9PubMedCrossRefGoogle Scholar
  119. 119.
    Sandier DP, Burr FR, Weinberg CR. Nonsteroidal anti-inflammatory drugs and the risk for chronic renal disease. Ann Intern Med 1991; 115(3): 165–72Google Scholar
  120. 120.
    Field TS, Gurwitz JH, Glynn RJ, et al. The renal effects of nonsteroidal anti-inflammatory drugs in older people: findings from the established populations for epidemiologic studies of the elderly. J Am Geriatr Soc 1999; 47(5): 507–11PubMedGoogle Scholar
  121. 121.
    Gurwitz JH, Avorn J, Ross-Degnan D, et al. Nonsteroidal antiinflammatory drug-associated azotemia in the very old. JAMA 1990; 264(4): 471–5PubMedCrossRefGoogle Scholar
  122. 122.
    Griffin MR, Yared A, Ray WA. Nonsteroidal anti-inflammatory drugs and acute renal failure in elderly persons. Am J Epidemiol 2000; 151(5): 488–96PubMedCrossRefGoogle Scholar
  123. 123.
    Perez Gutthann S, Garcia Rodriguez LA, Raiford DS, et al. Nonsteroidal anti-inflammatory drugs and the risk of hospitalization for acute renal failure. Arch Intern Med 1996; 156(21): 2433–9PubMedCrossRefGoogle Scholar
  124. 124.
    Evans JM, McGregor E, McMahon AD, et al. Non-steroidal anti-inflammatory drugs and hospitalization for acute renal failure. QJM 1995; 88(8): 551–7PubMedGoogle Scholar
  125. 125.
    Henry D, Page J, Whyte I, et al. Consumption of non-steroidal anti-inflammatory drugs and the development of functional renal impairment in elderly subjects: results of a case-control study. Br J Clin Pharmacol 1997; 44(1): 85–90PubMedCrossRefGoogle Scholar
  126. 126.
    Lewis JH. Drug-induced liver disease. Med Clin North Am 2000; 84(5): 1275–311PubMedCrossRefGoogle Scholar
  127. 127.
    Eastwood HD. Causes of jaundice in the elderly: a survey of diagnosis and investigation. Gerontol Clin (Basel) 1971; 13(1): 69–81CrossRefGoogle Scholar
  128. 128.
    Cham E, Hall L, Ernst AA, et al. Awareness and use of over-the-counter pain medications: a survey of emergency department patients. South Med J 2002; 95(5): 529–35PubMedGoogle Scholar
  129. 129.
    Chen L, Schneider S, Wax P. Knowledge about acetaminophen toxicity among emergency department visitors. Vet Hum Toxicol 2002; 44(6): 370–3PubMedGoogle Scholar
  130. 130.
    Jowett NI. Limitation of over the counter sales of paracetamol: restriction of 16g will not prevent overdose and is unhelpful for patients with chronic disease [letter]. BMJ 1998; 317(7173): 1657PubMedCrossRefGoogle Scholar
  131. 131.
    Bijlsma JW. Analgesia and the patient with osteoarthritis. Am J Ther 2002; 9(3): 189–97PubMedCrossRefGoogle Scholar
  132. 132.
    Rabbani F, Cheema FH, Talati N, et al. Behind the counter: pharmacies and dispensing patterns of pharmacy attendants in Karachi. J Pak Med Assoc 2001; 51(4): 149–53PubMedGoogle Scholar
  133. 133.
    Hawton K. United Kingdom legislation on pack sizes of analgesics: background, rationale, and effects on suicide and deliberate self-harm. Suicide Life Threat Behav 2002; 32(3): 223–9PubMedCrossRefGoogle Scholar
  134. 134.
    Hawton K, Townsend E, Deeks J, et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ 2001; 322(7296): 1203–7PubMedCrossRefGoogle Scholar
  135. 135.
    Pitkala KH, Strandberg TE, Tilvis RS. Management of nonmalignant pain in home-dwelling older people: a population-based survey. J Am Geriatr Soc 2002; 50(11): 1861–5PubMedCrossRefGoogle Scholar
  136. 136.
    Gloth III FM. Concerns with chronic analgesic therapy in elderly patients. Am J Med 1996; 101(1A): 19–24SGoogle Scholar
  137. 137.
    Gloth III FM. Geriatric pain: factors that limit pain relief and increase complications. Geriatrics 2000; 55(10): 46–8, 51-4PubMedGoogle Scholar
  138. 138.
    Brandt KD, Bradley JD. Should the initial drug used to treat osteoarthritis pain be a nonsteroidal antiinflammatory drug? J Rheumatol 2001; 28(3): 467–73PubMedGoogle Scholar
  139. 139.
    Griffin MR, Brandt KD, Liang MH, et al. Practical management of osteoarthritis: integration of pharmacologic and nonpharmacologic measures. Arch Fam Med 1995; 4(12): 1049–55PubMedCrossRefGoogle Scholar
  140. 140.
    Puett DW, Griffin MR. Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Intern Med 1994; 121(2): 133–40PubMedGoogle Scholar
  141. 141.
    Scudds RJ, Robertson JM. Pain factors associated with physical disability in a sample of community-dwelling senior citizens. J Gerontol A Biol Sci Med Sci 2000; 55(7): M393–9PubMedCrossRefGoogle Scholar
  142. 142.
    Won A, Lapane K, Gambassi G, et al. Correlates and management of nonmalignant pain in the nursing home, SAGE Study Group: systematic assessment of geriatric drug use via epidemiology. J Am Geriatr Soc 1999; 47(8): 936–42PubMedGoogle Scholar
  143. 143.
    Scudds RJ, Ostbye T. Pain and pain-related interference with function in older Canadians: the Canadian Study of Health and Aging. Disabil Rehabil 2001; 23(15): 654–64PubMedCrossRefGoogle Scholar
  144. 144.
    Leveille SG, Ling S, Hochberg MC, et al. Widespread musculoskeletal pain and the progression of disability in older disabled women. Ann Intern Med 2001; 135(12): 1038–46PubMedGoogle Scholar
  145. 145.
    Scudds RJ, McD Robertson J. Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens. Pain 1998; 75(2–3): 229–35PubMedCrossRefGoogle Scholar
  146. 146.
    Espino DV, Lichtenstein MJ, Hazuda HP, et al. Correlates of prescription and over-the-counter medication usage among older Mexican Americans: the Hispanic EPESE study (Established Population for the Epidemiologic Study of the Elderly). J Am Geriatr Soc 1998; 46(10): 1228–34PubMedGoogle Scholar
  147. 147.
    Vogel RJ, Ramachandran S, Zachry WM. A 3-stage model for assessing the probable economic effects of direct-to-consumer advertising of Pharmaceuticals. Clin Ther 2003; 25(1): 309–29PubMedCrossRefGoogle Scholar
  148. 148.
    Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274(1): 35–43PubMedCrossRefGoogle Scholar
  149. 149.
    Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324(6): 377–84PubMedCrossRefGoogle Scholar
  150. 150.
    Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA 2000; 284(1): 95–7PubMedCrossRefGoogle Scholar
  151. 151.
    Fischer LR, Scott LM, Boonstra DM, et al. Pharmaceutical care for patients with chronic conditions. J Am Pharm Assoc (Wash) 2000; 40(2): 174–80Google Scholar
  152. 152.
    Powell MJ, Knapp PB, Raynor DK. Testing the understanding of current and alternative warnings for paracetamol. Health Services Research and Pharmacy Practice Conference; 2001 Apr 19–20; NottinghamGoogle Scholar
  153. 153.
    Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999; 281(6): 545–51PubMedCrossRefGoogle Scholar
  154. 154.
    Brown H, Prisuta R, Jacobs B, et al. Literacy of older adults in America. Washington, DC: National Center for Education Statistics; 1996 Jan 23. Report no. NCES 97576Google Scholar
  155. 155.
    Mrvos R, Dean BS, Krenzelok EP. Illiteracy: a contributing factor to poisoning. Vet Hum Toxicol 1993; 35(5): 466–8PubMedGoogle Scholar
  156. 156.
    Olson RM, Blank D, Cardinal E, et al. Understanding medication-related needs of low-literacy patients. J Am Pharm Assoc (Wash) 1996; NS36(7): 424–9Google Scholar
  157. 157.
    Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother 2003; 37(7–8): 1003–9PubMedCrossRefGoogle Scholar
  158. 158.
    Ziegler DK, Mosier MC, Buenaver M, et al. How much information about adverse effects of medication do patients want from physicians? Arch Intern Med 2001; 161(5): 706–13PubMedCrossRefGoogle Scholar
  159. 159.
    Gray SL, Mahoney JE, Blough DK. Medication adherence in elderly patients receiving home health services following hospital discharge. Ann Pharmacother 2001; 35(5): 539–45PubMedCrossRefGoogle Scholar
  160. 160.
    Woloshin KK, Ruffin IV MT, Gorenflo DW. Patients’ interpretation of qualitative probability statements. Arch Fam Med 1994; 3(11): 961–6PubMedCrossRefGoogle Scholar
  161. 161.
    Ngoh LN, Shepherd MD. Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon. Patient Educ Couns 1997; 31(3): 245–61PubMedCrossRefGoogle Scholar
  162. 162.
    Ganguli M, Seaberg E, Belle S, et al. Cognitive impairment and the use of health services in an elderly rural population: the MoVIES project (Monongahela Valley Independent Elders Survey). J Am Geriatr Soc 1993; 41(10): 1065–70PubMedGoogle Scholar
  163. 163.
    Alander SW, Dowd MD, Bratton SL, et al. Pediatric acetaminophen overdose: risk factors associated with hepatocellular injury. Arch Pediatr Adolesc Med 2000; 154(4): 346–50PubMedGoogle Scholar
  164. 164.
    Barrett TW, Norton VC. Parental knowledge of different acetaminophen concentrations for infants and children. Acad Emerg Med 2000; 7(6): 718–21PubMedCrossRefGoogle Scholar
  165. 165.
    Klein-Schwartz W, Oderda GM. Poisoning in the elderly: epidemiological, clinical and management considerations. Drugs Aging 1991; 1(1): 67–89PubMedCrossRefGoogle Scholar
  166. 166.
    Dodd MD, Graham CA. Unintentional overdose of analgesia secondary to acute dental pain. Br Dent J 2002; 193(4): 211–2PubMedCrossRefGoogle Scholar
  167. 167.
    Kisely SR, Lawrence D, Preston NJ. The effect of recalling paracetamol on hospital admissions for poisoning in Western Australia. Med J Aust 2003; 178(2): 72–4PubMedGoogle Scholar
  168. 168.
    Caravati EM. Unintentional acetaminophen ingestion in children and the potential for hepatotoxicity. J Toxicol Clin Toxicol 2000; 38(3): 291–6PubMedCrossRefGoogle Scholar
  169. 169.
    Chui PT. Anesthesia in a patient with undiagnosed salicylate poisoning presenting as intraabdominal sepsis. J Clin Anesth 1999; 11(3): 251–3PubMedCrossRefGoogle Scholar
  170. 170.
    Berry DC, Raynor DK, Knapp P, et al. Patients’ understanding of risk associated with medication use: impact of European Commission guidelines and other risk scales. Drug Saf 2003; 26(1): 1–11PubMedCrossRefGoogle Scholar
  171. 171.
    Berry DC, Raynor DK, Knapp P, et al. Over the counter medicines and the need for immediate action: a further evaluation of European Commission recommended wordings for communicating risk. Patient Educ Couns. In PressGoogle Scholar

Copyright information

© Adis Data Information BV 2004

Authors and Affiliations

  1. 1.Quality Scholars Program, Veterans AdministrationTennessee Valley Healthcare SystemNashvilleUSA
  2. 2.Division of General Internal MedicineVanderbilt UniversityNashvilleUSA
  3. 3.Department of Preventive Medicine and Department of MedicineVanderbilt UniversityNashvilleUSA
  4. 4.Nashville VA Medical CenterNashvilleUSA

Personalised recommendations