Everyday Pain Relief: Ulcers

Many familiar over-the-counter pain relief drugs can cause harmful side effects for those with ulcers. Here's what you need to know.

From the WebMD Archives

We tend to think of over-the-counter painkillers as perfectly safe. If you can buy a drug sitting next to the toothpaste and shampoo, how dangerous could it be?

But even these drugs do have risks. And if you have an ulcer, you need to be very careful before popping over-the-counter (OTC) painkillers. Many commonplace drugs - such as aspirin, Advil, and Aleve -- can irritate the stomach lining, aggravating ulcers and potentially causing serious problems.

"People think that if a medicine is available over-the-counter, it has no risks," says Byron Cryer, MD, a spokesman for the American Gastroenterological Association. "But about a third of all ulcers are caused by aspirin and other painkillers. More than half of all bleeding ulcers are caused by these drugs."

In fact, according to the American Gastroenterological Association, 103,000 people are hospitalized every year because of side effects from common painkillers. Some 16,500 people die.

The problem isn't only with OTC painkillers. Many remedies for colds, sinus problems, and even heartburn contain the same potentially dangerous ingredients.

If you have an ulcer, you need to avoid any foods or medicines that will make your condition worse. So, before you grab a bottle of pain reliever the next time you have a headache, learn some dos and don'ts first.

How Do Pain Relief Drugs Work?

In a certain way, all pain is in your head. When we feel pain, it's the result of an electrical signal being sent from the nerves in a part of your body to your brain.

But the whole process isn't electrical. When tissue is injured (by a sprained ankle, for instance), the cells release certain chemicals in response. These chemicals cause inflammation and amplify the electrical signal coming from the nerves. As a result, they increase the pain you feel.

Painkillers work by blocking the effects of these pain chemicals. The problem is that you can't focus most pain relievers specifically on your headache or bad back. Instead, it travels through your whole body. This can cause some unexpected side effects.

What Are the Risks for People With Ulcers?

Why do painkillers increase the risk of gastrointestinal (GI) problems? The same chemicals that amplify pain -- which some pain medicines block -- also help maintain the protective lining of the stomach and intestines. When a painkiller stops these chemicals from working, the digestive tract becomes more vulnerable to damage from gastric acids.

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For people with ulcers, the risky pain relievers are nonsteroidal anti-inflammatory drugs, or NSAIDs. They include aspirin, ibuprofen, naproxen sodium, and ketoprofen, the active ingredients in medicines such as Bufferin, Advil, and Aleve.

Other pain relievers may be less dangerous. Acetaminophen -- the active ingredient in Tylenol -- works differently and poses a much lower risk of GI problems. However, like any drug, it does have side effects of its own. You shouldn't take any over-the-counter painkiller for more than 10 days without your health care provider's approval.

The risks from NSAIDs are quite serious. Studies show that people who use NSAIDs are about three times as likely to have gastrointestinal bleeding. Even at low doses, NSAIDs can make mild ulcers much worse.

Aspirin has additional risks. "Aspirin can help prevent blood clotting, which is why it helps people at risk of heart attacks and strokes," says Cryer. "But in people with ulcers, it can lead to more serious gastrointestinal bleeding."

However, what if you have an ulcer and a high risk of heart attack or stroke? Then what do you do? Cryer admits that balancing the benefits and risks of these medicines can be tricky.

"People need to talk to their doctors to figure out what's best in their case," he says. But in people with a high risk of heart attack or stroke, he says that the cardiovascular benefits of aspirin can outweigh its gastrointestinal risks.

If you have an ulcer, what should you do the next time you have a headache? In general, people with ulcers should use acetaminophen for over-the-counter pain relief. Unless your doctor has said it's OK, you should not use aspirin, ibuprofen, ketoprofen, or naproxen sodium. If acetaminophen doesn't help with your pain, see your doctor.

Other Options for Pain Relief

Painkillers aren't the only answer for many of life's aches and pains. Many effective and safe alternatives don't have any side effects at all.

  • Ice packs, for acute injuries such as a sprained ankle, can keep down swelling and ease pain.
  • Heat with a hot towel or heating pad can be helpful for treating chronic overuse injuries. (However, you shouldn't use heat on recent injuries.)
  • Physical activity can help reduce some kinds of discomfort, such as arthritis pain.
  • Relaxation with techniques such as yoga or meditation -- may reduce pain. Biofeedback may help as well. These approaches are best for pain that's amplified by stress, such as tension headaches.
  • Nontraditional techniques with low risks -- such as acupuncture -- benefit some people.

So remember: Pain relief doesn't only come from a pill bottle.

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The Pros and Cons of Pain Relief Drugs

Here's a rundown of the benefits and risks of some popular pain medications. It should help simplify your choices when you're in the drugstore.

Keep in mind that you shouldn't use any over-the-counter painkiller on a regular basis. If you're in that much pain, you need to talk with your doctor.

ACETAMINOPHEN
Tylenol, Panadol, Tempra (and also an ingredient in Excedrin)

  • How it works. Acetaminophen is not an NSAID. Experts aren't actually sure how it works, but it seems to affect chemicals that increase the feeling of pain.
  • Benefits. Acetaminophen reduces pain and lowers fevers. Unlike aspirin and other NSAIDS, acetaminophen is believed to be safe for people with ulcers. It doesn't affect the natural lining of the stomach. Since it doesn't thin the blood, it doesn't increase the risk of bleeding either. It is safe for women who are pregnant and nursing.
  • Side effects and risks. Experts say that acetaminophen is safe for people with ulcers. But like any drug, it can cause other side effects. Very high doses of acetaminophen -- well over the recommended maximum of 4,000 mg/day -- can cause serious liver damage. Long-term use of acetaminophen in high doses -- especially when combined with caffeine (Excedrin) or codeine (Tylenol with Codeine) can cause kidney disease.

    Acetaminophen doesn't reduce swelling, like aspirin and other NSAIDs do. It may be less helpful for treating pain that's caused by inflammation, such as some types of arthritis.

ASPIRIN
Bayer, Bufferin, Ecotrin (and also an ingredient in Excedrin)

  • How it works. Aspirin is an NSAID that circulates through your bloodstream. It blocks the effects of chemicals that increase the feeling of pain.
  • Benefits. Aspirin has earned its reputation as a "wonder drug." It eases pain and lowers fevers. It can also reduce inflammation, which means that it can treat the symptom (pain) and sometimes the cause (swelling.)

    Aspirin also lowers the risk of blood clots, heart attacks, and strokes, particularly in people at high risk of these problems. Usually, only very low daily doses -- 81milligrams, or one baby aspirin --are recommended for cardiovascular protection. Other NSAIDs (such as ibuprofen, ketoprofen, or naproxen sodium) and acetaminophen do not have this effect. However, you should never start taking aspirin daily without talking with your health care provider first.

  • Side effects and risks. Aspirin can cause or aggravate ulcers. If possible, people who have ulcers should avoid it. Even at very low doses, aspirin can cause gastrointestinal symptoms, such as heartburn, upset stomach, or pain. Coated or "buffered" aspirin does not decrease these risks. Over time, ulcers can cause swelling and a build-up of scar tissue. This can become so severe that it can block food from getting out of the stomach.

    Aspirin can be dangerous for people with liver disease, gout, juvenile arthritis, or asthma. Rarely, aspirin can cause ringing in the ears or hearing loss.

    Pregnant women shouldn't use aspirin, since it can harm the mother and cause birth defects. Unless your health care provider says it's OK, children and teenagers should not use aspirin because it puts them at risk of Reye's syndrome.

    While inflammation can cause pain, it's often a key part of the body's natural healing process. Since aspirin at high doses can prevent inflammation, it can also slow down recovery after certain injuries.

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IBUPROFEN
Advil, Motrin IB, Nuprin

  • How it works. Like all NSAIDs, ibuprofen blocks the effects of chemicals that increase the feeling of pain.
  • Benefits. Ibuprofen can lower fevers, ease pain, and reduce inflammation.
  • Side effects and risks. People with ulcers should not use ibuprofen unless their health care providers say it's safe. Ibuprofen can cause or aggravate ulcers. It also causes other gastrointestinal symptoms, such as heartburn, upset stomach, or pain. Drinking alcohol while using ibuprofen increases the risk of GI problems.

    Ibuprofen may also increase the risk of heart attacks and strokes. The U.S. Food and Drug Administration (FDA) now requires that drug companies highlight ibuprofen's potential risks. The use of this drug along with other NSAIDs in pregnant women has been linked to birth defects.

    Some people are allergic to ibuprofen and other NSAIDs. It can cause hives and facial swelling. It can be dangerous to some people with asthma. People with ulcers should avoid ibuprofen if possible. In some cases, ibuprofen can slow down the body's natural healing process.

KETOPROFEN
Actron , Orudis KT

  • How it works. Ketoprofen blocks the effects of chemicals that increase the feeling of pain.
  • Benefits. Ketoprofen can lower fevers, ease pain, and reduce inflammation.
  • Side effects and risks. People with ulcers should not use ketoprofen unless their health care providers say it's safe. Ketoprofen can cause or aggravate ulcers. It also causes other gastrointestinal symptoms, such as heartburn, upset stomach, or pain.

    Drinking alcohol while using ketoprofen increases the risk of GI problems. Ketoprofen my also increase the risks of heart attacks and strokes. The FDA now requires that drug companies highlight these risks.

    The use of this drug along with other NSAIDs in pregnant women has been linked to birth defects. In some cases, ketoprofen can slow down the body's natural healing process.

NAPROXEN SODIUM
Aleve

  • How it works. Naproxen sodium blocks the effects of chemicals that increase the feeling of pain.
  • Benefits. Naproxen sodium can lower fevers, ease pain, and reduce inflammation.
  • Side effects and risks. People with ulcers should not use naproxen sodium unless their health care providers say it's safe. Naproxen sodium can cause or aggravate ulcers. It also causes other gastrointestinal symptoms, such as heartburn, upset stomach, or pain.

    Drinking alcohol while using naproxen sodium increases the risk of GI problems. Naproxen sodium may also increase the risk of heart attacks and strokes. The FDA now requires that drug companies highlight these risks.

    The use of this drug along with other NSAIDs in pregnant women has been linked to birth defects. In some cases, naproxen sodium can slow down the body's natural healing process.

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PRESCRIPTION PAINKILLERS

Many painkillers -- including higher doses of NSAIDs -- are available by prescription. Since they are more powerful versions of over-the-counter NSAIDs, they often have the same or greater risks. Some examples are Daypro, Indocin, Lodine, Naprosyn, Relafen, and Voltaren.

Cox-2 inhibitors are a newer kind of NSAID. These medicines have recently come under fire for their dangers. Although these drugs are supposed to have fewer gastrointestinal side effects than standard NSAIDs, they can still cause some of the same problems. They may also raise the risks of heart attack and stroke.

Two of these drugs, Vioxx and Bextra, have been taken off the market because of various side effects. Celebrex is still available.

Narcotics are another type of prescription painkiller. Examples include OxyContin, Percocet, and Vicodin. These drugs are reserved for people with severe pain. They generally pose less of a risk for people with ulcers. They do have other side effects, including constipation, fatigue, and a risk of addiction.

WebMD Feature Reviewed by Louise Chang, MD

Sources

SOURCES: Byron Cryer, MD, spokesman, American Gastroenterological Association; associate professor of medicine, University of Texas Southwestern Medical School, Dallas. Nieca Goldberg, MD, spokeswoman, American Heart Association; chief of Women's Cardiac Care at Lennox Hill Hospital, New York City. Phillip E. Korenblat, MD, spokesman, American Academy of Allergy, Asthma, and Immunology; professor of clinical medicine, Washington University School of Medicine, St. Louis. American Academy of Family Physicians web site. American Heart Association web site. American Academy of Allergy, Asthma, and Immunology web site. American College of Gastroenterology web site. American Gastroenterological Association web site. National Institute of Diabetes and Digestive and Kidney Diseases web site. U.S. Food and Drug Administration web site. U.S. Department of Health and Human Services National Women's Health Information Center web site.

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