In October, U.S. Pain hosted a webinar, “Pain relief in your pharmacy aisle: A pharmacist discusses OTC options,” with Jeffrey Fudin, PharmD. The discussion covered different classes of over-the-counter (OTC) medications, what may work best for certain types of pain, the pros and cons of various delivery methods, how to avoid side effects and interactions, and more. During the webinar, patients in the audience asked a number of questions, but we weren’t able to get to all of them. Fortunately, Himayapsill Batista Quevedo, PharmD, in collaboration with Dr. Fudin, have put together answers to some of those questions below. We’ve arranged them into four categories: efficacy; specific indications; topical medications; and side effects and risks.

Efficacy

Q: Are store generics as effective as name-brand medications?

A: Most brand and generic medications are equivalent and interchangeable. The FDA closely monitors medications to ensure bioequivalence between brand and generics in order to maintain the efficacy and safety of the brand medication counterpart. There is a very small margin of difference allowed, which accounts for manufacturing and environmental factors; however, this does not impact efficacy. There are few exceptions to this, and if there is a specific question, it’s best to ask your pharmacist. Also, natural food supplements are not interchangeable.

Q: Besides Aleve, Tylenol, Advil, and Ibuprofen, are there any other OTCs available?

A: Please see the presentation for details; however, note those that you mention are the most common and most favorable oral options among medical providers and pharmacists. There also are unique formulations within these categories.

Q: What if you have tried all these OTC medications and none of them work?

A: If you have ongoing pain for over one week and medications are not providing adequate pain relief, then we recommend that you see a medical provider.

Specific indications

Q: What is the best OTC medicine to help with neuropathy pain?

A: Topical products are particularly effective for local neuropathy, such as shingles (postherpetic neuralgia). Products that contain lidocaine, preferably 4% or higher, have been shown to be quite effective. Available OTC lidocaine products include Salonpas patches and gels, select IcyHot, and Aspercreme products. Other effective products, including certain Salonpas patches, include capsaicin-containing topicals, however the downside to these is the frequent (3-4 times) a day application requirement. In general, neuropathies do not respond well to NSAIDs or acetaminophen.

Q: What are the best OTC pain relievers for muscle pain?

A: For muscle pain, any of the drugs discussed are appropriate: acetaminophen, ibuprofen, and naproxen, etc. Sometimes these medications combined with antihistamines are particularly useful as discussed during the presentation. (An example is Aleve PM, with active ingredients being naproxen and diphenhydramine). Low-dose acetaminophen with an anti-inflammatory can also be beneficial, such as Advil Dual Action, which contains both acetaminophen and ibuprofen.

Topical medications

Q: How are topical NSAIDs different from an oral pill? Does it really work and offer the same amount of relief?

A: Assuming the question asked above is referring to NSAIDs, yes, topical and oral NSAIDs have demonstrated similar efficacy if the topical is used as indicated in the label and on the areas for which it is approved. For Voltaren (diclofenac), that includes “for the temporary relief of arthritis pain in the hand, wrist, elbow, foot, ankle or knee in adults (18 years and older).” For Salonpas (methyl salicylate, menthol, and sometimes camphor) the labeling includes backache, sore muscle, sprains, and bruises.

Q: What is the difference between prescription and OTC versions of lidocaine patches and diclofenac?

A: OTC Voltaren (diclofenac gel) and prescription drug are the exact same formulation with the same active ingredient. Voltaren was recently granted FDA approval for nonprescription use. A diclofenac patch, brand name Flector, is also available by prescription, this formulation is good for application on flat areas of the body. There is currently no data that supports one or the other is more or less effective. A study was published evaluating efficacy between lidocaine products demonstrating noninferiority (i.e one is not worse than the other) of OTC lidocaine 3.6%/menthol 1.25% patch and compared to prescription lidocaine 5%. This study also showed the superiority of the OTC patch compared to placebo. In other words, the OTC product containing both lidocaine and menthol could provide an effective alternative to the prescription product.

Q: Can you take diclofenac with an oral NSAID?

A: As discussed during the presentation, according to the package insert for topical products, the same toxicity warning is listed in both labels (oral and topical). The reason for this is because this is a templated label that the FDA requires for safety reasons. However, the blood level of topical NSAIDs are 158 times lower compared to that of oral treatment. See this article for more information: Fudin J. Should Topical NSAIDs Have Strict Heart Risk Warnings? Pharmacy Times.

Q: Are there topical creams that are available OTC besides the IcyHot?

A: Yes. The following is not an all-inclusive list: Banalg, Bengay, Salonpas patches and gels, Biofreeze, and various others.

Side effects and risks

Q: Should you take NSAIDs with food?

A: Yes.

Q: Can you provide more specific information on the downside of OTC medications like Benadryl?

A: Benadryl has anticholinergic side effects, as described during the presentation. Although not an all-inclusive list, side effects are dry eyes, dry mouth, urinary retention, constipation, dizziness, and sedation, which can lead to increased risk of falls and enhance risk for dangerous respiratory depression from opioids.

Q: Can the long-term use of OTC or prescribed meds cause serious side effects?

A: It depends on the situation, indication, other medications one takes, as well as age, and medical conditions. For example, long-term omeprazole can result in decreased bone density, which could lead to fractures, vitamin B12 deficiency, and disturb the “normal” or “good” bacteria in our gut making the body unable to fight bad bacteria. But some conditions require long-term use of omeprazole; so this should be prescribed and closely monitored by the prescribing physician. There are many other examples and if you have a specific question, your pharmacist is the best person to ask.

Q: Are there OTCs that affect the thyroid?

A: St. John’s wort and certain natural products are more likely to cause thyroid issues. Dangerous medications to take with a poorly controlled thyroid condition include decongestants and OTC diet products that contain drugs such as pseudoephedrine, phenylephrine, phenylpropanolamine, and/or caffeine.

Q: I can’t have NSAIDS because of chronic kidney disease and I have a lot of inflammation and arthritis and acetaminophen does not cut it. Topicals don’t work either. What OTC do you recommend?

A: This needs to be discussed with a medical provider – the most appropriate medications, in this case, will require a prescription.

 

About Himayapsill Batista Quevedo, PharmD

Dr. Batista Quevedo is currently completing a PGY-2 Pain and Palliative Care Pharmacy Residency at the Stratton VA Medical Center, Albany, NY. She received her PharmD from Wilkes University Nesbitt School of Pharmacy Wilkes-Barre, PA, and completed a PGY-1 residency at Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.

About Jeffrey Fudin, PharmD

Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, FFSMB, is the Clinical Pharmacy Specialist and Director, PGY-2 Pharmacy Residency Programs, at the Stratton VA Medical Center in Albany, New York. He is also the CEO and founder of Remitigate Therapeutics, a virtual pain management consulting firm, and owner and managing editor for paindr.com. Dr. Fudin holds adjunct faculty positions at Western New England University College of Pharmacy and the Albany College of Pharmacy & Health Sciences; he also serves as Section Editor for Pain Medicine, Co-Editor-At-Large for Practical Pain Management, Senior Editor for Pain Medicine, and as a peer reviewer for several professional journals. In addition, Dr. Fudin is the Founder and Board of Trustee for the Society of Pain and Palliative Care Pharmacists, where he serves on several committees and is a Diplomate to the Academy of Integrative Pain Management and a Fellow to the American College of Clinical Pharmacy, the American Society of Health-system Pharmacists, and the Federation of State Medical Board. Dr. Fudin is a prolific lecturer, writer with over 300 publications, and researcher on pain management topics.

The Oct. 15 event was sponsored by GlaxoSmithKline.