acetaminophen/ibuprofen (OTC)

Brand and Other Names:Advil Dual Action
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

acetaminophen/ibuprofen

tablet

  • 250mg/125mg

Pain

Indicated for temporary relief of mild pain caused by headache, backache, muscular aches, toothache, menstrual cramps, minor pain of arthritis

2 tablets PO q8hr while symptoms persist; not to exceed 6 tablets/day, unless directed by physician

Maximum dose

  • Acetaminophen containing products: Not to exceed a cumulative dose of 3.25 g/day of acetaminophen; under supervision of healthcare professional, daily doses of up to 4 g/day may be used

Dosage Forms & Strengths

acetaminophen/ibuprofen

tablet

  • 250mg/125mg

Pain

Indicated for temporary relief of mild pain caused by headache, backache, muscular aches, toothache, menstrual cramps, minor pain of arthritis

<12 years: Safety and efficacy not established

≥12 years: 2 tablets PO q8hr while symptoms persist; not to exceed 6 tablets/day, unless directed by physician

Maximum dose

  • Acetaminophen containing products: Not to exceed a cumulative dose of 3.25 g/day of acetaminophen; under supervision of healthcare professional, daily doses of up to 4 g/day may be used
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Interactions

Interaction Checker

and acetaminophen/ibuprofen

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            Contraindicated (0)

              Serious - Use Alternative (3)

              • lonafarnib

                acetaminophen will increase the level or effect of lonafarnib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of lonafarnib (a sensitive CYP3A substrate) with weak CYP3A inhibitors is unavoidable, reduce to, or continue lonafarnib at starting dose. Closely monitor for arrhythmias and events (eg, syncope, heart palpitations) since lonafarnib effect on QT interval is unknown.

              • pexidartinib

                acetaminophen and pexidartinib both increase Other (see comment). Avoid or Use Alternate Drug. Pexidartinib can cause hepatotoxicity. Avoid coadministration of pexidartinib with other products know to cause hepatoxicity.

              • pretomanid

                acetaminophen, pretomanid. Either increases toxicity of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Pretomanid regimen associated with hepatotoxicity. Avoid alcohol and hepatotoxic agents, including herbal supplements and drugs other than bedaquiline and linezolid.

              Monitor Closely (24)

              • apalutamide

                apalutamide will decrease the level or effect of acetaminophen by increasing elimination. Use Caution/Monitor. Apalutamide induces UGT and may decrease systemic exposure of drugs that are UGT substrates.

              • avapritinib

                acetaminophen will increase the level or effect of avapritinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • axitinib

                acetaminophen increases levels of axitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • bupivacaine implant

                acetaminophen, bupivacaine implant. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Local anesthetics may increase the risk of developing methemoglobinemia when concurrently exposed to drugs that also cause methemoglobinemia.

              • busulfan

                acetaminophen increases levels of busulfan by decreasing metabolism. Use Caution/Monitor. Use of acetaminophen prior to (< 72 hours) or concurrently with busulfan may result in decreased clearance of busulfan due to acetaminophen-induced decreases in glutathione levels.

              • dapsone topical

                acetaminophen increases toxicity of dapsone topical by altering metabolism. Modify Therapy/Monitor Closely. May induce methemoglobinemia .

              • eltrombopag

                eltrombopag increases levels of acetaminophen by decreasing metabolism. Use Caution/Monitor. UGT inhibition; significance of interaction unclear.

              • exenatide injectable solution

                exenatide injectable solution will decrease the level or effect of acetaminophen by unspecified interaction mechanism. Use Caution/Monitor. To avoid potential interaction, give acetaminophen at least 1 hour before or 4 hours after exenatide injection.

              • exenatide injectable suspension

                exenatide injectable suspension will decrease the level or effect of acetaminophen by unspecified interaction mechanism. Use Caution/Monitor. To avoid potential interaction, give acetaminophen at least 1 hour before or 4 hours after exenatide injection.

              • finerenone

                acetaminophen will increase the level or effect of finerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor serum potassium during initiation and dosage adjustment of either finererone or moderate CYP3A4 inhibitors. Adjust finererone dosage as needed.

              • flibanserin

                acetaminophen will increase the level or effect of flibanserin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Increased flibanserin adverse effects may occur if coadministered with multiple weak CYP3A4 inhibitors.

              • imatinib

                imatinib decreases levels of acetaminophen by decreasing hepatic clearance. Modify Therapy/Monitor Closely. In vitro, imatinib was found to inhibit acetaminophen O-glucuronidation (Ki value of 58.5 micro-M) at therapeutic levels; avoid chronic acetaminophen therapy with imatinib; if occasional acetaminophen administered, do not exceed 1300 mg/day.

              • isoniazid

                isoniazid will increase the level or effect of acetaminophen by affecting hepatic enzyme CYP2E1 metabolism. Use Caution/Monitor.

              • ivacaftor

                acetaminophen increases levels of ivacaftor by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor when coadministered with weak CYP3A4 inhibitors .

              • lemborexant

                acetaminophen will increase the level or effect of lemborexant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Lower nightly dose of lemborexant recommended if coadministered with weak CYP3A4 inhibitors. See drug monograph for specific dosage modification.

              • levonorgestrel oral/ethinylestradiol/ferrous bisglycinate

                levonorgestrel oral/ethinylestradiol/ferrous bisglycinate will decrease the level or effect of acetaminophen by unknown mechanism. Use Caution/Monitor.

                acetaminophen increases levels of levonorgestrel oral/ethinylestradiol/ferrous bisglycinate by decreasing hepatic clearance. Use Caution/Monitor. Coadministration of ascorbic acid and certain combined hormonal contraceptives (CHCs) containing EE may increase plasma EE concentrations, possibly by inhibition of conjugation.

              • lixisenatide

                lixisenatide will decrease the level or effect of acetaminophen by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. GLP1 agonists delay gastric emptying, which may affect absorption of concomitantly administered oral medications. No effects on acetaminophen Cmax and Tmax were observed when acetaminophen was administered 1 hr before lixisenatide. When administered 1 or 4 hr after lixisenatide, acetaminophen Cmax was decreased by 29% and 31% respectively and median Tmax was delayed by 2 and 1.75 hr, respectively.

              • lomitapide

                acetaminophen increases levels of lomitapide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Lomitapide dose should not exceed 30 mg/day.

              • midazolam intranasal

                acetaminophen will increase the level or effect of midazolam intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of mild CYP3A4 inhibitors with midazolam intranasal may cause higher midazolam systemic exposure, which may prolong sedation.

              • mipomersen

                mipomersen, acetaminophen. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Both drugs have potential to increase hepatic enzymes; monitor LFTs.

              • tazemetostat

                acetaminophen will increase the level or effect of tazemetostat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • tetracaine

                tetracaine, acetaminophen. Other (see comment). Use Caution/Monitor. Comment: Monitor for signs of methemoglobinemia when methemoglobin-inducing drugs are coadministered.

              • tinidazole

                acetaminophen will increase the level or effect of tinidazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • warfarin

                acetaminophen increases effects of warfarin by unknown mechanism. Use Caution/Monitor.

              Minor (50)

              • acetazolamide

                acetazolamide decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • albiglutide

                albiglutide decreases levels of acetaminophen by unspecified interaction mechanism. Minor/Significance Unknown.

              • antithrombin alfa

                acetaminophen increases effects of antithrombin alfa by unknown mechanism. Minor/Significance Unknown.

              • antithrombin III

                acetaminophen increases effects of antithrombin III by unknown mechanism. Minor/Significance Unknown.

              • argatroban

                acetaminophen increases effects of argatroban by unknown mechanism. Minor/Significance Unknown.

              • bemiparin

                acetaminophen increases effects of bemiparin by unknown mechanism. Minor/Significance Unknown.

              • bivalirudin

                acetaminophen increases effects of bivalirudin by unknown mechanism. Minor/Significance Unknown.

              • carbamazepine

                carbamazepine decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • cholestyramine

                cholestyramine decreases levels of acetaminophen by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • clonazepam

                clonazepam decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • colestipol

                colestipol decreases levels of acetaminophen by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • dalteparin

                acetaminophen increases effects of dalteparin by unknown mechanism. Minor/Significance Unknown.

              • diazepam

                diazepam decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • disulfiram

                disulfiram will increase the level or effect of acetaminophen by affecting hepatic enzyme CYP2E1 metabolism. Minor/Significance Unknown.

              • enoxaparin

                acetaminophen increases effects of enoxaparin by unknown mechanism. Minor/Significance Unknown.

              • ethanol

                ethanol will decrease the level or effect of acetaminophen by affecting hepatic enzyme CYP2E1 metabolism. Minor/Significance Unknown.

                ethanol increases toxicity of acetaminophen by decreasing metabolism. Minor/Significance Unknown.

              • ethosuximide

                ethosuximide decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • felbamate

                felbamate decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • fondaparinux

                acetaminophen increases effects of fondaparinux by unknown mechanism. Minor/Significance Unknown.

              • fosphenytoin

                fosphenytoin decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • gabapentin

                gabapentin decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • gabapentin enacarbil

                gabapentin enacarbil decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • green tea

                green tea increases effects of acetaminophen by pharmacodynamic synergism. Minor/Significance Unknown. (Theoretical, due to caffeine content).

              • heparin

                acetaminophen increases effects of heparin by unknown mechanism. Minor/Significance Unknown.

              • isoniazid

                isoniazid increases toxicity of acetaminophen by unknown mechanism. Minor/Significance Unknown.

              • lacosamide

                lacosamide decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • lamotrigine

                lamotrigine decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • levetiracetam

                levetiracetam decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • liraglutide

                liraglutide decreases levels of acetaminophen by unspecified interaction mechanism. Minor/Significance Unknown.

              • lorazepam

                lorazepam decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • methsuximide

                methsuximide decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • metoclopramide

                metoclopramide increases levels of acetaminophen by enhancing GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

              • metronidazole

                metronidazole will increase the level or effect of acetaminophen by affecting hepatic enzyme CYP2E1 metabolism. Minor/Significance Unknown.

              • oxcarbazepine

                oxcarbazepine decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • oxybutynin

                oxybutynin decreases levels of acetaminophen by unspecified interaction mechanism. Minor/Significance Unknown.

              • oxybutynin topical

                oxybutynin topical decreases levels of acetaminophen by unspecified interaction mechanism. Minor/Significance Unknown.

              • oxybutynin transdermal

                oxybutynin transdermal decreases levels of acetaminophen by unspecified interaction mechanism. Minor/Significance Unknown.

              • phenindione

                acetaminophen increases effects of phenindione by unknown mechanism. Minor/Significance Unknown.

              • phenobarbital

                phenobarbital decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • phenytoin

                phenytoin decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • primidone

                primidone decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • protamine

                acetaminophen increases effects of protamine by unknown mechanism. Minor/Significance Unknown.

              • rifabutin

                rifabutin decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • rifampin

                rifampin decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • rufinamide

                rufinamide decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • ruxolitinib

                acetaminophen will increase the level or effect of ruxolitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

              • tiagabine

                tiagabine decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • topiramate

                topiramate decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • valproic acid

                valproic acid decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

              • zonisamide

                zonisamide decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism increase levels of hepatotoxic metabolites.

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              Warnings

              Black Box Warnings

              Ibuprofen

              • Cardiovascular risk
                • NSAIDs may increase risk of serious cardiovascular thrombotic events, MI, and stroke, which can be fatal
                • Risk may increase with duration of use
                • Patients with existing cardiovascular disease or risk factors for such disease may be at greater risk
                • NSAIDs are contraindicated for perioperative pain in setting of coronary artery bypass graft (CABG) surgery
              • Gastrointestinal risk
                • NSAIDs increase risk of serious GI adverse events, including bleeding, ulceration, and gastric or intestinal perforation, which can be fatal
                • GI adverse events may occur at any time during use and without warning symptoms
                • Elderly patients are at greater risk for serious GI events

              Contraindications

              Ibuprofen

              • Hypersensitivity to ibuprofen, other NSAIDs, aspirin, or excipients
              • Perioperative pain in setting of CABG surgery

              Acetaminophen

              • Hypersensitivity
              • Severe active liver disease

              Cautions

              Acetaminophen

              • Hepatotoxicity risk
                • Risk of hepatotoxicity is higher in patients taking long-term high dose, or use of more than one acetaminophen-containing product
                • Acetaminophen is available in many dosage forms and products; check label carefully to avoid overdose
                • Limit acetaminophen dose from all sources and routes to <4 g/day in adults
                • Consumption of 3 or more alcoholic drinks/day may increase risk of liver damage
              • Allergic reaction
                • Risk for rare, but serious skin reactions that can be fatal; these reactions include Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis; symptoms may include skin redness, blisters, and rash
                • Discontinue if symptoms occur and seek medical help immediately

              Ibuprofen

              • NSAID allergy
                • May cause severe allergic reaction, especially in patients allergic to aspirin
                • Symptoms may include hives, asthma, skin redness, blisters, rash, facial swelling, and shock
                • Discontinue if symptoms occur and seek medical help immediately
              • GI bleeding
                • NSAIDs increase risk of serious GI adverse events, including bleeding, ulceration, and gastric or intestinal perforation, which can be fatal
                • Risk is higher with patients who are aged ≥60 yr, have history of peptic ulcer disease or GI bleeding, take anticoagulants or corticosteroids, take aspirin or other NSAIDs, consume ≥3 alcoholic drinks every day while taking this drug, or take a higher dose or for a longer duration than recommended
              • Cardiovascular risk
                • NSAIDs, except aspirin, increase risk of MI, heart failure, and stroke, which can be fatal
                • Higher risk if higher dose consumed or taken longer than directed
              • Renal injury
                • Long-term administration of NSAIDs may result in renal papillary necrosis and other renal injury
                • Patients at greatest risk include elderly individuals and those with impaired renal function, hypovolemia, heart failure, liver dysfunction, or salt depletion
                • Risk increased if coadministered with diuretics, ACE inhibitors, or angiotensin receptor blockers
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              Pregnancy & Lactation

              Pregnancy

              Ibuprofen

              • Avoid use in pregnant women starting at 30 weeks’ gestation; NSAID use during third trimester increases risk of premature closure of the fetal ductus arteriosus
              • There are no adequate and well-controlled studies in pregnant women; data from observational studies regarding potential embryofetal risks of NSAID use in women in the first or second trimesters of pregnancy are inconclusive

              Acetaminophen

              • Low risk of cryptorchidism in boys if used for several weeks or longer

              Lactation

              Ibuprofen

              • Considered compatible with breastfeeding (LactMed)
              • No lactation studies have been conducted; however, limited published literature reports that following oral administration, ibuprofen is present in human milk at relative infant doses of 0.06-0.6% of the maternal weight-adjusted daily dose

              Acetaminophen

              • Considered compatible with breastfeeding (LactMed)

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Acetaminophen

              • Acts on hypothalamus to produce antipyresis
              • May work peripherally to block pain impulse generation; may also inhibit prostaglandin synthesis in CNS

              Ibuprofen

              • Elicits anti-inflammatory, analgesic, and antipyretic activity
              • Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase (COX) isoenzymes, COX-1 and COX-2
              • May inhibit chemotaxis, alter lymphocyte activity, decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may contribute to its anti-inflammatory activity
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              Administration

              Oral Administration

              Take with food or milk if GI distress occurs

              Storage

              Store at 20-25ºC (68-77ºF); avoid excessive heat >40ºC (104ºF)

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              Images

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              Patient Handout

              A Patient Handout is not currently available for this monograph.
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.