How bad is it really to mix NSAIDs?

[tryp]

Stupid doc from the clinic didn't give me strong enough meds - my period pain is still absolutely unbearable even on what he prescribed (250 mg mefenamic acid). How bad is it really to take another NSAID too?

[mika]

you can take another Nsaid. No biggie

[AirMarshall]

Ponstel PI sheet:

After observing the response to initial therapy with PONSTEL, the dose and frequency should be adjusted to suit an individual patient's needs.

For the relief of acute pain in adults and adolescents =14 years of age, the recommended dose is 500 mg as an initial dose followed by 250 mg every 6 hours as needed, usually not to exceed one week.4

For the treatment of primary dysmenorrhea, the recommended dose is 500 mg as an initial dose followed by 250 mg every 6 hours, given orally, starting with the onset of bleeding and associated symptoms. Clinical studies indicate that effective treatment can be initiated with the start of menses and should not be necessary for more than 2 to 3 days.5

[Silver]

I wouldn't be stacking the NSAIDs, actually, without some oversight. Some of them are over the counter, but NSAIDs really are not happy fluffy drugs. Do not make me start in with the distal tubules again... Pick one or another.

Tryp, did s/he tell you to take it every 6h or prn, or every 6h for the first couple doses and then prn? You're trying to block the prostaglandin effects, not just muffle pain, and that takes a different dosing strategy. Prostaglandins don't last long, so the prn dosing is often good after that first loading dose... but those initial couple doses really help.

It might be worth talking to your doctor about starting the NSAID a day early next time to see if you can head this off at the pass if this is severe and every month. Sometimes that works really well (total anecdata on my part, mind you.)

[Artemisia]

A few years ago when I was had bruised my sternum (or something--there were no fractures on the x-ray), the doctor told me to take 800 mg of ibuprofen 3x a day for the resulting chest pain. That's 2400 mg a day!!!

So it's likely safe to take more than the max recommended daily dose (provided you don't have and liver or kidney issues, or if your stomach or small intestine likes getting ulcers), but personally, I wouldn't go mixing different NSAIDs together. (I also wouldn't take 2400 mg/day of ibuprofen for too long--but it really did the trick for me that time.)

I'd feel best if you talked to your doctor about how much you can take of what painkillers... Good luck.

[Silver]

2400mg per day is within range for ibuprofen; the labeled prescription range is up to 3200 mg with appropriate monitoring in appropriate patients. That is where the "prescription" part comes in.

But you wouldn't want to combine 2400mg ibuprofen with a high dose of naproxen, for example.

Combined NSAIDs have additive effects. This includes the undesired systemic effects.

I would not go over the highest prescribed dose of an NSAID. Renal damage sucks, as do other sequelae of overuse.

By the same token, I wouldn't combine them without oversight. (Actually, I just wouldn't combine them.)

[tryp]

I wouldn't be stacking the NSAIDs, actually, without some oversight. Some of them are over the counter, but NSAIDs really are not happy fluffy drugs. Do not make me start in with the distal tubules again... Pick one or another.

Tryp, did s/he tell you to take it every 6h or prn, or every 6h for the first couple doses and then prn? You're trying to block the [link=http://books.google.com/books?id=YjrQla7JPD0C&pg=PA374&lpg=PA374&dq=prostaglandin+dysmenorrhea+NSAID&source=bl&ots=sCrzauUheg&sig=yRKkmDB3IeHzV7mHctO2_H1ga9s&hl=en&ei=U4M9SuuzE4vcswPIxaH3Cg&sa=X&oi=book_result&ct=result&resnum=8" target="_blank]prostaglandin effects[/link], not just muffle pain, and that takes a different dosing strategy. Prostaglandins don't last long, so the prn dosing is often good after that first loading dose... but those initial couple doses really help.

It might be worth talking to your doctor about starting the NSAID a day early next time to see if you can head this off at the pass if this is severe and every month. Sometimes that works really well (total anecdata on my part, mind you.)

I was told to take two mefenamic at once, then one every six hours. Which I've been doing and literally getting NO pain relief. So I took a naproxen and I've also been taking a couple of ibuprofen every 4-6 hours. I know that's really bad, but I was basically curled up in a ball unable to move, so I had to take something.

Mine cycles are horribly irregular, as well, so I can't predict my periods well enough to load up beforehand.

I have ANOTHER doctor's appointment on July 8th, since the first stupid doc blew me off and gave me meds that aren't doing jack shit. So this should be the last period like this provided Student Health actually does something.

[Silver]

I've always been an ibuprofen fan for this kind of thing, myself.

Still, I have a good healthy respect for ibuprofen and all the NSAIDs.

You asked. My reply: I don't mix them, as I think there are in fact risks.

"Bad" is a evaluation that you're applying to your behavior, incidentally. It's not a description. It's certainly not an evaluation on my part.

Really, if you can get the drug going at the first glimmer of prostaglandin effects (such as bowel changes), it makes a huge difference.

What are you hoping the SHC will do differently for you next time?

[Artemisia]

2400mg per day is within range for ibuprofen; the labeled prescription range is up to 3200 mg with appropriate monitoring in appropriate patients. That is where the "prescription" part comes in.

I was just really surprised because the maximum daily dosage listed on OTC ibu is something like 1200 mg. Prior to that incident, I never thought that legitimate dosing of OTC meds in non-emergency situations could be so much higher than the maximum daily dose on the label.

I love ibuprofen. I lurve it. It's the most effective painkiller for me. (Never needed I/V morphine or anything. Got some opiate at some point for something, and it worked like magic but wasn't worth the wuzziness and nausea.)

[tryp]

Well, the other doc I saw didn't even do an exam. I think it might be good for Student Health to do an exam and/or run whatever tests they ought to run. Other doc basically just looked at me and told me to fuck off.

Also, since the meds he gave me actually were worse than the OTC meds I was taking before, I would like other painkillers.

The truth is, I REALLY don't want to be on hormonal BC. I just really don't want to, for various reasons.

It seems like my med-loading yesterday took the edge off. I find that if I keep taking meds til the pain goes away on the first day, it's usually pretty manageable after that. So maybe I'll be able to just stick to the mefenamic for the rest of the week.

Ibuprofen used to work for me with only the dosage on the package, but then it stopped working so I went on to naproxen, same story - worked for a few months then stopped working. Which was when I got to the point of stacking and decided I probably really needed to see a doctor. I don't know if my periods are getting more painful or I'm just somehow becoming immune to the meds, but something's up there.

[mika]

Now I feel bad that I told you to mix them since everyone thought otherwise, but I still dont think it's the end of the world. Its not very common to mix Nsaids but I dont think its too harmful if you dont overdo it and take it all the time. You know what I mean

[Silver]

Loading an NSAID for the first day or two - within the safe range for that given drug - and then using for the rest of the period is a pretty classic strategy.

A thorough physical exam if something doesn't respond to hormonal contraception (OCPs) plus NSAIDs is pretty standard, but menstrual pain unto itself, if pelvic inflammatory disease isn't on the list of possibilities, doesn't always get a pelvic exam - especially if the clinic is aware of your abuse history? If that's in your problem/diagnosis list or health profile, they may be trying to minimize pelvic exams and triggering situations. Just a thought. (Um, a thorough clinical exam is usually going to include a rectal exam. FYI. There are very legitimate clinical reasons for it, but it's something we tend not to expect, and I think this is one of those times where a little anticipatory guidance goes a LONG WAY. Sorry for the digression here. But I know a lot of women who would have appreciated just a little heads up to sort of expect that.)

Sometimes there's ultrasound. Generally not tons of tests.

You can expect that OCPs are going to be mentioned, because, as you know, they regulate cycles, and, well, the rest is better described in the link in my first post (they're acronymed in that book as COCs, for combined oral contraceptives - estrogen/progestin pills.) They do work well, when they work. So no one would be picking on you, but expect that they'll come up from time to time.

And here, you might find this useful.

[tryp]

Silver,

So do you think I'm barking up the wrong tree with this?

I mean, admittedly, I'm a bit of a hypochondriac. My main issue is really that I would like painkillers that work, but maybe if I tweak my mefenamic timing, it will work?

I mean, if it's something that doesn't need me to see a doctor about it, I can accept that. It's mostly the lack of painkillers that has me wanting someone to look at it. Also, I'm sort of worried I have some sort of hormonal and/or thyroid problem, but that's a totally unfounded fear.

Clinic isn't aware of my abuse history, but I'm definitely not looking forward to this one - totally willing to call it off if it's unnecessary.

I don't really want birth control because the idea of it really bothers me. It seems like really messing up your body, and since I'm not straight, I've always felt I'd prefer not to do that to my body. I know it's a little irrational when I take psych meds and everything, but there you go.

The mefenamic really doesn't seem to be working all that well, given the amount of additional painkillers I had to heap on yesterday, and it's going to be really hard for me to predict my period well enough to take it in advance, but I guess I could try.

[tryp]

Oh, also, from a harm reduction standpoint, if I have to do SOMETHING, is it better for me to take a little extra mefenamic than to stack NSAIDs?

[gizmo]

I know you don't want a monkey thrown in your already messed up engine, but please keep this in the back of your head for possible discussion with your doctor...

Like you, I have moderate to severe pelvic pain. Mine is all month long. I had a pelvic ultrasound done and it turned out I had a "cluster" of fibroids growing. Now, this was not exactly a surprise to me, as my mother and three of her four sisters all had hysterectomies before the age of 42 because of fibroids. The fourth sister just had a hysterectomy.

My fibroids are small, but you know, they never go away, they only slowly grow and grow. My doctor said that the standard treatment is BC pills, because the progesterone shrinks the fibroids. Temporarily, as in they stay shrunk as long as you are on the pills. But there's a catch: progesterone is known for making people with depression more likely to have an episode. He told me to ask my pdoc about the BC treatment before he would prescribe anything. My pdoc said no, that given my relatively unstable nature, progesterone was not something she felt comfortable with introducing on a long-term basis into my body.

So I guess what I'm trying to say is that if you decide you do want to go with the BC pills, give your pdoc a call before committing to the treatment.

[Silver]

Silver,

So do you think I'm barking up the wrong tree with this?

I mean, admittedly, I'm a bit of a hypochondriac. My main issue is really that I would like painkillers that work, but maybe if I tweak my mefenamic timing, it will work?

I mean, if it's something that doesn't need me to see a doctor about it, I can accept that. It's mostly the lack of painkillers that has me wanting someone to look at it. Also, I'm sort of worried I have some sort of hormonal and/or thyroid problem, but that's a totally unfounded fear.

Clinic isn't aware of my abuse history, but I'm definitely not looking forward to this one - totally willing to call it off if it's unnecessary.

I don't really want birth control because the idea of it really bothers me. It seems like really messing up your body, and since I'm not straight, I've always felt I'd prefer not to do that to my body. I know it's a little irrational when I take psych meds and everything, but there you go.

The mefenamic really doesn't seem to be working all that well, given the amount of additional painkillers I had to heap on yesterday, and it's going to be really hard for me to predict my period well enough to take it in advance, but I guess I could try.

It's not a matter of barking up the wrong tree - it's that the NSAIDs/OCs are intended to actually address the pathology / process that's causing the pain. The NSAIDs aren't being used as "painkillers" per se. It's why you're taking an NSAID and not Tylenol or morphine.

And I'll say, having had prostaglandin-induced pain (renal colic) and having received some nasty-evil-ass NSAIDs for it and also morphine - the NSAIDs worked a lot better.

I think if you're this uncomfortable and unhappy, yes, you should follow up and be evaluated for it, and you should be informed. That AAFP article (the last link) is pretty thorough as far as being informed, and it describes what the usual evaluation process is.

I think it's appropriate to let the provider know about your abuse history. They usually won't make a big deal out of it but will note it to the chart. My FP's office has a sexual assault/abuse history checkbox screener on intake for each/every visit - I don't know if SHC does.

As Gizmo said, progestins (the synthetic progesterone found in OCs) can have strong mood effects - good for some, bad for others. OCs do wash out pretty damn fast, though, and so it's not like a Depo-Provera shot, where you've committed yourself for three months. Sometimes it's an issue of trying OCs with different types of progestin, as the different progestins act differently, etc. Sometimes monophasic pills, in which hormone levels don't fluctuate, are a little more tolerable than triphasic pills, if mood responds to progestin. There is a whole weird art to this; OCs are NOT interchangeable, and what sucks for me might be great for my cousin and vice versa. If it's a route you ever decide to explore, and the first couple of trials don't work, then it's worth going to someone who does a LOT of contraception management - which would likely be SHC, or perhaps Planned Parenthood. There's a good table somewhere of the profiles of different OCs in terms of androgenicity, progestational activity, etc., but I can't find it. I'll add it on later if I can - it's on my bookmarks on some machine...

If someone isn't taking them for contraception, they're not really OCs, but that's a lot more convenient for me than typing out the full hormonal name, so I'm stickin' with the lazy version, 'cause I'm like that. Using them for hormonal manipulation doesn't imply intent to have sex with men, or availability to, and I guess I don't see it as any different than the gazillion and one off-label weird uses for drugs we're all familiar with on the boards; they're a tool to be used appropriately if that's what you want to do. Or not, if that's what you choose. (How many people here are on off-label anti-epileptic drugs and don't have epilepsy?) But I see how that would be a personal/cultural barrier.

I think you'll get this sorted, Tryp - it's early days, and you're motivated, and you're advocating for yourself and doing the right stuff. But I'm sorry it's so miserable right now.

Heat? (I'm a big fan of the "apply one warm purring cat to abdomen" method of treatment, but I know it's of very limited utility when you're in severe distress.)

[tryp]

Cold and heat work well for me - I have spent many an hour with an ice pack down my pants

I'm feeling a bit better today, having loaded up on NSAIDs yesterday, so I'm managing to mostly take only the mefenamic as prescribed and not be in horrible pain, thank goodness. First day is always the worst.

Thanks for all the info & help, Silver