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Acetaminophen, aspirin, and caffeine

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MEDICATION SAFETY ISSUES
Sound-alike/look-alike issues:
Excedrin® may be confused with Dexatrim®, Dexedrine®

Duplicate therapy issues: This product contains acetaminophen, which may be a component of other combination products. Do not exceed the maximum recommended daily dose of acetaminophen.

U.S. BRAND NAMES — Anacin® Advanced Headache Formula [OTC]; Excedrin® Extra Strength [OTC]; Excedrin® Migraine [OTC]; Fem-Prin® [OTC]; Genaced™ [OTC]; Goody’s® Extra Strength Headache Powder [OTC]; Goody’s® Extra Strength Pain Relief [OTC]; Pain-Off [OTC]; Vanquish® Extra Strength Pain Reliever [OTC]

PHARMACOLOGIC CATEGORY
Analgesic, Miscellaneous

DOSING: ADULTS
Pain management:
Based on acetaminophen component:
Mild-to-moderate pain: Oral: 325-650 mg every 4-6 hours as needed; do not exceed 4 g/day
Mild-to-moderate pain associated with migraine headache: Oral: 500 mg/dose (in combination with 500 mg aspirin and 130 mg caffeine) every 6 hours while symptoms persist; do not use for longer than 48 hours
Based on aspirin component:
Mild-to-moderate pain: Oral: 325-650 mg every 4-6 hours as needed; do not exceed 4 g/day
Mild-to-moderate pain associated with migraine headache: Oral: 500 mg/dose (in combination with 500 mg acetaminophen and 130 mg caffeine) every 6 hours; do not use for longer than 48 hours

Product labeling:

Excedrin® Extra Strength, Excedrin® Migraine: Oral: 2 doses every 6 hours (maximum: 8 doses/24 hours)
Note: When used for migraine, do not use for longer than 48 hours

Goody’s® Extra Strength Headache Powder: Oral: 1 powder, placed on tongue or dissolved in water, every 4-6 hours (maximum: 4 powders/24 hours)

Goody’s® Extra Strength Pain Relief Tablets: Oral: 2 tablets every 4-6 hours (maximum: 8 tablets/24 hours)

Vanquish® Extra Strength Pain Reliever: Oral: 2 tablets every 4 hours (maximum: 12 tablets/24 hours)

DOSING: PEDIATRIC
Product labeling:

Excedrin® Extra Strength, Excedrin® Migraine: Oral: Children >12 years: Refer to adult dosing

Goody’s® Extra Strength Headache Powder: Oral: Children >12 years: Refer to adult dosing

Goody’s® Extra Strength Pain Relief Tablets: Oral: Children >12 years: Refer to adult dosing

Vanquish® Extra Strength Pain Reliever: Oral: Children >12 years: Refer to adult dosing

DOSING: ELDERLY — Refer to adult dosing.

DOSING: HEPATIC IMPAIRMENT — Use with caution. Limited, low-dose therapy usually well tolerated in hepatic disease/cirrhosis. However, cases of hepatotoxicity at daily acetaminophen dosages <4 g/day have been reported. Avoid chronic use in hepatic impairment. DOSAGE FORMS — Excipient information presented when available (limited, particularly for generics); consult specific product labeling. Caplet:
Excedrin® Extra Strength, Excedrin® Migraine: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg
Vanquish® Extra Strength Pain Reliever: Acetaminophen 194 mg, aspirin 227 mg, and caffeine 33 mg

Geltab (Excedrin® Extra Strength, Excedrin® Migraine): Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg

Powder (Goody’s® Extra Strength Headache Powder): Acetaminophen 260 mg, aspirin 520 mg, and caffeine 32.5 mg [contains lactose]

Tablet:
Anacin® Advanced Headache Formula: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg
Excedrin® Extra Strength, Excedrin® Migraine, Genaced™ , Pain-Off: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg
Fem-Prin®: Acetaminophen 194.4 mg, aspirin 226.8 mg, and caffeine 32.4 mg
Goody’s® Extra Strength Pain Relief: Acetaminophen 130 mg, aspirin 260 mg, and caffeine 16.25 mg

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DOSAGE FORMS: CONCISE
Caplet: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg; acetaminophen 194 mg, aspirin 227 mg, and caffeine 33 mg
Excedrin® Extra Strength [OTC], Excedrin® Migraine [OTC]: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg
Vanquish® Extra Strength Pain Reliever [OTC]: Acetaminophen 194 mg, aspirin 227 mg, and caffeine 33 mg

Geltab: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg
Excedrin® Extra Strength [OTC], Excedrin® Migraine [OTC]: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg

Powder: Acetaminophen 260 mg, aspirin 520 mg, and caffeine 32.5 mg
Goody’s® Extra Strength Headache Powder [OTC]: Acetaminophen 260 mg, aspirin 520 mg, and caffeine 32.5 mg

Tablet:
Anacin® Advanced Headache Formula [OTC], Excedrin® Extra Strength [OTC], Excedrin® Migraine [OTC], Genaced™ [OTC], Pain-Off [OTC]: Acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg
Fem-Prin® [OTC]: Acetaminophen 194.4 mg, aspirin 226.8 mg, and caffeine 32.4 mg
Goody’s® Extra Strength Pain Relief [OTC]: Acetaminophen 130 mg, aspirin 260 mg, and caffeine 16.25 mg

GENERIC EQUIVALENT AVAILABLE — Yes

USE — Relief of mild-to-moderate pain; mild-to-moderate pain associated with migraine headache

ADVERSE REACTIONS SIGNIFICANT — See individual agents.

CONTRAINDICATIONS — Hypersensitivity to acetaminophen, aspirin, salicylates, caffeine, or any component of the formulation; pregnancy

METABOLISM / TRANSPORT EFFECTS
Acetaminophen: Substrate (minor) of CYP1A2, 2A6, 2C9, 2D6, 2E1, 3A4; Inhibits CYP3A4 (weak)

Aspirin: Substrate (minor) of CYP2C9

Caffeine: Substrate of CYP1A2 (major), 2C9 (minor), 2D6 (minor), 2E1 (minor), 3A4 (minor); Inhibits CYP1A2 (weak), 3A4 (moderate)

DRUG INTERACTIONS
ACE Inhibitors: Salicylates may diminish the antihypertensive effect of ACE Inhibitors. They may also diminish other beneficial pharmacodynamic effects desired for the treatment of CHF. The effects are likely dose-related. 100 mg doses aspirin appear to cause no problems, whereas 300 mg doses appear to significantly affect ACE Inhibitor efficacy. Risk C: Monitor therapy

Alendronate: Aspirin may enhance the adverse/toxic effect of Alendronate. Specifically gastrointestinal adverse events. Risk C: Monitor therapy

Anticoagulants: Salicylates may enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy

Anticonvulsants (Hydantoin): May increase the metabolism of Acetaminophen. This may 1) diminish the effect of acetaminophen; and 2) increase the risk of liver damage. Risk C: Monitor therapy

Antidepressants (Tricyclic, Tertiary Amine): May enhance the antiplatelet effect of Aspirin. Risk C: Monitor therapy

Antiplatelet Agents: May enhance the adverse/toxic effect of Salicylates. Increased risk of bleeding may result. Risk C: Monitor therapy

Atomoxetine: May enhance the hypertensive effect of Sympathomimetics. Atomoxetine may enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy

Barbiturates: May increase the metabolism of Acetaminophen. This may 1) diminish the effect of acetaminophen; and 2) increase the risk of liver damage. Risk C: Monitor therapy

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Calcium Channel Blockers (Nondihydropyridine): May enhance the anticoagulant effect of Salicylates. Risk C: Monitor therapy

Cannabinoids: May enhance the tachycardic effect of Sympathomimetics. Risk C: Monitor therapy

CarBAMazepine: May increase the metabolism of Acetaminophen. This may 1) diminish the effect of acetaminophen; and 2) increase the risk of liver damage. Risk C: Monitor therapy

Carbonic Anhydrase Inhibitors: Salicylates may enhance the adverse/toxic effect of Carbonic Anhydrase Inhibitors. Salicylate toxicity might be enhanced by this same combination. Risk D: Consider therapy modification

Cholestyramine Resin: May decrease the absorption of Acetaminophen. Effect is minimal if cholestyramine is administered 1 hour after acetaminophe
n. Risk D: Consider therapy modification

Corticosteroids (Systemic): Salicylates may enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Risk C: Monitor therapy

CYP1A2 Inhibitors (Moderate): May decrease the metabolism of CYP1A2 Substrates. Risk C: Monitor therapy

CYP1A2 Inhibitors (Strong): May decrease the metabolism of CYP1A2 Substrates. Risk D: Consider therapy modification

Dasatinib: May enhance the anticoagulant effect of Antiplatelet Agents. Risk C: Monitor therapy

Drotrecogin Alfa: Salicylates may enhance the adverse/toxic effect of Drotrecogin Alfa. Bleeding may occur. Risk D: Consider therapy modification

Ginkgo Biloba: May enhance the antiplatelet effect of Salicylates. Risk D: Consider therapy modification

Heparin: Aspirin may enhance the anticoagulant effect of Heparin. Risk C: Monitor therapy

Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Salicylates. Bleeding may occur. Risk D: Consider therapy modification

Ibritumomab: Antiplatelet Agents may enhance the adverse/toxic effect of Ibritumomab. Both agents may contribute to impaired platelet function and an increased risk of bleeding. Risk C: Monitor therapy

Imatinib: May increase the serum concentration of Acetaminophen. Risk D: Consider therapy modification

Iobenguane I 123: Sympathomimetics may diminish the therapeutic effect of Iobenguane I 123. Risk X: Avoid combination

Isoniazid: May enhance the adverse/toxic effect of Acetaminophen. Risk C: Monitor therapy

Ketorolac: May enhance the adverse/toxic effect of Aspirin. Risk X: Avoid combination

Loop Diuretics: Salicylates may diminish the diuretic effect of Loop Diuretics. Loop Diuretics may increase the serum concentration of Salicylates. Risk C: Monitor therapy

Methotrexate: Salicylates may increase the serum concentration of Methotrexate. Salicylate doses used for prophylaxis of cardiovascular events are not likely to be of concern. Risk D: Consider therapy modification

Nonsteroidal Anti-Inflammatory Agents: May enhance the adverse/toxic effect of Antiplatelet Agents. An increased risk of bleeding may occur. Nonsteroidal Anti-Inflammatory Agents may diminish the cardioprotective effect of Antiplatelet Agents. This interaction is likely specific to aspirin, and not to other antiplatelet agents. Risk C: Monitor therapy

NSAID (Nonselective): May enhance the adverse/toxic effect of Salicylates. An increased risk of bleeding may be associated with use of this combination. NSAID (Nonselective) may diminish the cardioprotective effect of Salicylates. Salicylates may decrease the serum concentration of NSAID (Nonselective). Exceptions: Diclofenac. Risk D: Consider therapy modification

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Omega-3-Acid Ethyl Esters: May enhance the antiplatelet effect of Antiplatelet Agents. Risk C: Monitor therapy

Peginterferon Alfa-2b: May decrease the serum concentration of CYP2D6 Substrates. Risk C: Monitor therapy

Pentosan Polysulfate Sodium: May enhance the adverse/toxic effect of Antiplatelet Agents. Specifically, the risk of bleeding may be increased by concurrent use of these agents. Risk C: Monitor therapy

Pentoxifylline: May enhance the antiplatelet effect of Antiplatelet Agents. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the antiplatelet effect of Antiplatelet Agents. Risk C: Monitor therapy

Quinolone Antibiotics: May decrease the metabolism of Caffeine. Exceptions: Gatifloxacin; Gemifloxacin; Levofloxacin; Lomefloxacin; Moxifloxacin; Nalidixic Acid; Ofloxacin; Sparfloxacin; Trovafloxacin. Risk C: Monitor therapy

Regadenoson: Caffeine may diminish the vasodilatory effect of Regadenoson. Risk D: Consider therapy modification

Salicylates: May enhance the anticoagulant effect of other Salicylates. Risk C: Monitor therapy

Selective Serotonin Reuptake Inhibitors: May enhance the antiplatelet effect of Aspirin. Risk C: Monitor therapy

Serotonin/Norepinephrine Reuptake Inhibitors: May enhance the antiplatelet effect of Aspirin. Risk C: Monitor therapy

Sulfonylureas: Salicylates may enhance the hypoglycemic effect of Sulfonylureas. Of concern with regular, higher doses of salicylates, not sporadic, low doses. Risk C: Monitor therapy

Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Risk C: Monitor therapy

Thrombolytic Agents: Salicylates may enhance the adverse/toxic effect of Thrombolytic Agents. An increased risk of bleeding may occur. Risk C: Monitor therapy

Tiludronate: Aspirin may decrease the serum concentration of Tiludronate. Risk C: Monitor therapy

Tositumomab and Iodine I 131 Tositumomab: Antiplatelet Agents may enhance the adverse/toxic effect of Tositumomab and Iodine I 131 Tositumomab. Specifically, the risk of bleeding-related adverse events may be increased. Risk C: Monitor therapy

Treprostinil: May enhance the adverse/toxic effect of Salicylates. Bleeding may occur. Risk C: Monitor therapy

Uricosuric Agents: Salicylates may diminish the therapeutic effect of Uricosuric Agents. Specifically, uricosuria. Risk C: Monitor therapy

Valproic Acid: Salicylates may increase the serum concentration of Valproic Acid. Risk C: Monitor therapy

Varicella Virus-Containing Vaccines: Salicylates may enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. Reye’s Syndrome may develop. Risk D: Consider therapy modification

Vitamin K Antagonists (eg, warfarin): Salicylates may enhance the anticoagulant effect of Vitamin K Antagonists. Risk D: Consider therapy modification

Vitamin K Antagonists (eg, warfarin): Acetaminophen may enhance the anticoagulant effect of Vitamin K Antagonists. Most likely with daily acetaminophen doses >1.3 g for >1 week. Risk C: Monitor therapy

ETHANOL / NUTRITION / HERB INTERACTIONS — Ethanol: Excessive intake of ethanol may increase the risk of acetaminophen-induced hepatotoxicity. Avoid ethanol or limit to <3 drinks/day. PREGNANCY RISK FACTOR — D (show table) PHARMACODYNAMICS / KINETICS — See individual agents.

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