Medications: ‘Over-the-Counter’ Doesn’t Mean It’s Safe for You

Beware of multiple drugs in single products and possible interactions

When you go to the pharmacy to pick up over-the-counter medications for yourself or someone you care for, it’s important to be aware that just because these products don’t require a prescription doesn’t mean they are safe for everyone.

All medications, whether prescribed by your doctor or available over-the-counter, have the potential for unwanted side effects, interactions with other medications or food, and the possibility of harm.

As we age, our metabolism changes, consequently making us more sensitive to medications and more vulnerable to certain side effects. Of course, these changes happen on a continuum, intensifying over the years. It is crucial to ask your doctor about what is safe for you, given your medical conditions and any prescribed medications you take.

In the Pharmacy, Choices Abound

Who among us is not overwhelmed by the huge number of choices of over-the-counter medications at our local pharmacy or grocery stores? Many decades ago, if you had pain, you would pick up some aspirin. Maybe there were two brands. Now there are a mind-boggling number of choices for each drug: different brands, sizes, shapes, strengths and generic equivalents.

Many decades ago, if you had pain, you would pick up some aspirin. Maybe there were two brands.

Would you like tablets? Capsules? Caplets? Chewables? Coated? Time-release? To add to the confusion, familiar brands like Tylenol have come out with combination products that relieve pain and congestion. There are equally as many choices for allergy relief, digestion, constipation, cold and flu, and so on.

To make the confusion worse, ingredients are written in tiny print and use chemical names. It can be frustrating trying to figure out what to buy, and importantly, what is safe, particularly since certain over-the-counter products contain ingredients that some people should not be taking.

Here are some important facts to keep in mind when choosing over-the-counter medications, broken down into five categories of commonly purchased medication types, plus vitamins and other supplements:

Products for Colds and Flu Symptoms

When choosing an over-the-counter symptom reliever, be aware that these medications often contain multiple drugs within one pill. Most of these combinations will include a strong antihistamine — like Benadryl (diphenhydramine) — which could lead to dizziness, falls and confusion in some people.

These effects become more dangerous as people age. So, a 65-year-old, in general and barring other medical conditions, is less likely to be harmed than an 85-year-old. When you see “night” on the packaging, it’s a safe bet that Benadryl is an ingredient, and therefore not safe for many older adults.

Many cold and flu products contain Tylenol (acetaminophen), which some people might already be taking in a prescribed medication for arthritis or other pain.

Although a multi-symptom medication might be tempting (after all, fewer pills to swallow), it is quite possible that it contains something that is either not suitable for some people or mixes poorly with their other medications. Unless specifically recommended by their doctor, people should try to stick with one-ingredient, over-the-counter medications.

Pain Relief Medications

Tylenol is a commonly used analgesic (pain reliever). It is also effective in reducing fever. Many older adults have chronic pain due to arthritis, requiring pain medication to maintain a good quality of life and to participate more fully in their daily activities. Tylenol is, generally, very well tolerated and considered safe for older adults. However, even Tylenol at inappropriate doses can lead to serious adverse effects such as liver failure. The key is to ensure people take a dosage within the appropriate limits.

The general recommendation for older adults is to take no more than 3 grams of Tylenol/acetaminophen per day — that’s nine pills of 325 mg, or six pills of 500 mg in 24 hours. Given the different formulations, it is important to keep in mind the dose. For those who are underweight or have liver problems, even smaller doses may not be appropriate. People with liver disease should not take Tylenol without first discussing it with their doctors.

Beware, there are many over-the-counter and prescription medications that contain acetaminophen. All of these doses should be added into the daily total.

Nonsteroidal Anti-Inflammatory Medications

Another commonly used drug class for treating pain are the nonsteroidal anti-inflammatory medications (NSAIDs), including Motrin and Advil (ibuprofen), Aleve and Naprosyn (naproxen) and Voltaren (diclofenac).

While very effective in managing pain, NSAIDs can be particularly problematic for some, with the risk increasing as people age. NSAIDs are filtered by the kidneys, and in people who already have reduced kidney function due to a chronic disease or other problem, using NSAIDs can lead to kidney injury and kidney failure.

People who have a chronic kidney disease should consult with their doctors prior to taking any NSAIDs. Another important side effect of NSAIDs is stomach irritation, which can lead to ulcers and gastrointestinal bleeding. If gastrointestinal bleeding occurs, a doctor should be called immediately.

Sleep Aids, Allergy Remedies and Antihistamines

Like many cold and flu remedies, sleep aids and allergy drugs contain antihistamines, which belong to the anticholinergic class of medications. These pose risks to some older adults because they can cause drowsiness, dizziness and inhibit muscle activity. For frail people or those who are unsteady on their feet, the risk of falls and injury are a serious concern.

Many older adults have difficulty sleeping, turning to over-the-counter sleep aids. Yet, some non-prescription drugs marketed as sleep aids contain a strong antihistamine, like Benadryl. In fact, ZzzQuil is just plain old Benadryl.

Be aware that medications can be marketed as “natural” and still contain these very “unnatural” medications.

Common Gastrointestinal Medications

Antacids prevent or decrease stomach acidity, and are one of the most frequently used medications by older adults to treat heartburn (acid indigestion) and prevent stomach ulcers. There are many brands of antacids on the market, such as the popular Tums and Maalox, as well as generics; they vary in strength and the way they work.

Many people take Pepto Bismol (bismuth subsalicylate) for heartburn, stomach discomfort and diarrhea relief. However, it can cause bleeding, if taken in large quantities and in combination with aspirin or other blood thinners.

A stronger class of antacid medications are histamine (H2) receptor blockers, such as Pepsid (famotidine), which blocks acid production. While these medications are generally well tolerated, they may cause dizziness and confusion, especially when taken with other anticholinergic medications.

In 2019, there was a recall of the H2 blocker Zantac (ranitidine) due to contamination from a carcinogen. As of this writing, the Food and Drug Administration (FDA) has taken a stronger stance and called for the removal of all ranitidine from the market.

People with kidney disease should not take H2 blockers without first speaking with their health care providers, as they can worsen kidney function.

People with kidney disease should not take H2 blockers without first speaking with their health care providers, as they can worsen kidney function.

Strongest in the antacid treatment lineup are the proton pump inhibitors (PPIs), extremely effective in treating heartburn, ulcer disease and stomach irritation. However, their use has been linked to rare, yet troubling side effects, including bacterial infections.

In 2017, the FDA issued a warning based on studies that showed reduced stomach acid from PPIs is associated with clostridium difficile (also known as C. diff) diarrhea. Since stomach acid is a barrier to gut bacteria, which can spread to the lungs, there have also been links between PPIs and pneumonia.

The other important consequence of reducing stomach acid is decreased ability to absorb vitamins and nutrients, such as vitamin B12 and calcium. There is controversy around the long-term use of PPIs increasing the risk for osteoporosis.

Constipation often affects older adults and is usually self-treated with over-the-counter medications, which run the gamut from very gentle (stool softeners like Colace/docusate sodium) to stronger laxatives (Senna/sennosides). Some, like Miralax (polyethylene glycol), require large quantities of fluids to work and, therefore, are not advised for people with swallowing issues. Some constipation medications contain magnesium, such as Milk of Magnesia (magnesium hydroxide), so they must be used cautiously in people with kidney disease.

There are many other types of constipation relief products, and some are combinations of medications. All laxatives can cause nausea, bloating, cramps and diarrhea. Most individuals will need to experiment with finding the best amount to take, regardless of the recommendation on the package. This may take some trial and error, adjusting in accordance with different types of food intake and activity level. People should discuss these medications with their doctors.

Vitamins, Supplements and Alternative Medicine Products

Vitamins and dietary supplements are a multi-billion-dollar industry (over $100 billion in the U.S.). In surveys, up to 85% of older adults reported taking at least one vitamin or supplement. The vitamin and supplement industry is not regulated by the FDA so it is not subject to the same regulations as medications, such as proving effectiveness.

All large, high-quality studies have failed to show benefits from most vitamins, despite the claims manufacturers make. For example, antioxidants (vitamins A and E) are not shown to reduce cancer or improve on memory loss; B vitamins do not improve heart health; and multi-vitamins have not demonstrated benefit for heart disease, cancer and brain function.

Furthermore, new studies show potential harm in some cases: Vitamin E was associated with increased risk of prostate cancer and vitamin A was associated with increased risk of lung cancer in smokers.

Vitamin D was touted as a wonder micronutrient to prevent many diseases and is one of the most commonly used vitamins. Yet, new studies no longer support its use for cardiovascular health or preventing cancer. Vitamin D for bone health is the exception since osteoporosis is a major issue for older adults. The evidence for calcium supplements for bone health is less conclusive since some studies show it is associated with an increased risk of stroke and heart attacks.

Although many supplements are not harmful, there have been incidents that led to serious adverse events, including death, and recalls of products. The supplements receiving the most recent attention — omega-3 fatty acids, ginkgo biloba, St. John’s Wort, saw palmetto and glucosamine — have not demonstrated benefit in randomized trials.

As with any drug, supplements can have side effects and interact with other medications. Supplements can be marketed as “natural” while containing dangerous medications. For example, Ginkgo biloba interacts with the blood thinner Coumadin (warfarin), increasing bleeding risk; St. John’s Wort interacts with numerous medications and can alter drug levels in the body, causing them to be less or more effective.

It is important that people regularly review all of their medications — including prescriptions, supplements, vitamins and over-the-counter drugs — with their doctors. Pharmacists also are excellent sources of important medication information.

By Dr. Liron Sinvani
Dr. Liron Sinvani is a fellowship-trained geriatrician and hospitalist at Northwell Health and Feinstein Institutes for Medical Research in New York. She divides her time between patient care and research, and is currently funded by the National Institutes of Aging at the NIH. She has published widely in the scholarly literature and is passionate about helping older adults learn about enhancing health and wellness. Find her on twitter @LSinvani.
Sara Merwin
Sara Merwin, MPH, is a clinical researcher with training in epidemiology. Most recently, she was Director of Clinical Research in Orthopaedic Surgery at Montefiore Medical Center in New York. Her research focus includes patient and professional education and communication. She is co-author of The Informed Patient: A Complete Guide to a Hospital Stay, Cornell University Press, 2017. Find her on twitter at @Saramerwin1.

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