Table 4.

Mitigation strategies that may be useful for patients receiving paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management

Area of concern	Mitigating strategies
Labeling of paracetamol, acetaminophen, and combination products, particularly over-the-counter preparations	Plain language labeling Patient education initiatives about high-dose, long-term, and cumulative doses of paracetamol and NSAIDs “Do ask, do tell” approach
High-dose paracetamol seems necessary	Consider lower doses of paracetamol in combination with other pain medication due to risk of hepatotoxicity, hypertension, and gastrointestinal complications
High-dose NSAID seems necessary	Consider lower doses used in combination with other pain relievers on account of increased risk for gastrointestinal complications and particularly in light of risk factors (old age, ulcer history, smoking, comorbidities) Add proton pump inhibitor Limit dose
NSAID seems necessary in a patient with a cardiovascular risk	Consider the lowest possible dose of NSAIDs or avoid NSAIDs altogether. An alternative might be a low-dose fixed combination product