An update on drug interactions involving anti-inflammatory and analgesic medications in oral and maxillofacial medicine: a narrative review

Abstract

Background and Objective: The management of pain has always been an integral aspect of the provision of high-quality dental care. Fortunately, the cornerstone dental pharmaceutical analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and select opioids, have favorable drug profiles and are safe for use in healthy patients when prescribed according to dosage guidelines. Prudent clinicians must be aware of numerous crucial drug interactions associated with these common analgesics, as their severity can be influenced by the presence of various diseases. Particularly, with the increasing prevalence of polypharmacy and chronic diseases in the aging population, the risk of drug interactions is inherently higher, making it challenging to determine safe prescriptions. This article discusses the relevant drug interactions seen with the concomitant use of dental analgesics. Emphasis is placed on NSAIDs due to their common prescription and over-the-counter availability, non-addictive properties, and significant number and severity of interactions. Methods: This narrative review utilized electronic databases including MEDLINE, PubMed, PubMed Central, Cochrane Library, and ScienceDirect as sources. Various study designs such as meta-analyses, systematic reviews, clinical trials, narrative reviews, case-control, cross-sectional, and case report studies were included. All articles were in English or translated to English. Key Content and Findings: The search spanned from 1988 to 2021, with approximately 50% of the studies published between 2015 and 2021, and 25% published from 2018 to 2021. NSAIDs have been found to escalate lithium toxicity in a manner that is dependent on the dosage. It has been observed that no dosage of methotrexate appears to be clinically safe when used concurrently with NSAIDs. Acetaminophen, when combined with warfarin, causes an increase in international normalized ratio (INR) in a linear and dosage-dependent manner. Lastly, combining tramadol with serotonergic medications increases the risk of serotonin syndrome. Conclusions: When developing pain management strategies, clinicians must consider the patient’s pain level, comorbidities, current medications, and overall health. It is important to avoid prescribing NSAIDs to patients taking methotrexate, lithium, digoxin, and to those taking both a diuretic and an angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker. Alcoholics should not take acetaminophen without concurrent alcohol consumption, and certain opioids, namely meperidine, tramadol, and methadone, should not be used in combination with monoamine oxidase inhibitors or alcohol.