What is safe for pain management in a patient on Brilinta (ticagrelor), metoprolol, lisinopril, and aspirin?

Pain Management After Recent MI on Dual Antiplatelet Therapy

Start with acetaminophen 650-1000 mg every 4-6 hours (maximum 4000 mg/day) as your first-line pain medication, as this provides effective analgesia without interfering with your antiplatelet regimen or increasing cardiovascular or bleeding risks. 1

Why Acetaminophen is the Safest Choice

• You are only 2 days post-MI on Brilinta (ticagrelor) plus aspirin, which puts you in the highest-risk category for both thrombotic events and bleeding complications 1
• Acetaminophen does not interfere with platelet function, has no cardiovascular toxicity, and does not increase bleeding risk 2, 3
• The American Heart Association specifically recommends acetaminophen as first-line therapy before considering any NSAIDs in post-acute coronary syndrome patients 1

Stepped-Care Approach If Acetaminophen is Insufficient

Second-Line Options (if acetaminophen inadequate):

• Nonacetylated salicylates (like salsalate or trilisate) can be used as they have minimal antiplatelet effects 1
• Tramadol 50-100 mg every 4-6 hours is reasonable for moderate pain 1, 2
• Short-term low-dose narcotics (such as codeine or oxycodone) may be used for severe pain under close monitoring 1, 2

What You Must Avoid:

NSAIDs (ibuprofen, naproxen, diclofenac) and COX-2 inhibitors are contraindicated in your situation for multiple critical reasons:

• NSAIDs significantly increase cardiovascular event risk in recent MI patients, with one study estimating 6 excess deaths per 100 person-years of treatment 1
• Ibuprofen specifically interferes with aspirin's antiplatelet effect when taken within 8 hours of aspirin, potentially negating your cardioprotection 4
• The combination of NSAIDs with dual antiplatelet therapy dramatically increases bleeding risk 1
• The 2014 AHA/ACC guidelines classify NSAIDs with COX-2 selectivity as Class III: Harm in post-ACS patients when safer alternatives provide acceptable relief 1

Critical Timing Considerations

• You are in the highest-risk period (first 30 days post-MI) where even small increases in thrombotic or bleeding risk can be catastrophic 1
• Patients with recent MI, unstable angina, or bypass surgery have the greatest absolute risk increase from COX inhibitors 1
• Your dual antiplatelet therapy should continue for at least 12 months without interruption 1

Additional Safety Measures

• Consider adding a proton pump inhibitor (like omeprazole 20-40 mg daily) given your dual antiplatelet therapy, as this reduces gastrointestinal bleeding risk 1
• Use the lowest effective dose of any analgesic for the shortest duration possible 1
• If you require chronic pain management beyond a few weeks, reassess with your cardiologist to ensure optimal risk-benefit balance 1

Practical Dosing Strategy

• Acetaminophen 1000 mg every 6 hours scheduled (not as-needed) provides consistent pain control 2
• Keep breakthrough doses available if pain is severe 2
• Monitor for adequate pain relief within 48 hours; if insufficient, add tramadol rather than switching to NSAIDs 1, 2