Painkillers and Liver Disease/Hepatitis
Acetaminophen (Tylenol) is a medication used to control pain (known as an analgesic) and fever (known as antipyretic). It does this without producing the stomach discomfort often experienced with aspirin and other nonsteroidal anti-inflammatories (NSAIDs). This characteristic has made acetaminophen a very popular alternative to NSAIDs. In small doses (less than 4 grams per day, or eight pills taken over a twenty-four hour period of time) acetaminophen is quite safe for the liver—unless combined with alcoholic beverages (see below). (Note: each acetaminophen tablet or pill typically contains 500 milligrams of acetaminophen.) In fact, acetaminophen is the recommended medication for relieving minor aches, pains, and headaches in people with liver disease.
However, when taken in excessive quantities or when combined with alcohol, acetaminophen may cause death due to liver failure. In fact, an overdose of acetaminophen is the most common cause of fulminant hepatic failure as well as the most common cause of drug-induced liver disease in the United States. After acetaminophen became readily available in 1960 as an over-the-counter medication, it became one of the most popular means of attempting suicide. For liver injury to occur, acetaminophen must generally be consumed in quantities exceeding 15 grams within a short period of time, such as in a single dose. Although uncommon, ingestion of 7 to 10 grams at one time may cause liver damage.
The consumption of alcohol in conjunction with acetaminophen significantly increases the likelihood that a person will incur severe liver damage. Therefore, people who consume alcohol on a regular basis should probably limit acetaminophen intake to a maximum of 1 to 2 grams per day (that is, two to four pills within a twenty-four hour period). Still, the best advice for people with liver disease is to totally abstain from alcohol.
People should take special note that acetaminophen is also an active ingredient in more than 200 other medications, including Nyquil and Anacin 3. Therefore, it is essential to read the labels of all over-the-counter medications carefully. Other commonly used medications, such as omeprazole (Prilosec), phenytoin (Dilantin), and isoniazid (INH), may increase the risk of liver injury caused by acetaminophen. It is always in the liver patient’s best interest to consult with a liver specialist prior to taking any medication.
Acetylsalicylic acid (aspirin) and other NSAIDs are drugs that are widely used for their anti-inflammatory and analgesic effects. They also have the potential to cause drug-induced liver disease. In fact, many NSAIDs have been withdrawn from the market due to their hepatotoxicity. All NSAIDs have the potential to cause liver injury. However, some NSAIDs are more hepatotoxic than others. NSAIDs presently on the market that have been frequently associated with liver injury are aspirin (ASA), diclofenac (Voltaren), and sulindac (Clinoril). Ibuprofen (Motrin) has been reported to cause severe liver injury in people with hepatitis C. A new generation of NSAIDs, known as the cyclooxygenase-2 (COX-2) inhibitors, has recently been approved by the FDA. This group of NSAIDs has the advantage of having fewer gastrointestinal side effects – less abdominal discomfort and less risk of gastrointestinal bleeding, than conventional NSAIDs. There are three different COX-2 inhibitors currently available to the public– Vioxx, Celebrex and Bextra. COX-2 inhibitors have been associated with some liver dysfunction, although not as commonly as other NSAIDs. Recently, Vioxx has been removed from the market due to heart-related problems. Celebrex and Bextra are currently being investigated for similar heart-related toxicities.
It is recommended that people with liver disease avoid using all NSAIDs. If NSAIDs are medically required for the treatment of another medical disorder, a reduced dose should be used for a limited period of time and only by people with stable liver disease. Older women with liver disease seem to be particularly susceptible to the hepatotoxicity of NSAIDs and are advised to avoid NSAIDs altogether. Since NSAIDs may cause salt and water retention people with fluid retention problems such as ascites or leg swelling may suffer worsening of these conditions. People with decompensated cirrhosis are at increased risk kidney damage stemming from the use of NSAIDs. Since this may lead to hepatorenal syndrome (see Chapter 6), people with advanced liver disease are advised to totally avoid all NSAIDs. Furthermore, people with ascites (fluid accumulation) may not respond to treatment with water pills (diuretics), while on NSAIDs, as they counteract their actions. ( see chapter 20). People with liver disease who have had internal bleeding, - from an ulcer or esophageal varices, for example, may be at risk for recurrent bleeding induced by NSAIDs, and should totally avoid this class of medications. People who are also taking corticosteroids (such as prednisone), or anticoagulants (such as coumadin) may have and increased risk of complications from NSAIDs. Finally, people with liver disease who smoke cigarettes or drink alcohol should avoid NSAIDs as they are also at increased risk for its complications.
All contents of this article are Copyright © Melissa Palmer, MD
Melissa Palmer, MD is the author of " Dr. Melissa Palmer's Guide of Hepatitis and Liver Disease". (Published 2004. Penguin Putnam).
Dr. Palmer is an internationally renowned hepatologist who has been practicing medicine since 1985. Prior to 2012, she maintained perhaps the largest medical practice devoted to liver disease in the United States. Dr. Palmer is Clinical Professor of Medicine at New York University Medical Center. Dr. Palmer graduated from Columbia University with a B.A. and was trained in hepatology (as well as medical school) at the Mount Sinai School of Medicine in New York City.
Dr. Palmer is Board Certified in Gastroenterology and in Internal Medicine.
She has authored numerous scientific publications in the field of hepatology in such peer-reviewed journals as Hepatology, Gastroenterology, Seminars of Liver Disease, Transplantation and Archives of Internal Medicine.
She is frequently called upon by the media for her opinion on various topics related to liver disease. Dr. Palmer has appeared many times on television as a liver disease expert and has been quoted in such publications as TIME magazine, Cosmopolitan magazine, Prevention magazine, the Los Angeles Times, and Newsday. She also has appeared in numerous videos and CD-Roms aimed at educating doctors and the public about hepatitis C and other liver diseases, such as primary biliary cirrhosis. Dr. Palmer lectures to the medical and general public on liver disease-related topics on a regular basis.
Dr. Palmer has performed numerous clinical trials on various experimental medications for the treatment of hepatitis.
Dr. Palmer is currently available for lecturing, investor and hedge-fund consultations, consultations to industry, and media interviews and appearances-- including television. For such matters, she can be contacted through hepatitismedia@gmail.com.
Return to liverdisease.com home page