# Dangers of acetaminophen (aka Tylenol or paracetamol)



## Andy H.

As we all get a little older and those aches and pains nag a little more, we have to bear in mind that those OTC pain and inflammation remedies can be bad for us.

I've long tried to stay away from Tylenol because I've heard about the liver damage it can cause. Now there's even more evidence that just a little more than the max dosage can be *really* bad for you. Here's an article from Discover Magazine on just how bad it is for you.

The stuff's in everything ranging from cold meds to prescription pain killers. Alcohol greatly exacerbates the liver toxicity.

After some recent dental work I discovered acetaminophen was in all the standard the prescription pain meds they wanted to prescribe for me and I realized how easy it would have been for someone unaware of the danger to take a little OTC Tylenol as well. Any time a doctor is writing a prescription, you may be able to get an alternative without the acetaminophen (aka Tylenol or paracetamol) by asking for it up front.

Treat your liver right and avoid the Tylenol.

-AH


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## Bilge Rat

When one of my kids was little they managed to get the cap off of a bottle of children's OTC pain reliever, and drank almost the whole bottle. We called the pediatrician who lived just up the street from us and he made me get the bottle and read it over the phone to him because he was VERY concerned about it. When I read him the bottle and it turned out to be Ibuprofin he sighed relief and told us our kid would be fine other that probably an upset stomach. He then made a comment that really stuck with me. He said, "Good thing that wasn't Tylenol, that could have killed him". I've been a little leery of Tylenol ever since


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## danger

asking for hydrocodone or oxycodone (the narcotic found in Vicodin and Percocet respectively) for pain relief is a red flag for drug seekers in the er. better to say you're allergic to Tylenol.


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## asleep.at.the.oars

Actually, having listed allergies to non-narcotic pain meds is a huge red flag too. As is a prescription history of oxycodone / hydrocodone alone - narcotic prescriptions are tracked so prescribers can look up your history before giving a script. 

You can take up to 4000mg of acetaminophen per 24 hours (2000mg when combined with alcohol), and up to 3200mg of ibuprofen. Those numbers decrease with some chronic conditions - ask your doctor. 

A good pain management strategy combines non-pharmacologic (i.e. ice & stretching), non-narcotic (i.e. Tylenol), anti-inflammatory (i.e. Advil), and psychologic (mentally prepared for a tolerable level, not no pain) approaches. Skipping any of those makes the narcotics less effective. Telling people to completely avoid Tylenol is doing them a disservice. 

It's sort of like alcohol. One drink a day makes you more healthy, but lots will kill you. That article was talking about people taking 24,000mg of acetaminophen over several days. If you're 6 days into max doses of OTC pain meds without seeking evaluation, you probably have other problems brewing as well. Being well aware of what is in all the OTC meds you are mixing, however, is very sound advice.

My $0.02


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## stubby

Watch out for Ibuprofen in excessive amounts as well. It's metabolized by the kidneys and has been known to contribute to renal failure (most often in combination with other stuff-ie dehydration, kidney stones, hypertension). 

Beer's a pretty good painkiller for achy joints at the end of the day.


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## JCKeck1

Interesting topic here on the buzz. If you're really concerned you can try to get percocet which comes as 5mg oxycodone/325 mg Tylenol (APAP). Your dose of APAP is significantly lower if you're taking them every 6 hours when compared to vicoden/loratab which generally comes as 5mg hydrocodone/500mg APAP. Taking two vicodens every 6 hours puts you right at the 4000mg recommended limit daily. 

There has been some new research suggesting that even the 4000mg APAP dose can be hepatotoxic. This is a pretty good article I found:Overdoing acetaminophen

Of curious note, in Europe, APAP overdose is one of the most common ways to commit suicide. Seems crazy to me because it will definitely kill you, but over a couple of days or weeks. Somewhere in there, after the decision is done, you've got to regret it, right? Weird.

I tend to disagree with my comrads about asking specifically for hydrocondone or oxycodone. If you have a severe injury and the prescriber was planning to write for vicoden or percocet, they'll likely have no problems writing for just the hydro or oxy. You're probably not going to get either if they were just planning on giving you APAP anyway. Just explain your thought process. It's not really that hard to tell seekers from concerned educated patients if you take a minute to tell your provider. Realize, however, the reason the narcotic is packaged with the APAP is because the different medications relieve pain by affecting different receptors in the body. The two meds act synergistically and provide much better relief than either medication alone.

Also, I think that saying you're allergic to any pain medication is the biggest red flag that there is in medicine. It's definitely likely to be questioned seriously.

My 0.02 is that APAP is pretty much the safest analgesic we prescribe assuming you don't have liver problems and it's taken exactly as prescribed without alcohol or added OTC doses. Unless necessary for severe pain, I try to stay way below the 4000mg dose on a daily aches/pains/bruises basis. 
Joe


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## asleep.at.the.oars

JCKeck1 said:


> Interesting topic here on the buzz. If you're really concerned you can try to get percocet which comes as 5mg oxycodone/325 mg Tylenol (APAP). Your dose of APAP is significantly lower if you're taking them every 6 hours when compared to vicoden/loratab which generally comes as 5mg hydrocodone/500mg APAP. Taking two vicodens every 6 hours puts you right at the 4000mg recommended limit daily.
> 
> There has been some new research suggesting that even the 4000mg APAP dose can be hepatotoxic. This is a pretty good article I found:Overdoing acetaminophen
> 
> Of curious note, in Europe, APAP overdose is one of the most common ways to commit suicide. Seems crazy to me because it will definitely kill you, but over a couple of days or weeks. Somewhere in there, after the decision is done, you've got to regret it, right? Weird.
> 
> I tend to disagree with my comrads about asking specifically for hydrocondone or oxycodone. If you have a severe injury and the prescriber was planning to write for vicoden or percocet, they'll likely have no problems writing for just the hydro or oxy. You're probably not going to get either if they were just planning on giving you APAP anyway. Just explain your thought process. It's not really that hard to tell seekers from concerned educated patients if you take a minute to tell your provider. Realize, however, the reason the narcotic is packaged with the APAP is because the different medications relieve pain by affecting different receptors in the body. The two meds act synergistically and provide much better relief than either medication alone.
> 
> Also, I think that saying you're allergic to any pain medication is the biggest red flag that there is in medicine. It's definitely likely to be questioned seriously.
> 
> My 0.02 is that APAP is pretty much the safest analgesic we prescribe assuming you don't have liver problems and it's taken exactly as prescribed without alcohol or added OTC doses. Unless necessary for severe pain, I try to stay way below the 4000mg dose on a daily aches/pains/bruises basis.
> Joe


Like. Oh, wait, not Facebook...


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## Junk Show Tours

So what is the best pain medicine for you if you like to drink a lot, besides, of course, alcohol?


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## GAtoCSU

danger said:


> asking for hydrocodone or oxycodone (the narcotic found in Vicodin and Percocet respectively) for pain relief is a red flag for drug seekers in the er. better to say you're allergic to Tylenol.


drug seekers are allergic to the above drugs, and request the "one that starts with a d...what is is.. dilaudid?"


4grams of acetaminophen is the max daily dose. It is a very valuable drug that does wonder in combination with the opiate family. We even give iv tylenol these days in the hospital.


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## JCKeck1

mmmm.... the other NSAIDs are better. Ibuprofen is my personal choice, but it's pretty hard on the gut. If you drink enough to have ulcers, it's a bad choice as well. Narcotics don't mix with alcohol because acutely you significantly increase the likelihood that you will stop breathing and die. As my dermatologist once told me, if you decrease your drinking, you can decrease a lot of health problems.... including skin issues. He got paid a lot, seemed real smart. Go figure. Medicine for kayaking and skiing is always funny because we're always asking questions like, "What's worse, the fire or the frying pan?"
Joe


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## wyosam

The 4g a day limit has been lowered to 3 FYI. Not sure if all facilities are recognizing it yet, but the that is the latest recommendation. I dont understand why the non-APAP combos aren't used more (ie vicuprofin).


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## JCKeck1

JCKeck1 said:


> Realize, however, the reason the narcotic is packaged with the APAP is because the different medications relieve pain by affecting different receptors in the body. The two meds act synergistically and provide much better relief than either medication alone.


Right...


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## GAtoCSU

I'm a naproxen guy myself.


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## cataraftgirl

wyosam said:


> The 4g a day limit has been lowered to 3 FYI. Not sure if all facilities are recognizing it yet, but the that is the latest recommendation. I dont understand why the non-APAP combos aren't used more (ie vicuprofin).


Somebody better tell the makers of Tylenol about this because they sell Arthritis Formula Tylenol with a recommended dose of 1300mg every 8 hours. That's 3000mg in 24 hours. Their label warns not to exceed this dosage, but it sounds like this dose is already excessive.
KJ


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## cataraftgirl

Oops - that was supposed to say 3900mg in 24 hours.


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## asleep.at.the.oars

I'm pretty sure the FDA still says 4g, what was lowered was how much can be combined with a narcotic. (FDA limits acetaminophen in prescription combination products; requires liver toxicity warnings)

If you drink enough to beat up your liver with Tylenol, you probably drink enough to get ulcers, bleeding issues or kidney failure with NSAIDs, to get a head bleed with aspirin, and to stop breathing with narcotics. Which is why if we lived in a sane society, MJ would be de-medicalized and alcohol would get way more restricted - but that's a totally different conversation. Basically, if you're drinking away the pain, it's time to stop drinking. And I'll admit it can kind of suck to practice what I preach on that.

I would give hydrocodone alone before using Vicoprofen. There's not enough ibuprofen to make a difference if you have working kidneys, and way too much if your kidneys are on the edge.


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## Kendi

Wait- so I'm not supposed to be washing down my Motrin with beer? Damn....


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## basil

I hate it when the drug labels says "do not take with alcohol", but they don't say what the problems will be or how much alcohol. I'll ty it once, nothing bad, so I do it again. 

OK, doing acetaminophen (Tylenol) with alcohol is bad. How much Alcohol? What if I drink 2 beers over 3 hours in the evening? What if I do 5 beers on a river trip? 

How bad is alcohol with NSAIDs like Naproxen (Aleve), Ibuprofen, or Meloxicam? If I do 880 mg of Naproxen, how much alcohol can I drink? I guess the more accurate question is, how much naproxen can I take if I drink 2 beers an evening?


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## asleep.at.the.oars

Two beers an evening - in a normally sized, normally hydrated male - shouldn't impact your NSAID use unless you develop gastric ulcers. 
Likewise for APAP as long as you're not pushing the daily dosing limits. 
The problem comes in with regularly elevated consumption of either or both. So chasing your 6-pack with 3000mg of Tylenol day after day is likely going to end up in liver failure some years down the line, even though neither one on their own might have. Putting down a case a day, or 1-2 fifths, is just counting down the time until you turn yellow. 

You're kind of getting to the biggest problem with medicine. People are all different, and the situations vary, but our system and expectations are set up for definitive answers. Basically, for any concrete question the most honest answer is "it depends." Sorry.

As for personal anecdote: I drink way less since I've gone into medicine than I did before, but still use OTC pain meds in limited amounts.


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## Phil U.

Good thread. Can we talk vitamin I? I self medicate with ibuprofin very frequently. I should have a knee replacement but that's not gonna happen in this medical system. So its not unusual for me to take 2400 or more mgs in a day to deal with swelling and pain. I go without as much as I can. I also drink a couple beers a night... Feedback?


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## basil

Ibuprofen is similar to Naproxen and Meloxicam. All NSAIDs. The way I read it, the problem with drinking and doing NSAIDs is you increase stomach problems (acid), which can be easily treated with Prilosec (Proton Pump Inhibitor). 

Why bother with Ibuprofen? It lasts only 4 hours. Your pain doesn't wear off after 4 hours? Naproxen (Aleve) lasts 12 hours. Meloxicam lasts 24 hours, but it is prescription, off patent so cheap. If your knee is that bad, get a Meloxicam prescription.


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## Phil U.

Aleve bothers my stomach more noticeably that ibu. I'm often taking ibu cuz I'm about to do heavy work for the day and it will get me to the end of the day with less issues in the knee. I don't need it 24/7.


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## lhowemt

I agree this is a good thread. I didn't know this, and take largish quantities of tylenol once a month since I am allergic to NSAIDS. I've avoided narcotics and just upped the dose of tylenol (yes everyone warns to be careful...) for a day or so. This is a good reminder to be really careful with meds, and sometimes good old fashioned codeine type stuff is where it's at.


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## wasatchbill

When you said "good old fashioned", I thought you were going to say something really good and old-fashioned . Like castor oil! That stuff is good for sore muscles and joints. Rub it in, leave it on (make a "castor oil pack", or, I've just been sacrificing old shirts or socks to cover the oil, and sleep on it). 
http://www.gabrielcousens.com/LinkC...5lG42UmnaQ=&tabid=172&mid=6704&language=es-MX

Homeopathic arnica gel is another great rub for sore muscles and bruising. I saw it used in the spa at a ski lodge in Alta; for an extra $10 the massage therapists will use arnica gel; or you can buy a whole tube for less than $10. You can also take homeopathic arnica pills concurrently, for overtraining, sprains, bruising, sore muscles. I have not heard of any side effects. 
Really good hydration is also helpful. I like the filtered reverse osmosis water from the health food store machines. Drinking a liter in the morning, and a liter after a big workout, feels great. 

There are lots of holistic, non-drug things that help. Turmeric and ginger can help reduce inflammation. Here is an article on curcumin (turmeric) research. 
Curcumin May Reduce Tendinitis-Related Inflammation


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## GAtoCSU

asleep.at.the.oars said:


> Two beers an evening - in a normally sized, normally hydrated male - shouldn't impact your NSAID use unless you develop gastric ulcers.
> Likewise for APAP as long as you're not pushing the daily dosing limits.
> The problem comes in with regularly elevated consumption of either or both. So chasing your 6-pack with 3000mg of Tylenol day after day is likely going to end up in liver failure some years down the line, even though neither one on their own might have. Putting down a case a day, or 1-2 fifths, is just counting down the time until you turn yellow.
> 
> You're kind of getting to the biggest problem with medicine. People are all different, and the situations vary, but our system and expectations are set up for definitive answers. Basically, for any concrete question the most honest answer is "it depends." Sorry.
> 
> As for personal anecdote: I drink way less since I've gone into medicine than I did before, but still use OTC pain meds in limited amounts.


What year are you?


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## asleep.at.the.oars

PGY-3


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## GAtoCSU

asleep.at.the.oars said:


> PGY-3


In what? I may be interviewing in CO next fall!


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## asleep.at.the.oars

Family medicine - at St. Anthony's. If all goes well, I'll have a lot more free time to start playing again next year. Make sure you rotate out here if you want to match here.
Shoot me an email if you have questions about different programs. I looked hard at EM before deciding FM, went to CU for school, and worked a bit in the area before that, so know just enough to be dangerous.


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## powdahound76

How did I miss this thread for so long? I am such an opinionated bastard, this is the perfect place to spew my BS.

Taking APAP for a couple of days or even a week when you hurt or are sick isnt going to hurt you in the long term. There are so many things that are so much more dangerous that we put into our bodies very regularly.
As for drinking with meds that say dont, it is a bad idea. There is a reason they tell you not to. Maybe it is CYA lawyer stuff, maybe it is actual research that led them to tell you that, unfortunately they dont put that on the label. Maybe not so big with APAP or ibuprofen if you have an iron stomach. As for narcs and booze, it is impossible to tell what may happen if you try a Brett Favre cocktail that didnt bother someone else (or the last 50 people that tried it). 

The only time I use APAP personally is to fight fever. The rest of the time I hit my kidneys and use Ibuprofen. It works better for inflammation which is what causes most of our aches and pains.

As for weeding out drug seekers, it is like picking out the totaled car on a new car lot. 

Mostly, like everything else, following directions and using this stuff in moderation is the key.


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## bigben

OK I gotta chime in on this one...
I've personally known 2 people, and my brother knew 1 more, who have died because their liver shut down from drinking heavily while on prescription painkillers containing acetaminophen. Essentially they die from alcohol poisoning because their liver can't take any more and shuts down.
In general I stay away from acetaminophen anyway. When I broke my leg a few years back I was given percocet, but I made sure to get a variety without acetomanaphin as it's buffer. So I know for a fact that such a pill does exist, and now those are what I keep in my medical kit. 
So if you ever have to get prescription painkillers you should request the same thing, even if you're not planning on drinking while on them. And never drink while taking tylenol.
It seems like a lot of people don't know about this, so I'm glad to see this topic on the buzz, where probably most everyone is a heavy drinker!!


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## GAtoCSU

You can get oxycodone as an independent drug. You can get immediate and extended release as well. I have a patient right now getting 10mg oxycodone 4x/day.

With that said, another problem with opiates + alcohol or Benzo's + alcohol is respiratory depression. It's possible to shut down the entire system if you drink enough on those meds. 

There's a reason for a lot of the precautions that you see. Never exceed 4000mg Tylenol in a single day and avoid drinking any alcohol if you are using medication of any type, especially ones that are metabolized by the liver.


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## ezwater

I'm not sure why acetaminophen is teamed with opioid type painkillers. I disagree that there is any proof of a "synergy" in pain relief, though the effect may be additive.

Personally, I find acetaminophen to be a weak, mediocre pain medication. And looking through the literature, I have not been able to find evidence that it matches any particular NSAID in dealing with pain. 

HOWEVER, while I used to take Aleve routinely, I've encountered twenty plus years of literature showing that NSAIDs can actually delay healing, and therefore should be used very sparingly if at all by paddlers with aches and pains. Here's a lead in to the maze. 

Chicago Sports Medicine - NSAIDs Hamper Ligament & Tendon Healing

"NSAIDs have been shown to delay and hamper the healing in all the soft tissues, including muscles, ligaments, tendons, and cartilage. Anti-Inflammatory medications can even significantly delay healing in muscle injuries with their tremendous blood supply. In one study on muscle strains, Piroxicam essentially wiped out the entire inflammatory proliferative phase of healing (days 0-4 post-injury). At day two, there were essentially no macrophages (cells that clean up the area) in the area. By the fourth day after the muscle strain there was very little muscle regeneration compared to the normal healing. The muscle strength at this time was only about 40 percent of normal."

I have also seen a study where young men with comparable shoulder injuries (rotator cuff)were put in matched groups. One group took an NSAID, the other got a placebo, and rehab routine was matched. Then the state of tissue healing was evaluated both with scans and "clinically." Those who had taken NSAIDs were significantly behind in healing. 

One reason for this is that inflammation is an inherent part of the tissue healing process. NSAIDs interfere directly and specifically with the inflammation/healing mechanism. Reducing inflammation is NOT necessarily a good thing. 

I don't know why this has not hit the NSAID warning labels up to now, or why many doctors and paddlers seem fuzzy on the issue. 

Use NSAIDs for paddling pain only temporarily, with the goal of reducing pain that is directly keeping you from doing your everyday activities. Don't preload on NSAIDs. Don't take them routinely for paddling injury. (Some forms of arthritis are another matter.) 

Sorry to spoil your day.


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## Andy H.

ezwater said:


> I don't know why this has not hit the NSAID warning labels up to now, or why many doctors ... seem fuzzy on the issue.


ezwater, 

Thanks for the info. Seems to get worse the more we learn about it all.

And we'll all ponder how something that may decrease sales wouldn't appear on a medication label or be made widely known to doctors...

In the meantime, here's another article saying the stuff's not good for your respiratory system: Studies Suggest an Acetaminophen-Asthma Link


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