At least you feel better when you die…

OK, it looks like I’m a bit “late” on this story. (It’s been out for about 5 months now) But on the off chance others here have also missed it:

Common painkillers can kill you.

Mostly via increased heart attack and stroke risks. A large percentage increase, but not many individual actual cases as the base rate is generally quite low.

I saw the story on Fox News where their house doctor that they trot out for medical stories was basically slamming all NSAIDS. (Non-Steroidal Anti Inflammatory Drug) The group includes almost all the common OTC pain killers from Aspirin to Advil, Aleve, and even Vioxx and others. When you dig into the story, the problem is more limited than that. For one thing, it looks like Tylenol (acetaminophen) is not included in the NSAIDS problem (it looks like it’s only a pain relief agent – which would explain why it doesn’t ever do much for me… but has ‘other issues’ covered below.)

Not in the list, as near as I can tell, of study drugs was Aspirin, and low does aspirin is shown to be better for heart attack and stroke risks.

OK, the most readable article I ran into was from AARP American Association of Retired Persons (that mostly seems to be a political advocacy group from what I’ve seen).

In this article, they list the drugs that showed concerns:

http://www.aarp.org/health/drugs-supplements/info-07-2010/common_painkillers_increase_heart_risks_in_healthy_people_.html

The painkillers are widely used to ease the discomfort of everything from arthritis to headaches and muscle strains. Five such drugs were included in the study:

ibuprofen (Advil, Motrin),
diclofenac (Cataflam, Voltaren),
naproxen (Aleve, Anaprox),
celecoxib (Celebrex) and
rofecoxib (Vioxx), which was taken off the market in 2004 because of heart risks.

Interesting that Vioxx has less increase in risk than some of those that were NOT hounded out of the market with lawsuits.

ibuprofen: A 29 percent greater risk of fatal or nonfatal stroke.
diclofenac: Almost double the risk of death from heart disease.
celecoxib: Results were inconclusive.
naproxen: No greater likelihood of heart-related problems and a slightly lower risk of death, leading the researchers to conclude that naproxen could be a safer alternative to other such painkillers.

If you routinely take one of these painkillers, bring up the question of whether you need to continue and, if so, at what dose.

The study appeared in the June 8 online edition of the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes.

OK, I do well with Aleve for the odd inflammatory pain, but a family member gets a blood pressure bump from it. (Though Vioxx worked for them… perhaps it will be making a come back?)

Asprin also works well for me, but again many folks stomach erosion issues.

Tylenol is not on the list at all, but does nothing much for me.

(I also don’t like the way the package insert implies you need to be an alcoholic for it to blow out your liver, yet even just a glass or two is enough to cause problems in some sensitive folks and acetaminophen poisoning now accounts for a significant fraction of liver transplants…) So I generally avoid it on principle.

From:

http://emedicine.medscape.com/article/1008683-overview

Therapeutic doses of acetaminophen do not cause hepatic injury; however because hepatic glutathione stores are depleted (by 70-80%) in an acetaminophen overdose, NAPQI cannot be detoxified and covalently binds to the lipid bilayer of hepatocytes, causing hepatic centrilobular necrosis. Necrosis primarily occurs in this hepatic region due to the greater production of NAPQI by these cells. Glutathione stores to enable metabolism of this toxic metabolite are replaced by sulfhydryl compounds from the diet (eg, fruits and vegetables) or from drugs, such as the antidote, NAC.

So simply having a lousy diet low in fruits and vegetables can set you up a bit, especially if you take it for chronic needs. Other things can drive down the glutathione levels too, adding to the ‘set up’.

Age, diet, liver disease, and medical conditions (eg, malnutrition due to prolonged fasting, gastroenteritis, chronic alcoholism, or HIV disease) affect glutathione stores in the body. Ethanol and drugs such as isoniazid (INH), rifampin, phenytoin, phenobarbital, barbiturates, carbamazepine, trimethoprim-sulfamethoxazole, and zidovudine induce CYP2E1 enzymes (part of the CYP450 system). Activation of the cytochrome system increases the production of NAPQI and, therefore, can increase the risk of hepatocellular injury in patients who ingest these agents. Herbal supplements may also play a role in amplifying the risk for acetaminophen-induced hepatic injury.

That’s quite a list…

Frequency

United States

Acetaminophen is the drug most commonly ingested in overdoses. It is also a common co-ingestant. Because of acetaminophen’s widespread availability and the underestimation of its potential toxicity, acetaminophen poisoning is the most common cause of acute liver failure and overdose deaths.

International

In Great Britain, acetaminophen toxicity is cited as the most common etiology of hepatic failure requiring liver transplantation.

Other than that, no problem…

In Conclusion

So I’m going to stick to Aspirin and Aleve for the odd aches and pains.

With the occasional cup of whiskey for some particular types of aches and pains ;-)

And generally avoid the others, while strongly avoiding acetaminophen (especially when near the whiskey…)

No, that’s not paranoia. At a hockey game I’d had 2 or 3 beers, but developed a headache. (I rarely get a headache, and only get a hangover from far more than that, but had been pushing it for a few weeks and was rather run down and dehydrated). On asking at the aid station for aspirin, and specifically saying No Tylenol or Acetaminophen due to beers; I was given 2 “aspirin” that inspection showed were in fact Tylenol… It’s up to you to defend against the notion that acetaminophen is safe. I’ve seen folks eat it like candy for hangovers. A crazy action, as some residual alcohol is often still in the system.

At any rate, the Ibuprofen et.al. is going onto the ‘only with special needs’ list for me.

What a mess.

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About E.M.Smith

A technical managerial sort interested in things from Stonehenge to computer science. My present "hot buttons' are the mythology of Climate Change and ancient metrology; but things change...
This entry was posted in Human Interest, Science Bits and tagged , , , , . Bookmark the permalink.

22 Responses to At least you feel better when you die…

  1. Adrian Camp says:

    This reminded me of a discussion I saw a while back, about Vioxx. Here’s a link, the item is some way down the page

    http://www.numberwatch.co.uk/2005%20August.htm

    If you haven’t seen numberwatch before, I think you’ll find the guy who writes it is a man after your own heart. If you start reading on the site, you’ll lose a couple of hours, just like that. And never read a medical scare story again without thinking of what you learn there.

  2. Pascvaks says:

    Don’t think this “home remedy” is a problem to anyone who takes aspirin, and it may be more ‘psycosomatic’ than chemistry, but a great booster (for me) to 2 regular aspirin and a glass of water is something my dear sainted mother (God rest her) recommended many years ago – add a 500mg tab of Vit C w/RoseHips (or 2) to kick start the aspirin. It works too (for me).

    PS- Mom always said you had to take the ‘C with Rose Hips’ or it wasn’t as good or as fast acting.

  3. Larry Geiger says:

    Advil is like a magic pill. Take two right before I go to bed at night (when I’ve compeletly over done it, of course) and wake up like a new person. I do this probably 2 to 4 times a year. I used to wake up after overdoing it and be barely able to stand up due to back pain. No more. Especially helpful on backpacking trips.

  4. Tom Bakewell says:

    And here I thought it was just me that doesn’t get any relief from Tylenol at all.

  5. E.M.Smith says:

    @Adrian Camp: Thanks for reminding me…. It has been a while. I ran into number watch some many years ago and loved it, but then other things came along (like work) and life moved on. It ought to have occurred to me that they would be in arms about the horrid math of the “Global Warming Science”… (But my interest in AGW and involvement in the whole ‘blogging’ thing came years after “getting back to work” and forgetting about Numberwatch.

    Yes, I love the clear mind presented there. There I find things I understand, sometimes in a fuzzy way, that they present in a wonderful bit of clarity… and wit.

    I liked the “Rule Zero” of the EU (and also the article that followed it):

    http://www.numberwatch.co.uk/2005%20May.htm#rule zero

    Which brings us to the little known rule zero of the EU:

    Rule Zero: All rules apply equally to all members of the union, except France and Germany.

    I’ll snip some from the article that follows, but just wonderfully done. I’ve also bolded a bit. It’s about AGW:

    21/05/05

    The greatest conspiracy in human history

    If anything is more shocking than that secret letter from the Royal Society to the media it is the lack of reaction to it. If the equivalent had happened in any other field of human activity, such as the Chief Rabbi advocating anti-Semitism, there would have been uproar.

    There are by tradition two theories of history, the conspiracy and the cock-up. Conspiracy theories are a dime a dozen. Any notable statesman or film star meeting an untimely death will spawn dozens of books, all with different but incompatible conspiracy theories.
    […]

    It is therefore not only a dangerous step to nominate something as the greatest conspiracy ever, but it invites accusations of pretentiousness or worse. Just look, however, at the ingredients.

    Some of those involved are organisations of size and power never before seen in human affairs – The Murdoch Empire, the BBC, political parties (particularly the Greens, but also those overtly or covertly affiliated to them), demonstrably corrupt international bodies, such as the United Nations and the EU etc. In addition there are huge industries raking off obscene profits, such as the wind turbine manufacturer who is a major donor to the party of Government that diverted substantial tax revenues into his pocket (not unique, as a minister for the other lot , Gummer, launched the whole thing and then set up a couple of companies to exploit it). Above all there is that large proportion of the populace that is seduced by the idealistic preachments of the eco-theologues. They acquiesce to the destruction of the environment (and people) in the name of the environment, simply because they never hear the alternative argument. They are cold-bloodedly manipulated by a new priesthood, to whom science and its methods are at best an irrelevance.
    […]

    It is not that the proponents are simply mistaken – that would be forgivable. They know that they are lying: otherwise there would be no need for all the manufactured and selective evidence, the appeal to a claimed consensus (the like of which has never had a place within the scientific method), the gross attempts to censor any contrary argument, the abandonment of the essential scepticism of science, the vilification of doubters, the direction of huge quantities of taxpayers money into acquiescent “research” groups, the barrage of angled news-stories, the drama documentaries, irrelevant interpolations into editorial commentaries and on and on.

    The evidence for the global warming disaster theory does not stand up to the most cursory examination, like the global cooling disaster theory that preceded it. Yet, a majority of simple souls accept that it is true, because it has been drummed into their brains by incessant repetition.

    Now the appeal is based on the “scientific consensus”. From Galileo, through Darwin to Einstein, there is a clear law of scientific consensus;

    The law of scientific consensus:

    At times of scientific contention the consensus is always wrong.

    Alas, poor science.

    Yes, a few hours well spent… 8-)

  6. Dennis says:

    Perhaps not exactly on topic —more an interesting tidbit, I guess:

    Several years ago in an herbicide applicator’s workshop I attended, a researcher was explaining toxicity testing and the idea of the lethal dose that would kill 50% of the test population, the LD-50. He said that if aspirin were to be tested for release to the general public for the first time today, it’s LD-50 would exceed safe levels and would be denied. If I remember correctly it was worse than 2,4-D.

  7. E.M.Smith says:

    @Tom Bakewell: Don’t know why it is, but I am as well served eating bits of chalk as taking Tylenol. I get more relief from Chocolate (that does impact brain chemistry). Folks do have metabolic differences, so I’m willing to postulate that it does something for someone, but for me it’s a placebo, at best. (Or worst, since now even the placebo is blown for me…)

    @Pascvaks: Vit C is only a vitamin for the few species that can not make it (Chimps, us, and Hamsters?… he googles… Yes, a lot of references to using hamsters in Vit C research. This one was interesting: http://cancerres.aacrjournals.org/content/43/10/4638.short where it inhibits a kind of renal cancer and this one http://www.thefreelibrary.com/Vitamin+C+helps+cigarette-smoking+hamsters-a015717692 where I must ask “Smoking hamsters? Who knew?…” ) for most other animals it is more of a hormone. Made as needed.

    During illness, we need more C. Sometimes MUCH more. (I’m good for about 5 grams a day when ill…). I’d not be at all surprised that it helps a pain killer or anti-inflamatory (it is strongly involved in free radical scavenging and the immune response).

    Per Rose Hips: They have a bunch of other stuff in them that are helpful (bioflavinoids, I think) but for anything I’ve needed, the ascorbic acid alone has been enough. But on a subtle enhancement effect, I could see it. Would stand testing though…

    @Larry Geiger:

    My travel kit includes small bottles of aspirin, Aleve, and Advil. Taken in that order as severity of need increases.

    Most of the time a couple of aspirin is all I need. Couple of times a year the arthritic discomfort asks for Aleve. Then there are those times as you pointed out for Advil… (some marathon “double digging” sessions come to mind. 4 foot x 4 foot squares of heavy loam / clay mix turning to clay / stones 2+ feet down… do more than 2 or 3 of those in a day and you will regret it…)

    FWIW, the arthritic bouts basically ended when I stopped eating beef products and avoid ice cream. I have some kind of (mild?) beef allergy / response. I can have a single steak or burger per week, but not more.

    Not too surprising: I can often get similar relief from a few ounces of whiskey. Unfortunately, that does not last more than an hour or two, then it demands re-application, which I enjoy ;-) but which means it’s hard to sleep 8 hours while doing it…. So my preferred mode is “2 aspirin and check in the morning”, unless they don’t cut it…

  8. E.M.Smith says:

    @Dennis: “The poison is in the dose”.

    Salt can kill. Water can kill. (Hyper and hypo natremia)

    Some of the things we do with calling something or other “toxic” are just absurd. Everything is toxic.

    (Even air. At a few hundred feet down scuba diving, you die on plain air. Overdose of nitrogen…)

    The real test ought to be more of a ‘fitness for purpose’ than an LD-50. (though I understand the benefit of that measure too).

    FWIW, some time ago I had a very old “cap” on a tooth. Made with Uranium enamel. It lasted somewhere about 30+ years (maybe 35?). Since replaced. When installed, my dentist (who was a cool guy and liked to talk tech with a smart kid) informed me it was mildly radioactive, but not enough to worry about. I’ve sometimes wished I’d measured it… I would occasionally imagine a ‘radio photograph’ of me with a very glowing front tooth… At the time, depleted uranium was not common, so this was basically made with natural uranium of whatever activity.

    Most durable dental work I’ve ever had. Only replaced as my gums had moved back a bit from the edge.

    So water, salt and air can kill, or radioactive uranium can help make your smile brighter ;-)

  9. Joe says:

    It is not well know that Vicodin contains not only the narcotic hydrocodone, but also 500mg of acetaminophen. Since someone addicted to Vicodin will take ever increasing amounts of the drug to stay high, they end up damaging their liver and/or kidneys with the acetaminophen. It would not surprise me if told that this is the reason for high correlation of liver damage and acetaminophen.

  10. PhilJourdan says:

    I try not to use anything period. I figure my body is stronger for doing it alone (yea, I am old fashion and stupid). That being said, when I had an abcess in one of my teeth, I did take Tylenol PM (the dentist gave it to me), and that worked great! So maybe I just have a low threshold of working since I use the stuff so rarely.

    Does that mean I am going to die of nothing then? ;)

  11. E.M.Smith says:

    Reminds me of an old Gahan Wilson cartoon…. Bunch of folks standing around praying to a square pedestal with ornate “N” on it. One guy turns to another and asks: “Is Nothing Sacred?”… Found it here:

    http://discardedlies.com/entry/?13223

    scroll down a bit…

    So yeah, maybe you will die of ‘nothing’… ;-)

    I generally avoid everything unless pushed. But there are times…

    It was with great joy that I discovered “The Arthritics Cookbook” (that I think is a bit over the top in what it forbids). It helped me to discover beef as a trigger for me. Substantially complete control / elimination of arthritis discomfort.

    This looks like it:

    http://www.amazon.com/Arthritics-Cookbook-Dong/dp/0821748831

  12. Paul Hanlon says:

    Wow, never knew that about Tylenol. We call it paracetamol over here. You’re limited to a maximum of 24 tablets in a pharmacy, and they’re quite costly.
    There’s one brand called Solpadeine, a paracetamol/codeine/caffeine (same amount as a small tin of Red Bull) mix, that my Mother swears by for her sciatica.
    She also swears by Cod Liver Oil capsules to ward off Arthritis. At 78, so far so good :-)

  13. E.M.Smith says:

    Yeah, JNJ have kept a good lid on the “risks” of tylenol. Doctors are now conditioned to hand it out like candy rather than the ‘risky’ aspirin that can cause stomach bleeds… I always insist on aspirin whenever possible (as I don’t have a bleed issue).

    Surprised there isn’t a booming business in Tylenol smuggingit in, if it’s expensive. Dirt cheap here. For a while (maybe still) you could get a very low dose APC Aspirin Codeine in Canada OTC. Whenever we went over the boarder, we’d buy a few bottles.

    Wonderful stuff (at the time some family members got migraines – since controlled with a new ‘magic goo’ pill. Imatrix? Something like that.)

    FWIW, you can make a decent Rodinal film developer replacement using acetaminophen.

    http://photo.net/black-and-white-photo-film-processing-forum/00FLH4

    Among the useless things it is essential to know ;-)

    Oh, and having just gotten over a bout of sciatica, your Mother might want to visit a chiropractor. When the lower lumbar / sacrum are out of place it can pinch the nerves and cause sciatica. I get to use the “cured” word now, so it’s worth it… After things were ‘mobilized’, sleeping with a lumbar pillow helped keep it all in place till things tightened up in their proper place again. All better now…

    Caffeine changes blood vessel dilation and for many kinds of headache, that is a key issue. It’s why Excedrin has caffeine in it. Why sometimes an espresso can cure a headache. Over dilated surface blood vessels are an ‘issue’ in some cases and the caffeine constricts them, IIRC.

    I’ve learned a great deal about pain killers and headaches with a family member doing the Migraine thing… The latest round of drugs aimed directly at it are a Godsend. Tempted to use the “cure” word again, but it’s only a 90% of the time “cure”. Still a hell of a lot better; and the 10% that it doesn’t stop outright are far milder. Don’t know if I’d handle it well if if were me with the problem. I don’t do well with a garden variety headache…

  14. E.M.Smith says:

    Sorry, going to paste in a version of the Tylenol Rodinal alternative that I ran into that has a pointer to a version that does not need lye (which I can’t get at the grocer anymore…) Just don’t want to lose it in the internet clutter. If you are not into chemical photography, just ignore this comment…

    Quoting a comment on the prior link:

    Murray Leshner , Oct 21, 2007; 06:54 a.m.

    Hi:

    Patrick Gainer posted another variation of this on APUG, a sulfite-free variation (I think he was out of it). It’s in the middle of his “Experiments with Metol…” post.

    This one uses acetaminophen, lye, sodium ascorbate (ascorbic acid + sodium bicarbonate) and he recommends dilution with an ascorbic acid-borax-water mix.

    “If you should want to use acetaminophen (Tylenol) in place of p-aminophenol, the 5.45 grams of p-aminophenol will be supplied by 7.5 grams of acetaminophen or 15 of the 500 mg tablets. If you use the tablets, crush them to a powder.

    Add 1/2 teaspoon of ascorbic acid and 1/4 tsp of sodium bicarbonate to 40 ml water, let the effervescence subside.

    Then add the acetaminophen and 4 grams of NaOH or 5.6 grams of KOH.

    Stir well and let it stand a while.

    Bring the water up to about 700 ml

    Add 2 teaspoons of ascorbic acid and 2 tablespoons of borax.

    Add water to make a liter.

    You will probably have to dilute this developer at least 1+4 to make it managable.

    The best way to dilute these developers is to add more of the ascorbic acid-borax mixture.

    You can make 4 liters of it with 35 grams of ascorbic acid and 100 grams of borax.

    This way you need not worry about whether you will have enough of

    the developing agent in the working solution when you try such

    outrageous things as stand development for an hour with 1:50

    dilution of the working solution.

    There will be as much of the ascorbate in the diluted solution as in

    the full strength, and that will ensure that the p-aminophenol or

    phenidone is continually regenerated.

    This is a chance to see if the usual statements about starved
    development and characteristic curves, Mackie lines, etc. are

    pertinent here.”

    He said this blend also eliminates worry about the presence of visible crystals.

    He has also published a solution for people who cannot buy lye/sodium hydroxide anymore because of concerns about its use for illegal drug manufacture. This ‘solution’ uses sodium carbonate (washing soda) and ‘slaked’ or hydrolyzed lime, which is available apparrently for fertilizer and may be used in mixing some cement recipes.

    I haven’t been in a darkroom in 30 years and I have scrounged these items to start again…I’ve got to get more confident figuring out development times with this recipe.

    He suggested at least 1:4 dilution, but no charts for it.

    END QUOTE

    I still have some chemical film in the freezer and have done developing before. Since I suspect that Real Soon Now it will be hard to get developers at all, I’m interested in such tricks… I bought a couple of 25 m rolls of bulk film once, and they are stored in the freezer in lead foil. Another “someday project”…

  15. Keith Minto says:

    In my younger days, in Australia, we had ‘APC’ tablets, or powder, Aspirin, Phenacetin and Caffeine. The Phenacetin had to be dropped as liver damage could result but Aspirin was considered safe until the 1980’s, I think, until Reye’s Syndrome http://en.wikipedia.org/wiki/Reye%27s_syndrome was discovered.
    Where was this syndrome before ?
    Somehow I think that the profits from Aspirin substitutes were greater than from Aspirin.

  16. a jones says:

    I had to do some checking here because US brand names are different from ours in the UK.

    Tylenol is paracetamol, a perfectly good analgesic and antipyretic But deadly dangerous because LD50 is only a few times the therapeutic dose. I have campaigned for years to have it banned not least because many patent cough and cold medicines contain it and it all to easy for the user to mix these with a fatal outcome: about ten deaths a year in the UK.

    The results of my efforts? well some years ago the UK gov’t reduced the quantity that could be sold over the counter to a sub lethal dose. And a fat lot of good that will do.

    And what really infuriates me is that two different chemical modifications were developed in the 1980’s which reduce its toxicity by over a hundred times: and now both are out of patent. Either version is so safe you can eat it like sweeties. Yet instead of banning the drug in its dangerous form and requiring either of the safe forms the authorities do nothing. And it is not even a question of cost, there is no difference.

    As for aspirin there is an old rule, never take it on an empty stomach to avoid gastric problems: if you want to deal with your hangover then have a slice of toast with your black coffee before taking your aspirin. It is of course a no-no if you develop an ulcer. Most importantly aspirin is not only a a powerful anti inflammatory agent but also affects the clotting ability of platelets and in very small doses can improve impaired circulation and reduce the risk of a major and potentially fatal blood clot.

    Ibuprofen was developed as a non gastric irritating version of aspirin and shares most of its virtues but lacks its anti clotting capability.

    Used with care the hazards of all the above drugs is so low you have a much better chance of winning the lottery.

    Kindest Regards

  17. dearieme says:

    My understanding is that the limit on individual purchases of paracetemol (i.e.tylenol) at UK pharmacies was brought in at the request of doctors, in hopes of reducing suicides by paracetemol. I’ve seen claims in the papers that it worked. Whether the tortured souls killed themselves by some other route is not revealed, of course.

    I must say that every time I’ve bought some, the pharmacy assistants have been exemplary about warning me about maximum dose and warning me against combining the pills with other souces of the active ingredient.

  18. Paul Hanlon says:

    Jeez, E.M. Thanks for that.

    I’ll go out tomorrow and get her a lumbar pillow. She won’t let us get her a new bed.
    I have another brother doing a degree in Photography. I’ll pass on your tip to him. Part of what he did last year was developing black and white photos, and he wanted to set up his own small darkroom, just to get a handle on the different effects.

  19. E.M.Smith says:

    FWIW, all I use is a ‘travel pillow’ from Sears that cost $5 (and they had a 2 for 1 sale, so it was really $2.50 each).

    It’s small and compresses fairly thin.

    While “mattress testing” it seemed like the foam mattresses were fine without the pillow as the foam tended to support the lower back.

    I love doing darkroom stuff. Sad to see it being left behind. You can always make developers out of mild reducing agents of one sort or another. There are some really odd things folks have done ;-)

  20. Curt says:

    And a recent study implicates acetaminophen with asthma.

    http://www.cnn.com/2010/HEALTH/08/13/acetaminophen.may.double.asthma.risk/index.html

    The study concerns teenagers, but I wonder if this could be behind the surge in juvenile asthma over the last few decades, as aspirin for children has become “obsolete” due to fears of Reyes syndrome.

  21. DG says:

    E.M.,
    Take a look see at serrapeptase http://www.serrapeptase.info/

    I am not familiar with other brands as this is the only one I’ve used. Having had multiple joint injuries (shoulders, wrist and ankle) and back pain from from years of abuse, this substance allowed me to get off the NSAIDS and Acetaminophen. It takes a week or two to kick in, and you hit it hard at first, but then taper off to find the sweet spot amount.

    Quite an amazing little enzyme.

  22. E.M.Smith says:

    Hmm. Fascinating stuff. The page makes it sound like a miracle drug.

    I’ll have my spouse take a look at it. She’s the one running out of choices (stomach issues with Aspirin and related… Tylenol a dud. etc.)

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