Sometimes you notice things…
Sometimes the spouse does…
Sometimes they matter…
In this case I’d noticed that I was particularly lethargic while the spouse had noticed a tiny tinge of jaundice to the eyes (that resolved the same day). A bit of digging…
Some months back I’d swapped the “pain killer of choice” for arthritic moments from aspirin to ibuprofen. No particular reason other than that I had been nagged about stomach bleed risks by the medical establishment to the point of being a bit paranoid about it.
I was unwilling to swap to Tylenol / Acetaminophen for the simple reason that it is the leading cause of liver damage from drug overdose. Mixed with even modest quantities of alcohol you can end up needing a liver transplant; though the package insert tries to make it sound like you have to be a raving alcoholic; that isn’t the case. The two work to lower the threshold for liver damage and the overdose level for acetaminophen is a small distance above the normal dose. It has a narrow range between therapeutic and toxic dose.
Because acetaminophen (APAP) is the most widely used pharmaceutical analgesic and antipyretic agent in the United States and the world (contained in >100 products), it is reported by the American Association of Poison Control Centers to be one of the most common pharmaceuticals associated with both intentional and unintentional poisoning and toxicity. Acetaminophen toxicity is the most common cause of hepatic failure requiring liver transplantation in Great Britain. In the United States, APAP toxicity has replaced viral hepatitis as the most common cause of acute hepatic failure and is the second most common cause of liver failure requiring transplantation.
Acetaminophen is also known as paracetamol and N -acetyl-p-aminophenol (APAP). This agent is available in the United States as 325-mg and 500-mg immediate-release (IR) tablets, and as a 650-mg extended-release (ER) preparation marketed for the treatment of arthritis. Various children’s dissolvable, chewable, suspension, and elixir formulations of APAP are available. Acetaminophen is a component of many over-the-counter (OTC) cold and analgesic medications and prescription combinations, including codeine-acetaminophen (Tylenol #3) and oxycodone-acetaminophen (Percocet).
Acetaminophen is hepatotoxic if taken in overdoses, and for adults, more than 7.5 – 10g/d are considered an overdose (2002 FDA Advisory Meeting). The currently recommended maximal therapeutic dose is 4 g/d, however, instructions for use are often confusing. One product states that up to two 500 mg extra strength tablets can be taken every 4-6 h as required, but not more than 4 g/d. If the condition for which acetaminophen is taken extends over more than 18 h, even with the longer (every 6 hr) interval, there is a chance to go over the recommended daily dose.
So just a ‘double dose’ can be toxic and sometimes the label directions put you close to that. (the article goes on to show how following those directions and being a bit un-careful about the 4 gm / day can cause an overdose). Add a bit of wine with dinner or some beer at the beach and that toxic threshold drops. How much? That isn’t clear…
So I’ve generally avoided Tylenol / acetaminophen.
Once, when I was at the first aid station at the Sharks Game with a headache asking for an aspirin and specifically told the guy I’d had a couple of beers and did not want acetaminophen due to the liver risk, I was handed a generic acetaminophen and told it didn’t have any Tylenol in it… It is incredibly hard to avoid and it is very easy to take a Tylenol and some cold medicine that also has acetaminophen and get a double dose.
So I’m very sensitive about the issue.
But apparently not quite paranoid enough.
Aches and Pains
I’ve had sporadic arthritis. I’ve pretty much traced it back to foods. Primarily “cow stuff” but lately tomatoes too. It is easy to avoid beef and eat pork or lamb instead, but my weakness is beef burritos and ice cream. Oh, and marinara sauce…
About January I’d not yet figured out the tomato reaction (even though it is listed in The Arthritics Cookbook.) So I’ve had some ‘aches and pains’. Then the weekend marathon of schlepping tool boxes and lead batteries had brought some aches and pains as well.
Due to the aspirin and bleeding paranoia nag, I’d bought a bottle of Ibuprofen about last January. Didn’t think much of it. But I’d “upped” my use of Advil / Ibuprofen from ‘nearly none’ to ‘nearly daily’ due to those kinds of things. But I didn’t particularly worry about the wine every so often nor the occasional beers. ( I probably average about a bottle of wine per week, or less some weeks. Occasionally I’ll down a whole bottle in one day. At 100 kg, that’s not a whole lot.)
But what I had not done was be paranoid enough to check for Advil / Alcohol interactions to see if the same risks exist to the liver from that mix as exist with Tylenol / Acetaminophen.
So it caught me a bit by surprise when the spouse said she thought the whites of my eyes were tiny bit yellow last night. (Today all is fine). WHAT was different about yesterday? I’d had a glass of wine AND ibuprophen. Not much else.
So off I went to look things up…
Both alcohol use and Advil use may contribute to liver damage. Advil may, rarely, cause abnormal liver functioning and liver damage on its own. Although Advil and other brands of ibuprofen are usually safe when taken as directed and for a short period of time, the risks of liver damage with ibuprofen use increase with long-term use. Elevated liver enzymes, which indicate damaged liver cells, may occur in up to 15 percent of patients who regularly use NSAIDs, including Advil, according to Drugs.com. Alcohol use is also associated with liver damage, and combining alcohol with NSAIDs like Advil may quickly result in significant liver damage as alcohol activates enzymes that cause NSAIDs to be even more liver toxic than usual.
So one wonders if about 1/2 the days out of 4 months is “long term use”… and how much overlap with a glass of wine is an issue…
Over time, using Advil, alcohol, or especially both substances together may lead to diseases of the liver such as cirrosis, hepatitis, jaundice and liver failure. When used long-term or in higher-than-recommended doses, sustained liver damage from Advil use may result in hepatitis, jaundice and even complete liver failure. Heavy alcohol use may also cause these liver diseases and others without Advil use, but even when used in moderate amounts, such as three drinks nightly, alcohol may contribute to liver damage and disease if you are also taking an NSAID like Advil. Therefore, it is of utmost importance to never use alcohol and NSAIDs such as Advil together.
Well, the good news is that the liver is very good at regenerating and there have only been one or two times I’ve had ibuprophen with wine in the same day. So most likely whatever “compromise” there was is/was transitory. (Today, everything seems fine.)
Still: You would think folks would be making it a bit more clear that BOTH of those drugs (and how many others?) are potentially lethal at common levels of use and mixed with common levels of alcohol use (and don’t even get me started about the 1 Litre / Day wine consumption in some European countries and what THAT means about pushing Tylenol and Advil there).
That puts me back at Aspirin.
Being a bit paranoid, I decided to do some more “digging” about it. The “Livestrong” article tossed aspirin in the same bucket as the other NSAIDS with respect to alcohol, but was it true?
Aspirin shown to help prevent liver damage
Published on January 27, 2009 at 1:43 AM ·
According to scientists at Yale University ordinary aspirin may help prevent liver damage in millions of people suffering from the side effects of common drugs, alcohol abuse and obesity-related liver disease.
The new study by researchers at Yale School of Medicine suggests that aspirin may help prevent and treat liver damage from a host of non-infectious causes.
Dr. Wajahat Mehal from the Digestive Diseases and Department of Immunobiology, says research with mice has shown that aspirin reduced the number of deaths caused by an overdose of acetaminophen, best known as paracetamol.
Dr. Mehal says many agents such as drugs and alcohol cause liver damage, and they found that aspirin blocks a central pathway responsible for such liver injury.
He says aspirin could be used on a daily basis to prevent liver injury and suggests that promising drugs which have failed clinical trials because of liver toxicity might be resurrected if combined with aspirin.
Dr. Mehal says the strategy offers the exciting possibility of reducing a lot of pain and suffering in patients with liver diseases, using a new and very practical approach.
Aspirin it seems counteracts new mechanisms of acetaminophen or paracetamol-induced liver damage – overdoses of acetaminophen account for most drug overdoses in most Western countries.
Such overdoses cause two waves of liver damage – the first wave of liver cell destruction is a result of the toxic nature of acetaminophen – the second wave is mediated by molecules of the immune system, which is activated in response to the initial acetaminophen-induced liver damage.
A daily aspirin is already recommended to prevent heart attacks in people at high risk of having one and recent research has shown that aspirin can help treat heart attacks – doses of between 75 milligrams and 325 milligrams help thin the blood; it has also been suggested women who take aspirin once a day may slightly reduce their risk of the most common type of breast cancer.
The study is published in the latest issue of the Journal of Clinical Investigation.
Not only is it not accused of causing liver damage, it is asserted to help prevent damage from drugs like alcohol and Tylenol / Advil.
Needless to say, I’ve taken an aspirin…
As we all prepare for various celebrations, especially those of us in the USA with Memorial day, I’d like to suggest making sure you have a bottle of aspirin in the medicine cabinet for “the day after” and perhaps also for “the day before and the day of”…
I’m pretty sure I’ve had no long term damage from my ‘couple of months’ of being uncareful and not paranoid enough about Over The Counter medications. I do feel just a bit annoyed at having been “caught” by an effect to which I was already sensitized, simply from being a bit too lax and not paranoid enough.
So today the “energy” level is rising, the eyes are clear and white, and all is well with the world. Oh, and I’ve dumped the ibuprophen from the pill case and put aspirin back in.
With luck, that’s all that will come of it.