Tylenol and alcohol

Cecil's Columns/Staff Reports
21

I’m not sure I understand what a maximum average is.

22

Excellent posts, Another County!

(Perhaps the Reader could use you as an “adivsor”)

Couple of questions:

As one who enjoys wine with dinner on a daily basis, should I avoid acetaminophen completely?

You state that aspirin is more dangerous than acetaminophen. How so and what are the implications for people with heart/circulatory problems that use aspirin daily?

Finally, since it is possible that some people naturally have a low level of glutathione, isn’t acetaminophen effectively a poison for them.

Since these folks are unknown, isn’t there also a grand opportunity for litigation when/if someone with naturally low levels of glutathione croaks from Tylenol?

Thanks.

23

ACHF

Are you saying that “Alcoholic liver disease” is liver failure?

24

I have one or two beers pretty much every day. I’ve avoided taking Tylenol because of this, sticking to aspirin or occasionally ibuprofen. Are there dangers taking either one shortly before, or after (or during, even) having a beer?

25

Well, that was phrased poorly. I really don’t know the distinction here–and I did try to use some of those medical dictionaries. Is there such a thing as chronic liver failure? That sounds like “chronic heart attack,” but maybe there is such a thing.

26 
 *ALL* substances are poisons if taken to excess (ask a deep sea diver about the toxicity of air). No substance is a poison if a sufficiently small quantity is taken. (I recently read that they are testing arsenic trioxide as a treatment for certain forms of leukemia.)
27

RM Mentock posts:

Liver failure is a frustrating thing to try to define. The liver performs countless vital functions; when it is unable to perform one or more of these functions to the extent that it affects quality of life, or threatens life itself, one can reasonably use the term liver failure. This can be the liver’s inability to handle high volume blood filtration from the GI tract, resulting in hemorrhoids or enlarged veins called varices in the esophagus or stomach which are prone to bleeding, or resulting in fluid accumulation inside the abdomen called ascites, or dropsy. This can be the liver’s inability to manufacture key proteins needed throughout the body (Albumin to help keep fluid inside blood vessels and clotting factors to prevent serious bleeding episodes are examples). This can be the inability to clear toxic substances (including medications) from the bloodstream properly. When the liver is no longer able to adequately perform these functions, it is failing.

Despite many different potential causes, liver deterioration generally follows the same overall course of inflammation (hepatitis), scarring and fibrosis (cirrhosis), and ultimately failure, or End Stage Liver Disease (ESLD).

Referring back to the table I cited, when you subtract out the 6% of cases of liver failure that occurred as a result of an acute process, you are left with 94% of liver failure being due to chronic processes. Sometimes, the same cause can result in acute liver failure in some patients, and chronic liver failure in others. Hepatitis B can cause severe, (fulminant is the medical word), rapidly progressive destruction of liver cells, so that a healthy person develops liver failure in a matter of days or weeks. It can also cause no symptoms at all when first acquired, chronically infect liver cells, and over many years cause cirrhosis and liver failure.

Alcoholic Liver Disease covers the entire spectrum of liver pathology from intermittent and/or mild inflammation, to more severe or chronic hepatitis to cirrhosis to ESLD.

To directly answer your question, if you think of a Venn diagram, alcoholic liver disease and liver failure would be 2 circles with some overlap. Some, but not all cases of alcoholic liver disease progresses to liver failure. Some, but not all cases of liver failure are due to damage from alcohol.

You can also create a Venn diagram for Tylenol overdose and liver failure, which would look similar, but have a much smaller percentage of overlap. Fortunately, only a tiny minority of acetaminophen overdose cases do result in potentially fatal liver failure. And, as previously stated, the percentage of liver failure attributable to acetaminophen toxicity is on the order of 1-2%.

Your analogy to heart failure would not be bad, except that you misunderstand heart failure. Heart failure occurs when the heart cannot pump well enough to pump blood from places it is not needed (veins, lungs) and pressure builds up causing fluid to accumulate in the lungs or elsewhere in the body, or to places (brain, kidneys) it is needed. This can happen due to acute processes like a heart attack, or a bullet ripping through it, or from chronic processes like damage from alcohol, viruses, chronic poor blood flow, or severe high blood pressure.

Note: Hepatitis simply means inflammation (-itis) of the liver (hepat-). It can be caused by some viruses named Hepatitis A, B, C, D, Etc. Virus, by viruses with other names, like Epstein Barr Virus, better known for mono, or can be caused by chemical irritation by alcohol, acetaminophen or other toxins.

28

Nixon asks:

  1. Are we talking 2 glasses or 2 bottles?. Unless you have some pre-disposition to liver disease (Hepatitis infection, family history of chronic liver disease), there is probably no reason to avoid short-term tylenol use at recommended doses. If you are a regular drinker, particularly if the “Multiply by 3 whatever the patient tells you” rule applies, you should speak honestly with your doctor about your alcohol, and have blood tested periodically for signs of liver damage. Unless something turns up, tylenol is likely to be safe for you. From the Tylenol labeling: “If you generally consume 3 or more drinks (drink = 12 oz. beer, 3-4 oz. wine, 1 1/2 oz liquor - ACHF), you should consult your physician on when and how you should take Tylenol and other pain relievers.”

  2. All recommendations for use or avoidance of a particular substance should involve a consideration of the benefits of using that substance vs. the risks of using that substance. Acetaminophen risks include the well-established risk of liver toxicity, as well as an association (but with a known cause-and-effect relationship) to kidney problems. Aspirin carries the same risks as described for ibuprofen (and other members of the NonSteroidal AntiInflammatory Drug=NSAID class). One reason tylenol is safer is because it is less commonly used chronically. People tend to use acetaminophen for the occasional headache or fever, but tend to use aspirin or NSAIDs for conditions like a muscle strain or a tendonitis that may last several days, or arthritis, which may be lifelong. But even accounting for this, the likelihood of developing a bleeding complication on aspirin is higher than the likelihood of developing liver toxicity from acetaminophen.
    As far as aspirin use for preventing heart attacks and strokes, the same kind of risk-benefit analysis also takes place. For most people, the risk of dying from a heart attack is much higher than the risk dying from an aspirin-induced stomach ulcer. Thus, more lives are saved due to reducing heart attack deaths with aspirin than are lost due to GI hemorrhage caused by aspirin. These kinds of recommendations, however, apply to statistical averages, not individuals. Based upon your personal risks for heart attack, stroke, or GI hemorrhage, YMMV.
    You should also realize that heart attack prevention doses of aspirin range from 81-325 mg/day. OTC use for pain or fever is recommended to be kept under 2600-4000 mg/day, but under a doctor’s supervision, doses of 5200-7800 mg, or more, may be used. The risk of bleeding is largely dependent upon the dose used, so a heart protective dose is much safer than a therapeutic dose for arthritis. Buffering, or enteric coating aspirin decreases stomach symptoms, but does not eliminate the risk of bleeding.

  3. Malnutrition is not a major health problem in the US. As long as nutrition is adequate, the liver will not generally have low levels of glutathione. If someone is malnourished, however, it would be possible for tylenol taken at recommended doses to cause some toxicity because of low levels of glutathione. In my earlier post, I mentioned that glutathione contains a sulfur atom. In order to make adequate amounts of glutathione, one must consume a diet with enough sulfur-containing amino acids (Cysteine and Methionine). This is generally not a problem for most of us, although theoretically it could be for vegetarians, particularly vegans, who may not consume the full range of amino acids in optimal quantities. Other at-risk groups would include alcoholics, homeless, and incapacitated elderly persons.

  4. No, because low glutathione levels are not known to occur out of the blue. And, while toxicity may occur at doses close to the recommended 24 hour maximums, fatalities are rare for ingestions under 15 grams. There really is some margin of safety for acetaminophen.

29

ZenBeam, I think my answer to Nixon also addresses your concerns. Occasional use of up to 1000 mg acetaminophen should not pose a problem unless you have some underlying liver disease.

Information in this and preceding posts is for general informational purposes only. It is intended to improve, not replace, communication between readers and a health care professional familiar with their individual health histories.

30

In part 2 of my answer to Nixon, I stated:

That should read:
Acetaminophen risks include the well-established risk of liver toxicity, as well as an association (but without a known cause-and-effect relationship) to kidney problems.

I apologize for any confusion.

31

I’m not going to claim to understand heart failure, far from it, but my analogy was to heart attack.

And I appreciate your efforts here, but do you have a citation (hopefully, web) that covers the definition of liver failure?

32

Links? It’s all in how you search. Liver failure would lead to much frustration on most of the sites I’m familiar with. Cirrhosis, though, opens many doors.

Cirrhosis does not equal liver failure. Cirrhosis, however, is a precursor to liver failure. When cirrhosis leads to complications, especially when the complications cannot be controlled with standard medical therapy, and liver transplantation is the only option, the liver has failed.

These were among the most applicable articles at mayoheath.org, using cirrhosis for the search term:

http://www.mayohealth.org/mayo/askphys/qa000228.htm

http://www.mayohealth.org/mayo/askphys/qa980713.htm

http://www.mayohealth.org/mayo/0001/htm/hemo.htm

http://www.mayohealth.org/mayo/9812/htm/hepC.htm

This article http://www.niddk.nih.gov/health/digest/pubs/cirrhosi/cirrhosi.htm found at MEDlinePlus http://www.nlm.nih.gov/medlineplus/ was very thorough, and in the section covering complications describes many of the features I mentioned.

If it’s strictly definitions you want, from the OnLine Medical Dictionary @ http://www.graylab.ac.uk/cgi-bin/omd?liver+failure

and @ http://www.graylab.ac.uk/cgi-bin/omd?liver+failure,+acute

I would add, however, that not all hepatologists would limit the use of the term liver failure to patients with an altered mental status.

This article, also from the MEDlinePlus site, gives a good description of the typical progression of cirrhosis to liver failure:
http://www.gastro.org/public/cirrhosis.html