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Tylenol May Not Be As Safe and Effective As We Thought

I’ve always thought of Tylenol (AKA acetaminophen in the US and paracetamol in the UK) as one of the safest drugs around, with essentially no side effects when used as directed. But it has been in the limelight lately. Several SBM articles have addressed it here, here, and here. We know there is a risk of liver damage and death with acetaminophen overdose or accidental ingestion (458 deaths a year in the US). Since it is included in many other products (painkillers, cold and cough remedies, etc.) consumers may not realize how much they’re taking. The FDA has addressed this problem, and reformulations and lower daily dose recommendations are being implemented; but there is still no guarantee that consumers will realize that their “non-aspirin pain reliever,” pain pills like Vicodin, and many cold, sinus, and cough remedies have the same ingredient as Tylenol.

We have gradually become aware of other dangers not associated with overdose. Acetaminophen has been associated with kidney damage (especially with long-term use), gastrointestinal symptoms, and cardiovascular events. Combining the recommended dose with alcohol ingestion can lead to liver failure. It can also interact with some other drugs, for instance isoniazid. Allergic reactions can occur, and 7% of patients who are allergic to aspirin or NSAIDs also react to acetaminophen. It is excreted in breast milk, but in very low concentrations. The manufacturer’s professional product information includes detailed listings of reported reactions, drug/drug interactions, and safety studies in patients with various diseases. There is no need to adjust dosage for the elderly or for those with liver or kidney disease. For most patients, including those with chronic disease, acetaminophen is the pain-reliever of choice due to its low risk. But recently a draft recommendation from the UK’s NICE (National Institute of Health and Care Excellence) has warned us against using it, at least to treat the pain of osteoarthritis.

NICE warns against using it for osteoarthritis

Osteoarthritis is the “wear and tear” arthritis that most of us develop as we age. It is distinguished from inflammatory types of arthritis like rheumatoid arthritis. For inflammation, NSAIDs (non-steroidal anti-inflammatory drugs), steroids, and other drugs are helpful; but the initial treatment for the pain of non-inflammatory osteoarthritis has traditionally been acetaminophen. Last summer, NICE issued a warning against prescribing acetaminophen for osteoarthritis, saying they were “extremely concerned” about serious side effects. This advice was part of their draft for updated guidance on osteoarthritis. The report can be downloaded here.

It is exhaustive, with over 600 pages, and filled with tables listing the pertinent scientific studies and assessing the quality of evidence and the likelihood of bias.

It warns of the potential side effects of paracetamol and says it has “limited benefit.” When used, it should be the “lowest effective dose” for the “shortest possible time.”

It cites a very definite trend from observational data linking paracetamol at increasing doses to cardiovascular (fatal/non fatal MI, stroke, heart failure), gastrointestinal (upper and lower) and renal adverse events. The Guideline Development Group “felt that the increase in renal adverse events with long-term cumulative doses of paracetamol particularly would be a surprising finding for most clinicians and wishes to highlight this issue.”

NICE based its concerns mainly on these studies:

  • A US study published in the journal Circulation showed use of NSAIDs or paracetamol at high frequency or dose is associated with a significantly increased risk for major cardiovascular events.
  • A 2010 UK study of 1.2m general practice records in 2010 found a 28% increase in mortality with paracetamol and a 50% increase when used in combination with ibuprofen, compared with those not using the drugs. This compared with a 12% increase in the ibuprofen group. The study also shows a 36% increase in the risk of upper gastrointestinal events, 14% increase in heart attack and a 20% increase in renal failure risk with paracetamol use.
  • A 2010 Osteoarthritis Research Society International review of evidence for various analgesics in osteoarthritis concludes there is accumulating evidence to suggest high-dose paracetamol may have upper gastrointestinal side effects. It also finds ‘some evidence’ to suggest mild loss of renal function in women following long-term consumption of high doses. (Osteo Carti 2010;18:476–499)
  • A 2011 study by University of Nottingham researchers showed an increased risk of reduced hemoglobin after 13 weeks treatment with ibuprofen or paracetamol alone, with the risk doubling when the drugs are taken in combination.

Other recommendations

The guideline also recommends that glucosamine and chondroitin products should not be offered to manage osteoarthritis as the evidence on their clinical effectiveness is very limited and uncertain.

It recommends against acupuncture for osteoarthritis, because most studies showed no difference between sham and true acupuncture, and the studies showing a benefit were of lower quality.

It also recommends that osteoarthritis can be diagnosed clinically if the patient is 45 or over and has activity-related joint pain with either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. X-rays and other tests are not necessary.

How critics reacted

There was an uproar. Experts and organizations, including the British Society of Rheumatology, wrote to NICE to protest, saying that there was no new evidence to support the draft guidance and that it would impact self-management of pain and might increase the use of opiates.

The UK medicines regulatory body (MHRA) contradicted NICE, saying there was no new evidence to support the advice not to use paracetamol regularly for OA.

An article in Pulse generated a lot of unfavorable comments from clinicians, mostly aimed at the lack of alternatives. Here is a sampling:

  • “So what exactly is left then?”
  • “I’ll refer you to the appliance department for a piece of wood. You can chew on it if the pain gets too much. Trust me, it’ll be better for you, I’ve read the NICE guideline.”
  • “So now it’s official that we are to place defensive medicine over and above patient care. Nice one, NICE.”
  • “Without suggesting any alternatives these guidelines are utterly useless.”
  • “Here we go the reality check on the safest ever claimed medicine is no longer “SAFE” so what next?”

NICE responds to criticisms

NICE listened, and last week they made a dramatic U-turn that completely reversed the guidance of the first draft. The revised draft recommends GPs continue to use paracetamol as a first-line analgesic option in osteoarthritis. It said NICE was also “aware of an ongoing review by the MHRA of the safety of over-the-counter analgesics. Therefore NICE intends to commission a full review of evidence on the pharmacological management of osteoarthritis, which will start once the MHRA’s review is completed, to inform a further guideline update.”

Conclusion

This controversy can serve as a reminder to us all that Tylenol is not as harmless and not as effective in relieving pain as we would like to think. Still, when an analgesic is required, it’s safer to try Tylenol first than to bypass it for other more effective analgesics with worse side effects. Some might even consider it a “pseudo-placebo” – an effective drug that may not really do much, but that we can justify offering to the patient along with all the non-specific effects of the doctor/patient encounter, seeking to maximize placebo effects and avoid the use of more dangerous drugs. We can also keep in mind that not every pain has to be treated with medications. We can offer safe non-drug treatments like distraction, comfort measures, exercise, massage, and other safe modalities.

Tylenol is a good reminder that any drug that has effects has side effects; we can’t trust any drug to do only what we want it to do: it will do whatever it can do.

Posted in: Pharmaceuticals

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79 thoughts on “Tylenol May Not Be As Safe and Effective As We Thought

  1. palmd says:

    All medicines have “effects”—none are “sides”. If something works, we always have to consider undesired effects—and then make a decision. Many meds we use, and things we do, have risks, but we accept smaller risks for the benefits.

    Telling someone with OA to grin and bear it leads to further debility (studies are clear that people with OA are relatively inactive) and debility leads to morbidity and mortality.

    Guidelines usually require a lot more clinician input than the usually get.

  2. windriven says:

    The NICE report (haven’t read, not going to read, so much to read, so little time) raised two significant questions in my mind, one of which the blog addressed: absent acetaminophen, what?

    The other that wasn’t at all clear to me was whether the observational studies that NICE relied on disclosed risks that were really new or whether they simply underscored the importance of adhering to maximum dosing limits regardless of the source of the acetaminophen.

    To my mind a patient education problem and a newly understood toxicity problem are quite different and demand quite different responses.

    1. Calli Arcale says:

      THIS.

      Is there evidence of a newly discovered risk, or is this just more of what we already know — that Tylenol can quickly turn nasty, so it’s really important to stay under the maximum dose, but patients aren’t universally good at that?

      And the “if not Tylenol, what?” question. Vioxx got thrown out because of cardiovascular risks, which turn out to be pretty common among NSAIDs anyway. Aspirin can raise bleeding risks and affects blood pressure and is associated with Reye’s in infants. Tylenol can kill you if you’re particularly incautious with dosing. Opiates are seriously addictive. Steroids mess up your body in a lot of interesting ways. Caffeine has only modest effects at levels which would have most people vibrating. So all the pain relievers are bad for you. But pain is bad for you too, and honestly, there are times when pain is so bad you’d happily gnaw off your own leg if you thought it would help, so clearly just avoiding pain relievers because of possible risks is no good.

      1. windriven says:

        @Calli Arcale

        Re: risks, new or old – So what are you suggesting the answer to the question is? It appears to me that Dr. Hall is as uncertain as I just what NICE was claiming.

        ““if not Tylenol, what?” I think we are in agreement. As palmd noted above, not all effects of medications are desirable. It becomes a matter of balancing desired effects against undesirable ones.

        1. Calli Arcale says:

          I don’t have an answer; that’s sorta the point. ;-) I was agreeing with you and Dr Hall on that.

      2. Lizzy says:

        And I will keep taking my tylenol pm at night. Thank you drugs.

  3. stanmrak says:

    So what exactly is left for chronic pain then? Start grounding yourself when you sleep. Find grounding products on amazon, under “Earthing.” Not as woo as you might think.
    Or try astaxanthin. No need to poison yourself.

    1. MadisonMD says:

      Really Stan? You previously indicated that aliens, dolphins, or some other mysterious non-human force regularly comes to earth to secretly bend wheat without breaking it. Now you recommend pain relief by Earthing– plugging yourself into the ground of an electrical outlet?

      You are the Daffy Duck of SBM. Thanks for the comic relief!

      1. mousethatroared says:

        Ohhh, now I miss Douglas Adams.

      2. Lizzy says:

        Hahahha. Is there really such a thing as what Stan is prescribing?

        I will stick to my tylenol and all my lovely drugs recommended by my awesome doctor.

    2. Calli Arcale says:

      Y’know, stanmrak, it’s funny, but wearing my grounding strap in the lab at work has had no correlation to my debilitating tension headaches. You say “earthing” is non-woo, but what else do you call something that has no evidence it works and also no sensible reason it *would* work? You’d think the people in our manufacturing facility would be totally painfree by now, since they spend most of their working hours properly grounded.

      1. stanmrak says:

        I see you two have done the research like all good science-based thinkers would. You are clearly not scientists, you’re debunkers.

        1. MadisonMD says:

          Yes, Duck Dodgers. You have the hindsight of the 24th1/2 century to know actual 21st century scientific truth.

          PS– Careful not to plug yourself into a non-GFCI outlet again, Stan!

          1. Sawyer says:

            “Duck Dodgers”

            That one took me a minute to get. Nice tie in to your previous comment!

        2. windriven says:

          @stan

          “[Y]ou’re debunkers.”

          And stan, if nothing else, you are an expert on bunk.

        3. Calli Arcale says:

          Really, stanmrak? I just indicated that I’ve been properly grounded plenty of times, and it had no affect on my headaches, and you just handwave that away with “oh, you’re not a real scientist” (as if you are).

          And here’s a serious question for you. Repetitive stress injuries are very common among high tech workers. Grounding is often an integral part of high tech manufacturing, to avoid damaging the delicate products, some of which can be ruined with a discharge vastly below the pain threshhold. So why are high tech workers, many of whom use grounding straps throughout their workday, turning to pain relievers instead? You’re the one who recommended earthing for pain relief; explain to me why I’m supposed to believe you. “not as woo as you think” and pointing out that products are available on Amazon is not particularly persuasive.

          1. MadisonMD says:

            Calli,
            Recall that in Looney Tunes, scientists look like this.

            So, as a scientist, you don’t conform to the daft vision of this quack.

            1. Calli Arcale says:

              *laughs*

              Well, there’s also the fact that I am not, in fact, a scientist. I’m far worse — I’m an engineer. ;-)

              1. mousethatroared says:

                LOL – As the wife of an engineers and the daughter of another, I just had to thank you for the chuckle.

    3. mousethatroared says:

      I seriously read grounding yourself before you sleep and interpreted it to mean – you know – taking stock of your life and what you are grateful for – maybe coming up with a plan how you are going to accomplish your goals tomorrow.

      I had a moment where I thought, “look stanmrack has offered a reasonable (if not proven) piece of advice”.

      Then I got to the earthing part.

      NOT!

  4. Frederick says:

    I Like you the final of your article.

    I use Tylenol ( or other generic equivalent) combine with ibuprofen every time i have headache or muscle pain i can’t tolerate.
    And When i have cold or something like that, I used to use cold medicine ( wic i stop because of good review here that show that most of them do not work more than a placebo or cold symptoms ), But i always checked the incredient and dosage, so i don’t take too much of acetaminophen or ibuprofen.
    I can’t understand what in that is so hard to understand, the limit is what? 4000mg a day ( For Tylenol)? how hard is to keep track, buy 500mg pill and it is easy as pie. you use Neocitran that evening? the label clearly says that it contains 650mg.
    I Don’t think we should ban Such a effective, safe and cheap pain killer ( for me a 500mg of Tylenol ans on 250mg of Motrin best combo), because some people can’t read. Even if you modified the label the have Green Flashing Neons of it, saying to be careful, some people will still take too much of it.

    With that said, if new research shows how bad it can be combine with X or Y Drug, W or Y condition, New guidelines and new warning are a good Idea. Then again, you cannot guaranteed that 100% of user will use it right.

    Don’t touch My Tylenol! :-)

  5. goodnightirene says:

    The report concludes that people should “use the smallest dose possible for the shortest time possible”. It does NOT say not to use anything for pain relief.

    May I briefly rant about advertising? Thanks! What if there was no brand namee and only acetaminophen? How did people come to think of Tylenol (the brand) as safe and effective? How many people continue to buy the brand name thinking it to be “safer” or “more effective”? How would the answers to all these questions vary if there were no advertising for drugs–even OTC’s? What if you had to get acetaminophen from the pharmacist along with the little instruction talk that emphasizes the label warnings?

    It is advertising that has made us think that Tylenol is just some innocuous medication that we can grab at the first sign of discomfort with zero consultation with any medical personnel whatsoever. The print is so tiny on a small bottle that I cannot read it even with my new special close up glasses (for knitting!), but how many even try?–after all, everyone “knows” it’s perfectly “safe”–TV told them so.

    An ad campaign that can convince people that Tylenol is “better” than acetaminophen and portrays its use over a period of 30 years or more as a harmless antidote to the slightest headache is a bigger problem than primary care doctors recommending it for OA.

    By the way, in the cases of death, I’d love to know more details about the specific deaths and their circumstances. I wonder if any retirees using acet. as directed–or even a little more–were among the dead.

  6. mousethatroared says:

    I suppose one way the report might be helpful is in reevaluating the risk comparison between long term tylenol and NSAID usage in the cases were surgery may provide a benefit.

    My sister and father-in-law both put-off hip replacement surgery for a minimum of six months, when they knew the surgery was inevitable, but wanted to wait for a more convenient time. If that strategy has long term health disadvantages, It would be good to know. After surgery and some weeks of recovery, they were reasonably pain free and their medication usage dropped.

    I’d also guess that it wouldn’t hurt to consider switching to or supplementing with topical analgesics and anti-inflammatories or a controlled series of steroid injections when applicable.

    Clearly, any approach is going to have a variety of risks and benefits depending upon the individual case. Interventions should be based on the individual patient’s health history, ability to follow care instructions, particular conditions, etc. It seems like (just from reading HH’s post) NICE was overly broad in it’s recommendations.

    1. windriven says:

      What struck me most mouse, was that it took 600 pages to say so little that at the first sign of backlash NICE reversed field. Perhaps the title should have been “Much Ado About Nothing”.

  7. Young CC Prof says:

    I hate Tylenol profoundly.

    I’m one of the people who DOES suffer GI side effects from it, it aggravates my chronic erosive gastritis. Obviously I can’t have NSAIDS or aspirin either. For day-to-day pain, or my moderate back pain, I just deal. But I’ve been through some nasty things, including a tibial fracture, with no pain relief whatsoever, because the doctor wasn’t willing to prescribe a “straight” opiate.

    Look, I get it. It’s too dangerous to hand out an addictive drug that isn’t mixed with a dose-specific poison like Tylenol. And “obviously” someone who can’t have Tylenol or NSAIDs is a drug-seeking addict. But it’s still pretty awful from my point of view.

    1. mousethatroared says:

      Damn – can’t you get some sort of certified note or something from a reputable doctor saying “REALLY, this guy can’t tolerate Tylenol or NSAIDS.”

    2. MTDoc says:

      Frankly, I am appalled that opiates are adulterated with a potential poison to prevent abuse. Anybody with an ounce of brains should know that knowledge is not going to deter a real addict. I’ve personally witnessed the fatal consequences of that delusion. Not pretty dying of acute liver failure.

      1. Andrey Pavlov says:

        Indeed. Just look at what happens with krokodil in Russia. Basically a cheap heroin substitute with lots of solvent left in the product because it is made… cheaply. People know this will happen to them and they still take it.

        (Warning pictures in first link are graphic and perhaps NSFW; don’t know why Miley Cyrus appears in the search…)

        1. MTDoc says:

          Thanks for the link. I had not heard of krokodil before, but I spent three years treating meth addicts, and addiction in general. Compared to the people in those photos, perhaps liver failure isn’t so bad.

      2. Nashira says:

        Tomorrow is tomorrow, and their demons and withdrawal symptoms are in their face *right now*. (n.b. Not an addict, just someone who experienced similar urgent urges when she used to self-harm. How bad I’ll feel tomorrow, because I hurt myself today, doesn’t mean much in the face of overwhelmingly awful emotions.)

        While I suppose certain hard-hearted wastes of oxygen find it expedient to get rid of addicts by letting them poison themselves to death… omfg, let’s please please not be like those… “people”.

        1. Andrey Pavlov says:

          Allowing them to poison themselves to death does not address the underlying problem and does nothing to actually help anyone, let alone society. It is well known that deterrents do not affect behavior very much, particularly in certain things (such as addiction and murder). But creating a more stable, just, and supportive society does.

          It is just a lot easier and often viscerally more satisfying (to those uneducated or with some sort of ideological bias) to blame others and think that merely getting rid of them will fix the problem because, well, they can function in society effectively so why can’t the other person?

      3. mousetharoared says:

        Wow – Is that really an intentional strategy? I know there used to be drugs like like tylenol with codeine, but I thought the combo was for actual pain relief. Then they took that and NSAID/tylenol blends (was it flexerall?) off the market due to concerns of people double dosing with different combos like flexerall and cold medicine with tylenol.

        1. Andrey Pavlov says:

          I don’t know the full story off the top of my head, but yes that is one of the intended purposes (I believe…). The primary purpose is to combine analgesic effects to decrease the amount of opiate needed and thus (hypothetically) decrease the risk of opiate addiction and overdose for non-abusers. There was a big hullaballoo about reducing the amount of acetaminophen in codeine because it was felt that would increase/encourage abuse/dependence/whatever.

          Flexeril is different though – the generic is cyclobenzaprine and is a centrally acting muscle relaxant. I do not think it has ever been OTC. (minor point, I’m sure you just aren’t remembering the name, but I don’t know it either)

          1. mousethatroared says:

            Andrey – I guess Flexeril* wasn’t the right medication, then. I remember specifically that my sister was complaining about a particular prescription combo being taken off the market because it included tylenol and the FDA was trying to eliminate tylenol combo’s due to unintentional double dosing with OTC combos. I guess I can’t remember the name. It would have been something for migraines or osteo, but not an opiate, I think. Oh well, not important.

            *Oh I have some that, which I should just throw out. I hate it with a passion. Terrible nightmares with a topper of waking up in deeply anxious despair, AND it didn’t work (or even “work”.)

            1. Andrey Pavlov says:

              Yeah, it is obviously a minor point Mouse.

              However, Excedrin still contains aspirin and acetaminophen along with caffeine. Here is a list of drugs that contain acetaminophen in case you are like me and it will bug you endlessly until you figure it out.

              As for Flexeril…. I personally love the stuff. It is very mild for me and offers great relief when I throw out my back (which happens infrequently but when it does, OMFG!; it actually happened on Christmas day last year). If I have bad back spasms I take a couple flexeril, lay off the back for a day, and then get right back to my usual routine the following day and in no time I am 100%

              1. mousethatroared says:

                I suppose if I really want to know which medication she was taking I could just call her. She would think I was crazy, though. She has this (to me) complex migraine protocol that always flies over my head. Luckily she’s qualified to understand it.

              2. mousethatroared says:

                Really off topic! – Just as a silly anecdotal aside that the Flexirill reminded me of. I was given Skelaxin a couple of times for the muscle spasms I used to get under my left shoulder blade. They were really painful, so I went to a doctor who gave me like 6-10 Skelaxin and told me to take them before bed, because they might make me drowsy. I did and found I slept well (which isn’t easy with muscle spasms). But then when I woke up, I was in pain again. This went on 3 to 5 days, and then get better. This happened several times, then I moved. My new doctor didn’t approve of muscle relaxants and wouldn’t prescribe them. She gave me an NSAID instead. Which didn’t really touch the pain….but hey! the pain still went away in 3-5 days. I tried pillows, I tried massage, all seemed to help a bit and the pain went away in 3-5 day. :)

                Ultimately I found that if I just took a brisk gentle walk it would loosen the muscles enough that I could move, although with a lot of pain. And the pain always went away in 3-5 days, regardless.

                BUT – they spasms started coming more often. toward the end, it was coming a couple of times a month. Which was a drag. This went on until I was diagnosed with Hashimoto’s and given synthroid, even though my levels were borderline and both my doctors said I couldn’t be symptomatic.

                And the muscle spasm went away. I never get them except for the couple of times I’ve went several days without the synthroid (forgot to pack traveling).

                Hey I can have my anti-evidence anecdote too. ;)

          2. CHotel says:

            There are some combinations out there for the sole purpose of deterring abuse though. First example that jumps to mind is Lomotil: an anti-diarrheal containing the opioid diphenoxylate (similar to loperamide but with a higher BBB passage) as well as atropine as an (incredibly dangerous) anti-abuse component.

            I think there are a few oral opioids for pain also that contain naloxe/naltrexone in the formulation that becomes when crushed to be snorted/injected, but I can’t remember their names off the top of my head.

        2. Young CC Prof says:

          Drugs which are opiate + OTC are Schedule 3 and 4 drugs, controlled substances but considered lower abuse potential. Opiate alone is always Schedule 2, highest abuse potential. And yes, that’s why. With opiates, the more you take the higher your tolerance grows. With tylenol, the more you take… you just die. Dose-specific poison.

          Might deter casual recreational users, but probably doesn’t deter addicts at all, it just results in more of them being hospitalized and dying.

          1. Andrey Pavlov says:

            Thanks for the clarification.

            I agree though – not much of a deterrent at all. An addict will abuse no matter what. A typical person will use as much opiate as needed for pain relief and, based on how many times and in how many ways we have to explain it, doesn’t really get the issue with acetaminophen.

          2. mousethatroared says:

            Soulless idiotic decision, that.

          3. Marcus says:

            Not only that, but due to differing solubilities in water, it’s fairly easy for someone with pretty basic knowledge to extract a good portion of the acetaminophen out of something like Vicodin. So in essence, the addicts who know what they’re doing can get rid of a good deal of the Tylenol while keeping the opiate, while others are just at an increased risk of unnecessary harm.

  8. Randy says:

    Honestly, if people cannot be bothered to read the label, that’s not the fault of the drug. Do we reduce the roads because people die violating the road signs?

    “pseudo-placebo” – an effective drug … what is this, church?

    1. mousetharoared says:

      Do we reduce the roads because people die violating the road signs?

      Actually, we often change road systems when they result in what we regard as an undue number of preventable deaths.

      For instance when I was young most the railroad crossings in our area had stop signs. There were preventable deaths from train/car collisions when drivers would either race the train, stop, but not see the train and in one case stop, look and wait for a train but not think to look for a second train coming in the opposite direction.

      Installation of gate crossings have reduced the number of train/car collisions and deaths. They are a nuisance, because we have alot of trains stopping* in our area. I guess you just have to balance the reduction of deaths/injuries with the downsides of the change.

      *backing up, going forward…the excuse “I got stopped by a train” is actually very common in our area.

  9. steney01 says:

    So you get 30 experts together, review all the evidence over several months, dedicate 150 pages to reviewing pharmacological management of osteoarthritis much of which deals with paracetamol, then draft your exciting new “key priorities for implementation” stating “Do not routinely offer paracetamol for the management of osteoarthritis. Be aware of the potential side effects and limited benefit.” only to later say, just kidding, continue on as you were…

  10. AndrewL says:

    It’s been a while since reading the studies I did read on Tylenol and Ibuprofen/toradol so forgive my generalization. What I took away from them reading them during residency and fellowship is that 1. Tylenol really does not demonstrate great analgesic effects unless one approaches 1000 mg po. It works great to decrease fever at lower doses but only 2/3 of pt will notice significant analgesia at 1000 mg po. 2. IV Tylenol 1000 mg works well at reducing opioid use by roughly 30% as does iv toradol. Thus that indicates some opioid sparing analgesia. 3. I use these doses for Tylenol only for peri operative and inpatient acute pain, I never trust patients , aside from well educated healthcare colleagues, to use these doses in outpatient acute pain . 4. I abide by the relative and absolute contraindications. 5. I am against using them chronically on a daily basis as there is some evidence that their effectiveness diminishes outside acute period . I would rather use it for flare ups of arthritic pain, though as one can tell I don’t manage outpatient as do orthopedic surgeons and pcps.

    1. AndrewL says:

      Also I think that acetaminophen should not be included in combination with other medications as the risk for overdose is too high

  11. Keating Willcox says:

    First, thank you for discussing this. I had thought that alternating Ibuprofen and Tylenol would be a better choice. Exactly the opposite is the case.

    Second, no mention of controlled substances. Is there anything about legal medical marijuana or an opium inhaler that might be analgesic without kidney or liver damage?

    For body pain, use of a heated waterbed at night and perhaps some heat pads during the daytime can help?

    if nothing else, two fingers of Jack Daniel’s?

  12. Kevin Moore says:

    Mercola warned about tylenol years ago. He also talked about the dangers of gluten going way beyond the celiac population. I guess the “legitimate” health care industry has some catching up to do.

    http://www.ncbi.nlm.nih.gov/pubmed/24521561

    1. Andrey Pavlov says:

      Even a broken clock is right twice a day.

      And there is no reason or rationale to suspect gluten is harmful beyond celiacs, and a study of n=20 on IBS sufferers doesn’t change that (or mean what you think it means).

  13. Max says:

    Appreciate the post. It seems that often SBM makes a habit of simply critiquing the non mainstream methods of treatment. I can’t stand seeing a patient duped into some sham tx or supplement, but I also hate that risks seem to be so overlooked with OTC products. My dad used to take advil like vitamins. Seriously. Even with no symptoms or pain, he’d take like 3 in the morning like some kind of multivitamin! I realize these are different drugs, but the principle is the same. He seriously thought that because you could buy them without a script, they were completely without risks or negative effects. It seems a lot of people have the same mindset. Gobble them up like candy, even if it’s an extremely manageable or non existent discomfort!

    1. Chris says:

      I can’t take narcotic pain meds because I am one of 10% who end up upchucking instead of getting any kind of relief (and no fun when I was on crutches due to a broken ankle).

      So when I have severe pain, like the back pain I got from getting youngest in and out of car seat, the doctor told me I could take a certain number of ibuprofen per day, but only for three days. Then I was also given exercises to strengthen the back muscles to avoid the pain.

    2. mousethatroared says:

      I take two Ibuprophen at bedtime and two in the morn ish…and I’m generally not in pain. Unless I don’t take the ibroprophen. You think your dad took them for no good reason. I don’t know him, but I do wonder if there might be another side of the story, may be that he didn’t admit to being in pain, because that’s how some older men are. I know my dad and father in law were like that.

      1. nancy brownlee says:

        @Mouse
        I take 2 ibuprofen, three times a day- and I have for some time- years, and with the knowledge of all my doctors. The only comment I ever got from one of them was, “For godsake don’t stop!” (Maybe they’re planning on me croaking from the carcinoid before a heart attack gets me.)

        I’m 66, but had a hip replacement before I was 50, a second one before I was 60. Surgery (really, general anesthesia) is a big problem for people with carcinoid, the last one almost killed me, so I’m not planning any more surgeries if I can help it. Even so- if I could magically wish away a single ailment, it would be the osteoarthritis. It’s miserable, it just gets worse, and there is no real help for it.

        1. nancy brownlee says:

          PS I never take Tylenol. It doesn’t work for shit.

          1. mousethatroared says:

            When my neck was worse, I used to occasionally take a dose of Tylenol between higher doses of Ibuprofen, and the tylenol did seem to help (about equivalent to a manhattan).

        2. mousethatroared says:

          nancy brownlee – That sucks about the osteo. I do also, put my daily consumption of NSAIDS on my medical forms whenever I go to the doctor. Honestly, I’m not sure if they notice, though. But I’m not yet 50, I believe my heart disease and stroke risks are low (knock on wood) and my stomach seems to tolerate this level of consumption (knock, knock). Seems like the best option at this time. On the up side (for me, sorry) I’m hoping that everything might actually settle down, if not soon, then sometime in/after menopause when my hormones settle down. This is something I’ve decided, but I’ve got my google U degree, I say it could happen and I doubt any of my doctors would disagree.

        3. mousethatroared says:

          (Maybe they’re planning on me croaking from the carcinoid before a heart attack gets me.)

          Maybe if you are doing “okay” they think it may have a beneficial effect? Kinda, don’t upset the apple cart, philosophy?

          1. nancy brownlee says:

            @Mouse
            I suspect you may be right. I have (finally) a very good oncologist who is really knowledgeable about carcinoid – it only took fifteen years to find him. My PCP, a prim, elderly Muslim, is extremely conservative and extremely careful. I trust them both.

            Oddly, in spite of the carcinoid, the osteo, and the Type II diabetes caused by the Sandostatin, I think of myself as ‘robustly healthy, with a few problems’. I guess we can add ‘delusional’ to the list, huh?

        4. Stephen S. Rodrigues, MD says:

          Did you know that Travell/Simons back in the 50′s realized that joint surgery was not the best choice and that Myofascial Release therapy was overall better, safe and actually helps to realign the structures.

          With an artificial joint all bets are off but it will still help with pain and ROM.

          1. Nashira says:

            …in the 1950s? That’s sixty years ago. Science has moved on. I know it’s pointless telling you that, but seriously: sixty years is a long long long time.

          2. windriven says:

            Rodrigues is an intellectual fraud and coward. He uses these pages to peddle his infantile delusions but refuses to confront the fact that modern medicine has changed the human condition in revolutionary ways while the quackery that he advocates only seems to ‘work’ where actual outcomes can’t be objectively measured.

            We do not have “alternative chemistry” or “alternative aeronautics” or “alternative physics” because these delusions have nothing to offer while their non-alternative counterparts have delivered everything from smart phones to supersonic flight. So too the difference between medicine and the quackery that masquerades as “alternative medicine”. I’ve offered Rodrigues untold opportunities to prove me wrong, to humiliate me with the power and majesty of his quackery.

            So far, only the sounds of silence.

  14. Andrés says:

    Since I have already been accused of JAQing off… let’s go for it (with links, though):

    a) What’s the reason for simply not banning acetaminophen use in mixed medicines?

    b) What’s the reason for not directly mixing it always with its antidote (NAC)?

    c) Given the amount of data showing an association with neurological (via Dr. Cannell) and respiratory problems of babies born to mothers taking acetaminophen when pregnant, why hasn’t it been discouraged its use during pregnancy and for infants (via Dr. Deans) yet?

    d) Shouldn’t a reference either to vitamin K2 or vitamin K1 be in the NICE report?

  15. Stephen S. Rodrigues, MD says:

    What faith! You all expect the same people who put you in this predicament to help you with your pain??!. Fascinating!

    1. mousethatroared says:

      SSR – Did you have an accident with a head injury or something? I mean, I do think your are a leech, but I’ll feel bad if it’s due to some sort of head injury that caused you to loose your logical and ethical faculties.

      1. Stephen S. Rodrigues, MD says:

        Right as rain! :)

        1. windriven says:

          Rodrigues is an intellectual fraud and coward. He uses these pages to peddle his infantile delusions but refuses to confront the fact that modern medicine has changed the human condition in revolutionary ways while the quackery that he advocates only seems to ‘work’ where actual outcomes can’t be objectively measured.

          We do not have “alternative chemistry” or “alternative aeronautics” or “alternative physics” because these delusions have nothing to offer while their non-alternative counterparts have delivered everything from smart phones to supersonic flight. So too the difference between medicine and the quackery that masquerades as “alternative medicine”. I’ve offered Rodrigues untold opportunities to prove me wrong, to humiliate me with the power and majesty of his quackery.

          So far, only the sounds of silence.

    2. windriven says:

      Rodrigues is an intellectual fraud and coward. He uses these pages to peddle his infantile delusions but refuses to confront the fact that modern medicine has changed the human condition in revolutionary ways while the quackery that he advocates only seems to ‘work’ where actual outcomes can’t be objectively measured.

      We do not have “alternative chemistry” or “alternative aeronautics” or “alternative physics” because these delusions have nothing to offer while their non-alternative counterparts have delivered everything from smart phones to supersonic flight. So too the difference between medicine and the quackery that masquerades as “alternative medicine”. I’ve offered Rodrigues untold opportunities to prove me wrong, to humiliate me with the power and majesty of his quackery.

      So far, only the sounds of silence.

    3. mousethatroared says:

      Just logistically challenged then?

      I guess my vocabulary must be failing me. You appear to be talking about a side effect of a medication that occurs BEFORE you take the medication. I’m not familiar with the term for that.

      1. Harriet Hall says:

        Some chemotherapy patients develop anticipatory nausea before each treatment, not a direct side effect perhaps, but still a sort of side effect.

        1. mousethatroared says:

          That’s interesting HH, but I don’t think that’s the word for what SSR is suggesting. He appears to be suggesting that the doctor who is treating the pain – caused the pain. Yet, most of us don’t go to a doctor for treatment of pain until after we have a pain.

          It’s an accusation that’s not only lacking in evidence it’s lacking in basic ability to arrange events in order.

  16. Stella B says:

    I have to think these recommendations were put together by people under the age of 50. “Take for the shortest time possible” — which means what? Until the cartilage regenerates?

    1. Vicki says:

      Until the pain becomes more tolerable, maybe?

      For at least some people, while osteoarthritis doesn’t go away, the amount of pain varies over time, with worse times followed by better ones. Mine is mild enough that the good days are ones with no knee pain, but I can see someone else deciding that they’ll take pills on the days when it’s that or not exercise, but do without on the days when the pain is tolerable during walking or other exercise. Yes, it would be nice to get the pain down to zero, but if someone is making a choice between, say, joint pain and stomach problems, it makes sense to minimize the NSAIDs.

  17. Mark R. says:

    oh my! this is alarming!458 deaths a year?this is scary..no wonder why there are cases of dead celebrities…wrong intakes…well,i guess there are no safe drugs now a days huh….it’s really better/safer to see first your doctor before taking any meds..atleast this helps….thanks Harriet Hall!

  18. David J Gill says:

    I suspect that even Tylenol/Acetaminophen used as directed, that is within the limits specified on the package, can cause kidney and liver damage.

    A close friend died last year due, in the end, to unexplained liver damage. There were other contributing factors, but I do know that he was a long term frequent user of Acetaminophen. He was aware of the dangers of exceeding the maximum dosage; he often talked about that. The severity of liver damage could not be explained by his doctors as resulting from any known factor. I think long term use of Acetaminophen has to be considered a likely cause.

  19. Chet David says:

    Guys, not every medicine is for everybody. It is ok to do self medication especially when just taking sorts like pain reliever, anti-biotic, anti-inflammation but once you experience adverse effect, immediately stop taking your meds and consult your Doctor as soon as possible. Our body reacts differently on medicines.

  20. BRenda says:

    I no longer use Acetaminophen, but understand that many people are dealing with severe pain.
    But why is this medicine recommended for pregnant mothers, and their children.
    It has a strong association with asthma, most recently in Denmark with ADHD and with autism. On top of that are concerns about kidney and liver.
    And we know that the drug passes into the placenta-at the dose needed for pain control of the mother-not the embryo. I question whether it was a wise choice to give up aspirin for Acetaminophen.
    Acetaminophen reduces glutathione in the liver by a substantial amount. This is a key protective molecule of our immune system.
    The other depleting agents would be smoking, caffeine, alcohol, vigorous exercise, radiation and drugs. None of these other agents would be administered to a child or embryo-why have we decided that it makes sense to give Acetaminophen to our young.
    Neither aspirin not Ibuprofen have this dangerous action.
    It should be noted that it can be very hard to raise glutathione by eating food. Not a great idea to lower glutathione in sick or vulnerable people.

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