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Safety Bulletin: Pain Relievers and Liver Disease

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Learn how to keep your liver as safe as possible when choosing a pain reliever with chronic liver disease.

For some people, relieving pain is as simple as taking a few over-the-counter pills. For those with liver disease, pain relief can be a bit more complicated. Just like the food we eat and the beverages we consume, any medications we ingest must be processed by the liver. Regrettably, liver disease can impair drug metabolism – potentially putting the liver in peril when taking pain-relieving medications.

The American Liver Foundation reported that 30 million Americans were living with chronic liver disease in 2010, or roughly 1 in 10 people. According to a 2011 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education, 100 million Americans live with chronic pain. When taken together, the number of people likely in pain (especially chronic pain) concurrent with chronic liver disease is staggering.

Typically, those with mild liver disease can safely take most common medications (prescription and non-prescription) at the recommended dose. Mild liver disease does not necessarily increase the risk that a given medication will be toxic to the liver. However, should a problem occur in someone with mild liver disease, the drug-induced liver damage would be more severe than it would be in an otherwise healthy person. Unfortunately, those with more advanced liver disease (such as cirrhosis), have a greater risk of drug-induced liver damage because the liver’s ability to metabolize medications is impaired.

If you’re interested in a natural remedy for relieving chronic aches and pains (as well as headaches and stiff joints) – all without any gastrointestinal upset – consider trying Turmeric 95. It’s standardized to 95% curcuminoids, which is the highest level available of the beneficial ingredient in turmeric. Turmeric 95 offers 20x the absorption, and is the most potent and effective turmeric on the market.

NSAIDs and Acetaminophen

The two main categories of commonly used pain relievers are acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), which include aspirin, ibuprofen and drugs known as COX-2 inhibitors.

  1. NSAIDs – NSAIDs revolutionized the treatment of pain, but they are hard on the stomach, sometimes causing ulcers or gastrointestinal bleeding. In addition, NSAIDs have been linked to an increased risk of heart disease. All NSAIDs, including the COX-2 drugs, easily boost blood pressure. The effect is most pronounced in those who have high blood pressure already, but there’s evidence that people with normal blood pressure are also affected. Those with chronic liver disease may have portal hypertension and be at an elevated risk of gastrointestinal bleeding. For this reason, many physicians will suggest those with liver disease choose acetaminophen instead.
  2. Acetaminophen – Acetaminophen is easier on the stomach than NSAIDs, but has its own set of problems. Acetaminophen can damage the liver. This is because the liver breaks acetaminophen down into a chemical that is poisonous to liver cells. Usually, the antioxidant called glutathione prevents this toxin from harming the liver. Studies have shown that those with chronic liver disease have lower levels of glutathione than those with healthy livers. In addition, excessive doses of acetaminophen override glutathione’s protective ability; leaving the liver vulnerable to damage. Increase glutathione levels in your body with N-Acetyl L-Cysteine!

In 2013, the American Chronic Pain Association stated that although the maximum recommended adult dose for acetaminophen is 4 grams per day (and 3 grams per day in older persons), patients can have asymptomatic elevations in liver enzymes at 2 grams per day of acetaminophen. According to Dr. Melissa Palmer, MD, small doses of acetaminophen, such as one to two 500-mg tablets per 24 hours, can be safer for people with liver disease than some other drugs, such as aspirin.

As long as these acetaminophen dosage guidelines are adhered to, the liver is relatively safe from additional harm. However, the real problem of acetaminophen-related toxicity occurs from unintentional overdose from more than one medication. One of the most widely used drug ingredients, acetaminophen is found in more than 600 prescription and over-the-counter medications, including:

  • Allergy pills
  • Cold medicines
  • Cough syrups
  • Headache pills
  • Sleep aids

Especially important to those with liver disease, never take more than one product at a time that contains acetaminophen. Always review the “Active Ingredients” section of the “Drug Facts” box on over-the-counter medications, or the label on a prescription, where acetaminophen may be called paracetamol or abbreviated as “APAP” or “acetam.” For example, accidentally taking Tylenol® for back pain at the same time as Robitussin® for a cold could result in an acetaminophen overdose.

A handful of examples of common over-the-counter medications that contain APAP are:

  • Actifed®
  • Alka-Seltzer Plus®
  • Contac®
  • Dayquil®
  • Excedrin®
  • Midol®
  • Mucinex®
  • Robitussin®
  • Sudafed®
  • Theraflu®
  • Tylenol®
  • Unisom PM Pain®

A handful of examples of common prescription medications that contain APAP are:

  • Hydrocet®
  • Hydrocodone Bitartrate®
  • Lortab®
  • Oxycodone®
  • Percocet®
  • Tramadol
  • TYLENOL® with Codeine
  • Ultracet®
  • Vicodin®
  • Zydone®

Safety Checklist

For those with chronic liver disease, especially with an advanced illness like cirrhosis, pain relievers must be chosen carefully and dosed appropriately. The four items on this checklist will help assure your safety:

  1. Find out which pain reliever is most appropriate for you.
  2. Make certain you stay at or below the suggested dosage.
  3. Double-check that you are not taking more than one medication with APAP at a time.
  4. Be sure to properly space out doses.

As long as a physician authorizes it and the safety guidelines described are adhered to, taking medication for pain relief is not likely to further injure your liver.


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http://patients.gi.org/topics/medications-and-the-liver/, Medications and the Liver, Retrieved May 29, 2016, American College of Gastroenterology, 2016.

http://www.cpmc.org/advanced/liver/patients/topics/liver.html, Your Liver and Liver Disease, Retrieved May 29, 2016, California Pacific Medical Center, 2016.

http://www.health.harvard.edu/pain/12-things-you-should-know-about-pain-relievers, 11 Things You Should Know About Common Pain Relievers, Retrieved May 29, 2016, Harvard University, 2016.

http://www.knowyourdose.org/common-medicines/, Common Medicines, Retrieved June 5, 2016, The Acetaminophen Awareness Coalition, 2016.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250965/, The Therapeutic Use of Analgesics in Patients With Liver Cirrhosis: A Literature Review and Evidence-Based Recommendations, F. Imani, et al, Retrieved May 29, 2016, Hepatitis Monthly, October 2014.

http://www.painmed.org/patientcenter/facts_on_pain.aspx, AAPM Facts and Figures on Pain, Retrieved May 29, 2016, The American Academy of Pain Medicine, 2016.

http://www.practicalpainmanagement.com/treatments/pharmacological/non-opioids/safe-usage-analgesics-patients-chronic-liver-disease-review, Safe Usage of Analgesics in Patients with Chronic Liver Disease: A Review of the Literature, May 29, 2016, Vertical Health, LLC, 2016.

http://www.webmd.com/hepatitis/acetaminophen-liver-safety, Acetaminophen and Your Liver: What’s Safe?, Retrieved May 29, 2016, WebMD, LLC, 2016.

Institute of Medicine of The National Academies, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, The National Academies Press, Washington DC, 2011; 1.

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About the Author

Nicole Cutler, L.Ac., MTCM, Dipl. Ac. (NCCAOM)®

Nicole Cutler, L.Ac., MTCM is a long time advocate of integrating perspectives on health. With a Bachelor's degree in Neuroscience from the University of Rochester and a Master's degree in Traditional Chinese Medicine from Five Branches Institute, Nicole has been a licensed acupuncturist since 2000. She has gathered acupuncture licenses in the states of California and New York, is a certified specialist with the National Acupuncture Detoxification Association, has earned diplomat status with the National Commission of Chinese and Oriental Medicine in Acupuncture and Chinese Herbology and is a member of the Society for Integrative Oncology. In addition to her acupuncture practice that focuses on stress and pain relief, digestion, immunity and oncology, Nicole contributes to the integration of healthcare by writing articles for professional massage therapists and people living with liver disease.

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