Tylenol & Liver Damage--25 Facts You Should Know

Get to Know the Tylenol Toxicity Warning Signs.

Breathing Difficulty, Swelling or Rash, Grey Color Stool, or Yellowing Skin are ALL signs of Tylenol/Acetaminophen toxicity and potential liver failure. Even non-drinkers are at risk. 

By now you have probably heard that Tylenol (or, more specifically, acetaminophen) can damage the liver. In most cases, damage to the liver is thought to occur because of over-dosing, either accidentally or by design (as in sucide attempts). Problems can also arise if people drink alcohol while taking this drug, use more than one medication containing acetaminophen (thus possibly surpassing the recommended dosages without realizing it), use acetaminophen while pregnant, or take this medication in combination with other drugs that bring about dangerous interactions.

Because acetaminophen is such popular medicine, everyone needs to stay informed on the latest advice in order to avoid complications.  Liver damage because of this drug is not only common but it leads to over 100,000 phone calls to poison control centers, over 60,000 ER visits, and many deaths each year; in fact, liver damage due to Tylenol is one of the leading causes of liver transplants here and abroad.

The acetaminophen/liver damage connection, therefore, is not only important news, it's also a very interesting phenomenon in bio-medicine. How so? Well, Tylenol has been used for a very long time--in fact, it has an almost impeccable record, were it not for this side-effect/complication. The fact is that acetaminophen is still considered an extremely safe drug, as long as it is used responsibly and under the watchful eyes of healthcare professionals.

Having said that, acetaminophen is an OTC drug, meaning that it is often not used under the watchful eyes of healthcare professionals. Should this drug, then, be solely prescribed? At this time, this is not being recommended. What is being advised is that acetaminophen be used only under very carefully delineated guidelines; you also need to keep the following essential facts in mind:

1. Acetaminophen can be found in over 600 OTC and prescription medications, which is why it's not that difficult to take more than the recommended dosages in a given period of time; it also means that this is a multi-million dollar product for Johnson & Johnson/McNeil.
2. This drug is both an antipyretic (reduces fever) and an analgesic (pain reducer); it reduces fever by controlling the fatty acid prostaglandin E. (which can affect body temperature) and it reduces pain by inhibiting neurotransmitter pain-registering receptors substance P and N-methyl-D-aspartate. 
3. Acetaminophen can be safely used for chronic pain, as is seen in some types of arthritis; in general, it is not used for imflammatory purposes.
4. The maximum amount taken should not exceed 3,000 mg (3 grams) in a 24-hour period, maximum 6 pills per day at no more than 2 pills every 6 hours; it should be noted that even small amounts over this cap can be toxic for the liver.
5. Glucuronide and sulphate, two of the by-products of acetaminophen when processed by the liver, can become toxic if they overwhem the liver; even if this happens, the body produces cytochrome P-450 to get rid of these substances but, in doing so, the body can also produce NAPQ1, which is itself toxic to the liver--at least when produced in certain quantities. 
6. Drinking alcohol, as well as using certain medications (e.g. anti-TB and anti-seizure meds), in conjunction with acetaminophen can further enhance chance of liver damage/failure.
7. NAPQ1 can also be dangerous to the child carried by pregnant women; the danger is exacerbated after the fetus is over 14 weeks old.
8. Doctors can determine if acetaminophen poisoning has occurred by determining the amounts of the drug taken and by conducting blood tests; such assessments cannot wait for visual signs of liver damage since such signs may appear long after liver damage has already taken place. In fact, if you merely suspect a Tylenol over-dosage, medical attention needs to be sought immediately.
9. The FDA has taken steps to reduce chances of acetaminophen liver damage: it has recommended that individual capsule/tablets not exceed 325 mg, that the drug be removed from some pain medicines (e.g., Percocet & Vicodin) and that black box warning labels be required on all medications containing this drug.
10. Tylenol has been the focus of several drug recalls in the past.
11. Tylenol has also been the subject of several lawsuits which have alleged that the potential toxicity of the product was not clearly identified to consumers prior to their using the product; one aspect of the lawsuits was the potential danger of taking the drug while not eating (on an empty stomach?). 
12. In order to treat a potential acetaminophen overdose doctors may lavage (pump out) a person's stomach; in serious cases, the antidote N-acetylcystine (NAC) may be used. Additionally, oral activated charcoal may be used in conjunction with NAC.  Both of these can help hinder absorption of acetaminophen.
13. Treatment needs to take place soon after taking an overdose of acetaminophen--preferably within 8 hours.  Liver damage/failure, without treatment, can occur within days of ingestion.
14. A liver transplant may be the only viable option for patients with severe liver damage.
15. There are 4 phases of acetominophen-induced liver damage/poisoning. Phase 1: ingestion within 24 hours; symptoms include nausea, paleness, vomiting and diaphoresis (too much sweating). Phase 2: within 18 to 72 hours; right quadrant pain, irregular heart beat, and high blood pressure. Phase 3: 72 to 86 hours; the most critical phase; pain, liver damage/failure, noted by hypoglycemia (lowered blood sugar), jaundice, coagulopathy (leading to bleeding), possible loss of normal brain activity, and some organ failures. Phase 4: four days to 3 weeks; it involves recovery, for those who survive the onslaught.
16. Liver damage/failure may also include: clay-tinted stool, dark urine, jaundice (yellowing of skin, etc.), noticeable skin reactions/conditions. These skin conditions may include blistering, pignment changes, rashes, dry, scaly skin, scarring and, in severe cases, blindness.
17. Acetaminophen can be found in a number of OTC medications: Benadryl, Actifed, Dristan, Formula 44, Cepacol, Dayquil, Excedrin, Anacin, Dimetapp, Midol, Robitussin, Sinutab, Triaminic, Vicks, Nyquil, Saint Joseph, Sudafed, Panadon, Theraflu, etc. 
18. Acetaminophen can also be found in many prescribed meds: Endocet, Hydroct, Percocet, Tapano , Ulatracet, Hydrocodone, Phenaphen, Vicodin, Hycotab, Lortab, Sedapap, Tylox, Zydone, etc.
19. You need to determine if the drugs you take on a regular basis contain acetaminophen; it may be listed as "APAP," AC, Acetaminophen, Acetaminoph, Acetaminop, Acetamin, or Acetam.
20. Acetaminophen may also involve allergic reactions usually involving swelling of the mouth, face or throat, difficulty with breathing, rashes, itching, etc.
21. Acetaminophen's damage may be caused by its depletion of glutathione from affected persons' bodies.
22. Symptoms of liver damage include:  a swollen abdomen (ascites); Jaundice; tenderness to the abdomen; changes in urine; dry, itchy, irritated skin; changes to the stool; nausea; appetite loss; retention of fluid; and lack of energy/exhaustion.
23. Avoid taking chemicals to treat symptoms like pain or fever whenever possible; find natural alternatives (i.e., herbs like ginger) with no history of serious problems/complications in the literature; always consult a healthcare provider before beginning any such regimen.
24. Be especially careful when administering medications to minors without the supervision/advice of a healthcare provider.
25. If you suspect acetaminophen poisoning, seek medical attention ASAP; doing so may avert a damaged/failing liver--it may even prevent death.

Conclusion

Liver damage/failure because of acetaminophen poisoning should not be taken lightly. In fact, it is best avoided by using the drug responsibly. Beyond that, the more you know about this potential problem, the better you will be prepared to deal with it, should it rear its ugly head around you. Although best if avoided, if you run into this problem, you will know what to look for, and what to do for best results.

Other Sources:

https://www.ncbi.nlm.nih.gov/pubmed/21565648

https://www.poison.org/articles/2009-dec/acetaminophen-take-it-safely

https://www.ncbi.nlm.nih.gov/pubmed/15239078