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Why acetaminophen is the ‘most common cause of liver injury’ in Canada

Health Canada boosts labelling requirements, but some doctors want extra-strength products off the shelves

Dr. Michael Rieder, a pediatric clinical pharmacologist at Western University in London, Ont., says acetaminophen misuse is the most common cause of liver injury in Canada.

Health Canada’s new labelling rules for acetaminophen are not strict enough, and the extra-strength products should be removed from store shelves, some doctors say.

Acetaminophen is one of the most widely used pain and fever relievers in Canada and worldwide. It is safe if used properly, but too much can be dangerous, particularly over time.

“It is the most common cause of liver injury. Period. Full stop,” said  Dr. Michael Rieder, a pediatric clinical pharmacologist at Western University in London, Ont.

Part of the challenge is that the drug is ubiquitous. Acetaminophen is found in Tylenol and more than 400 over-the-counter products in Canada, including combination cold and cough medicines and nighttime products, such as NyQuil and Sinutab.

“It used to be that acetaminophen was just in tablets,” said Rieder. Now it’s found in a range of new products and “you may not know that unless you look at the ingredients.”

Acetaminophen products
You may not know that acetaminophen is in a product
unless you look at the ingredients. 

Doctors and pharmacists may recommend acetaminophen to treat minor aches and pains, such as those from the common cold, viral and bacterial infections, headache, toothache, strains and sprains and menstrual cramps.

Too much of it can damage the liver.

Each year, about 4,500 hospitalizations in Canada occur due to acetaminophen overdose, and about 16 per cent of these are accidental, Health Canada says.

Symptoms depend on how much acetaminophen is in the blood. They can range from none to vomiting and abdominal pain to liver failure and death.

The overdoses are one reason Health Canada will be requiring stricter labelling rules for acetaminophen.

“The challenge for us and for practitioners and for patients and anybody that is using this medication is, how do you manage and balance the benefits of the product with the risks?” said Dr. Supriya Sharma, a senior medical adviser in the health products and food branch at Health Canada.

Severe liver damage and failure

Rieder called Health Canada a “responsible regulator” for imposing the new labelling rules. But he’d like to see only regular strength acetaminophen products on store shelves for consumers to grab.

Dr. Eric Yoshida says he’s had patients die waiting for liver transplants that never came after they suffered inadvertent acetaminophen injury. (CBC)

As a liver specialist at Vancouver General Hospital, Dr. Eric Yoshida regularly sees patients with severe liver failure from accidental acetaminophen overdose.

acetaminophen
‘The challenge for us and for practitioners and for patients and anybody that is using this medication is,
how do you manage and balance the benefits of the product with the risks?’

– Dr. Supriya Sharma, medical adviser to Health Canada

“I’m on call to the liver transplant program for this province. I just got a phone call literally two days ago from another hospital of somebody who was a heavy consumer of alcohol and took Tylenol and now they’re in severe liver injury and they were calling for a transplant or possible transplant assessment.”

There’s a good chance of recovery for that individual, Yoshida said, but the problem is a common one.

Yoshida said he realizes that extra-strength products are big sellers. But he wants consumers to be aware that when they take extra-strength acetaminophen, they’re just getting more of that drug, not a different molecule with more pain-relieving properties.
Inadvertent overdoses

“It’s the inadvertent overdoses that are particularly bothersome to myself,” Yoshida said.

He described a typical scenario of someone taking two tablets every three to four hours and then losing track of how much they took. “Those are the kind of inadvertent uses that can lead to drug-induced liver disease, acute liver injury.”

Like Rieder, Yoshida would like to see the amount of acetaminophen in products restricted to the regular-strength dose of 325 milligrams.

Why is too much acetaminophen so toxic to the liver over time?

In most people, therapeutic amounts of acetaminophen are broken down into non-toxic forms and secreted in the urine.

If our detox systems are overwhelmed by high doses of acetaminophen — five to 10 times the regular amount, Rieder said — then dangerous byproducts build up. If severe enough, it can disrupt how the liver works or cause the organ to stop working.

At the University of Alberta Hospital in Edmonton, critical care physician Dr. Dean Karvellas said he’s seen patients have acute liver failure while taking the maximum daily dose. He’d like to see it lowered from four grams, or eight tablets of extra-strength acetaminophen, to about three grams.

Teens and children affected

The liver toxicity is reversible if mild, Karvellas said, but sometimes the damage can’t be reversed.

It’s the most common cause of drug-induced liver injury in teens, said Rieder, who also chairs the drug therapy committee of the Canadian Pediatric Society.

Health Canada says the risk of liver injuries involving acetaminophen may be higher if you:

  • Have liver disease.
  • Drink three or more alcoholic drinks every day, even if you follow the recommended dose limit.
  • Use acetaminophen for a long time, even at the recommended dose.
    Health Canada’s Dr. Sharma said the regulator heard concerns from patient groups who feared pulling the extra strength products would drive people towards using opioids and other pain medications with more serious side-effects.

As for combining the drug with booze, there’s a feeling alcohol may increase the liver injury, but the jury is out to what degree, Rieder said.

For some vulnerable segments of the population, such as children, taking slightly more than the therapeutic dose over long periods can also result in overdoses, he said.

By Amina Zafar, CBC News    Sep 16, 2016
source: www.cbc.ca
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Do You Fall for the ‘Nocebo Effect’? 5 Ways to Stay Positive for Better Health

Scientific studies confirm that a placebo (a dummy medication or procedure) can genuinely benefit a person’s health. But its sinister cousin, the “nocebo effect,” creates expectations of harm, which can lead to seriously negative health consequences.

A patient’s expectations of a treatment clearly influence the way it works. The authors of a 2012 German study note that vulnerable, ill, or injured patients are highly receptive to negative suggestion. A participant in one drug trial developed dangerously low blood pressure by “overdosing” on what he thought was an antidepressant—only when he learned that it was an inert substance did his blood pressure return to normal. (Conversely, the power of positive suggestion may explain some of the success of complementary therapies—from herbal remedies to homeopathy). The more strongly a patient believes in the treatment, the more likely it is to be effective. Here are some ways you can put this knowledge to practice:

1. Get authoritative information Before having treatment or taking medication, get advice from a reputable source. The Internet is a vast repository of information but obviously not all of it is reliable. If you have a tendency toward hypochondria, it can be more harmful than helpful, as the nocebo effect is known to influence those who have a pessimistic outlook more powerfully than those with a more balanced attitude.

pills

2. Control your response to health experts who are treating you. Focus on encouraging phrases, such as “most people tolerate this well” or “this shouldn’t hurt.” Try to tune out the negative comments, such as “this may be painful,” “expect a long recovery time” or “you may find that this treatment makes you feel sick.”

3. Engage your mind Use creative imagery to stay positive while you recover from illness. If you are in pain, for example, it may help to imagine tight muscles being massaged, visualize the muscle fibers separating and relaxing, and to concentrate on feelings of warmth. As you visualize, try to focus on your breathing and imagine that you are relaxing in the sunshine or floating in a pool.

4. Use the power of touch Studies have shown that the touch of a partner, friend, or health practitioner can benefit conditions as diverse as asthma, arthritis, hypertension, and migraine. Touch therapy has also been proven to reduce pain and accelerate wound healing. Even if, as some maintain, this is a placebo effect, it is the end result that is significant.

5. Keep positive There is overwhelming evidence that those who heal fastest maintain a positive attitude, take responsibility for their own health, and focus on getting well. Self-awareness also helps, especially of attitudes that may hamper your health.

From Health Secrets: The Best Remedies From Around the World (Reader’s Digest Association Books)
 
source: www.rd.com


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Seniors Can Often Simplify Medication Routines

By Allison Bond

Inez Willis, a senior citizen, cooks on her stovetop at her independent living apartment in Silver Spring, Maryland April 11, 2012.

(Reuters Health) – Miscommunication between healthcare providers and patient concerns over drug interactions lead to many seniors having an unnecessarily complicated medication regimen, a new study finds.

With a very complicated routine, “it’s easier to forget medications,” said the lead author, Dr. Lee Lindquist, a geriatrician at Northwestern University Feinberg School of Medicine in Chicago.

“If you consolidate the regimen, you can know that you’re done at the end of the day,” Lindquist told Reuters Health. For example, if a patient is prescribed three medicines that are each supposed to be taken twice per day, it’s likely they can be taken together each time.

For the study, published in the journal Patient Education and Counseling, nurses visited the homes of 200 patients over the age of 70.

All the participants had been discharged from the hospital one month prior and they averaged nearly 80 years old.

The nurses asked participants how and when they took their medications in a given day. Then a pharmacist and a doctor looked at each patient’s medication list to see the lowest number of times per day the participant could take his or her medications.

Next, they compared this number to the actual number of times per day that each patient had said they took their medicines.

medications

Lindquist and her team found that 85 of the participants – just over 42 percent – were following a medicine regimen that could be simplified. Of these, 53 participants, or more than one quarter, could cut the number of times they took their medicines by once per day; and 32 participants, or 16 percent, could reduce that number by at least two times each day.

The team also identified the most common reasons for an overly complicated medication routine. One was patients’ concerns about interactions between food and medicines, and between different medicines. Another was misunderstanding medication instructions given to the participants by healthcare providers like pharmacists or physicians.

Patients should check with their doctor before changing the way they take their medicines, but the results of the study show the importance of a discussion between patients and providers about the logistics of taking necessary medicines, Lindquist said.

“That dialogue has to start; patients need to ask their pharmacist or physician whether they can cut down medications or consolidate them,” she said. The big questions patients should ask their doctors, she added, is “can I make it easier on me?”

One way that people taking many medications can work with a doctor on the simplest regimen is to walk through how they take medicines each day.

Dr. Serena Chao, a geriatrician at Boston Medical Center who was not involved in the study, said patients should bring all medicines to each appointment, and arrive “prepared to talk about what time they take their medications.”

“Go through all of the details, and then with the doctor, figure out whether the routine can be consolidated,” Chao told Reuters Health. Because after all, keeping track of lots of medicines can be difficult – but the goal is to minimize the inconvenience they pose to living everyday life.

“Your medications should not dictate your life. They should be working for you, not the other way around,” said Lindquist.

SOURCE: bit.ly/R5c6rd Patient Education and Counseling, online April 4, 2014        www.reuters.com