Health Tip: Is Ibuprofen (Motrin) Safe?

On any given day, 30 million Americans use a non-steroidal anti-inflammatory drug (NSAID) to treat their pain. Studies show that NSAIDs can reduce pain by about four points on a ten point scale.

Ibuprofen is part of the NSAID class of drugs, and is the most popular. These common pain meds reduce inflammation by inhibiting a group of "cyclooxengenase" enzymes (abbreviated COX1 and COX2). The COX 2 enzymes are responsible for triggering the immune system to respond to injury. However, it so happens that the COX 1 enzymes protect the stomach lining and enhance blood clotting. So at the same time that most NSAIDs reduce pain and inflammation, they can also increase the risk of ulcers and bleeding. Other potential side effects include increased blood pressure, kidney injury, and ringing in the ears (tinnitus).

This list of side effects may seem worrisome at first, but they are actually not too common if ibuprofen is taken in small amounts for short periods of time. For those without stomach ulcers, kidney or heart disease, or blood clotting issues, NSAIDs have a less than half of one percent chance of causing an unwanted side effect.

For those with a history of gastritis or stomach ulcers, NSAID risk is greatly reduced by taking it in combination with a type of antacid called a "proton pump inhibitor" such as pantoprazole (Protonix) and omeprazole (Prilosec).

When we think about medicine risks, I think it's important to compare the alternatives. Acetaminophen has a different side effect profile and can be effective for arthritis pain.  But consider opioid pain medicines (oxycodone, hydrocodone, codeine, morphine, and tramadol, etc.) - they may be effective for severe, acute pain, but they come with a surprisingly high risk of dependence and addiction. Beyond the risk of severe constipation, nausea, and reduced breathing rate, is the risk of becoming addicted to the medicine. Did you know that 5% of people who are given a prescription for opioid pain medicines become addicted to them long-term, and 10% become addicted if they're given a second prescription? Dependence on opioids (meaning you experience physical withdrawal symptoms if you stop taking them, and/or need higher doses to control the pain) can begin as early as 3 days after starting them, and an estimated 26% of those who take them engage in "problematic behaviors" afterwards. Opioid overdose is a more common cause of death than automobile accidents in the United States these days!

You also may be surprised to know that NSAIDs such as ibuprofen have been shown to be equally effective in reducing arthritis pain as opioid medications. For chronic pain, opioids have shown to be ineffective.
My opinion is that ibuprofen is a reasonable first line drug for the management of inflammatory pain (from arthritis or an acute injury such as muscle strain, bruise, fracture, or surgical procedure) so long as you don't have significant stomach, heart, or kidney problems and are not taking a blood thinner (such as Coumadin, Pradaxa, Eliquis, Xaralto). Acetaminophen may be preferable in these cases, though may be less effective. However, the risks are far lower than an opioid medication, and the benefits are fairly similar.

It's important to know that the risks of bleeding, heart attacks, and kidney injury increase with higher doses or longer term use. Ideally, people should take the lowest effective dose for the shortest amount of time to reap the benefits of pain relief without the unwanted potential side effects. It is estimated that 20% of ibuprofen users exceed the recommended daily dosing, putting themselves at higher risk for side effects. Remember to be realistic about pain control - it is unlikely for pain to be completely removed by any medicine, but a 4 point drop (on the 0-10 scale) is an excellent result.

If you do have health problems, talk to your doctor first before taking NSAIDs. For the average American, ibuprofen's 0.4% risk of bleeding is a lot better odds than a 26% chance of dependency and a 5-10% chance of long-term drug addiction with an opioid pain medicine!

References
https://www.uptodate.com/contents/nonsteroidal-antiinflammatory-drugs-nsaids-beyond-the-basics
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478398/
https://www.drugabuse.gov/publications/teaching-packets/neurobiology-...
https://www.cbsnews.com/news/opioid-painkiller-addiction-dependence-can-start-in-days/
http://www.latimes.com/science/sciencenow/la-sci-sn-pain-opioids-ibuprofen-20171107-story.html
https://www.nbcnews.com/storyline/americas-heroin-epidemic/americans-are-abusing-over...;

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Health Tip: How Safe Is Acetaminophen (Tylenol)?

A patient recently told me that he had heard that Tylenol (acetaminophen) can damage the liver. He wondered if it was safe to use it, and how much was appropriate to take. Interestingly, acetaminophen is the most popular drug in America. The Consumer Healthcare Products Association notes:

Acetaminophen is the most common drug ingredient in the United States. It's found in more than 600 different medicines, including prescription and over-the-counter (OTC) pain relievers, fever reducers, and sleep aids as well as cough, cold, and allergy medicines. Each week, approximately 23 percent of U.S. adults — or 52 million consumers — use an acetaminophen-containing medicine.

So this is an important question, affecting 25% of American adults each week!

How does acetaminophen damage the liver?
After acetaminophen is digested in the stomach it is absorbed into the bloodstream and is broken down in the liver and eventually removed in the urine and feces. Enzymes in the liver "chop up" the acetaminophen into smaller compounds, 90% of which are harmless substances, but 10% require conversion into a water-soluble product that can be added to bile and removed in feces. If that 10%, consisting of a toxic compound called N-acetyl-p-benzoquinoeimine (NAPQI), is not successfully neutralized with a substance called gluthathione, it can cause harm to the nearby liver cells. Healthy livers have no problem neutralizing the NAPQI, especially in small amounts. But sick livers are at not as functional, and the toxin can build up, causing further damage to an already dysfunctional organ.

Therefore, people with liver disease (caused by hepatitis viruses, fatty liver, or alcoholic cirrhosis among others) should not take acetaminophen.

Alcohol interferes with the gene that makes the natural, acetaminophen-neutralizing gluthathione, so it is not recommended to drink more than 2 servings of alcohol per day when taking acetaminophen.

So how much acetaminophen is safe?
So long as you don't have liver disease, and do not drink alcohol with acetaminophen, the maximum recommended daily dose is 4 grams for adults and 3 grams for adults over 65. As we age, our ability to process acetaminophen decreases, so we need to adjust our dosing accordingly. Research suggests that taking 7g or more per day is likely to result in liver damage.

Advice to avoid overdosing:

1. Since acetaminophen is included in over 600 different medicines, make sure you don't get a double dose of it by accident, especially if you're taking multiple meds. Read the drug facts labels on your medicine bottles and follow the dosing instructions carefully. "Acetaminophen" may be listed as APAP, AC, Paracetamol, Acetam, or another abbreviation.
2. To be safe, I personally would recommend that you not drink alcohol on the same day you use acetaminophen.
3. Use the "minimal effective dose" of acetaminophen. If you get relief from 500mg tablets, don't take the 650mg ones, for example.

What are the signs of liver damage?
The early symptoms of severe liver damage are often vague and include loss of appetite, nausea, and vomiting, and can be mistaken for the flu. More serious symptoms usually begin a few days after an overdose and include abdominal pain, convulsions, diarrhea, irritability, jaundice, and coma. Symptoms of liver failure are a medical emergency and should be evaluated by a physician.

Conclusion
Tylenol is an effective pain and fever reducer, but is safe in a fairly narrow dosing range. Too much of it can overwhelm the liver's toxin-neutralizing capacities, and result in injury to the organ before it can be removed from the body. Liver damage can be life-threatening, so acetaminophen should be taken at its minimal effective dose. In short, I like what Harvard Health says about acetaminophen: "be cautious but not afraid."

References:
https://www.chpa.org/Acetaminophen.aspx
https://www.knowyourotcs.org/how-to-read/
https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm168830.htm
https://www.health.harvard.edu/pain/acetaminophen-safety-be-cautious-but-not-afraid

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Fevers: When Should I Be Concerned?

The idea of checking our temperature when we are sick is deeply ingrained in most Americans. Elevated body temperature most commonly occurs when the immune system is actively fighting off an infection (bacterial, viral, or fungal). However, fevers can occur with alcohol withdrawal, drug abuse (such as methamphetamines), or heat stroke from being exposed to high environmental temperatures. There are natural body temperature fluctuations as well (“normal” body temperature is 98.6 degrees Fahrenheit plus or minus 1 degree). Our body temperature is lowest in the mornings and highest in the afternoons.

It’s important to keep in mind that temperature can vary depending on how it’s measured. Rectal (internal) temperature tends to be higher than skin (surface) temperature. Oral and armpit temperatures can approximate actual body temperature and are more convenient to measure.

When an infection occurs, our body’s “thermostat” (located in the brain, known as the hypothalamus) increases body temperature. This is a natural response that may reduce the speed of viral and bacterial replication. Certain infectious agents are quite temperature-sensitive, and so having a fever can help defend the body against disease progression.

The truth is that for adults, a temperature up to 103 degrees F is not generally a concern unless it is accompanied by any of these symptoms (they could indicate an infection that requires immediate medical attention):

• Severe headache
• Unusual skin rash, especially if the rash rapidly worsens
• Unusual sensitivity to bright light
• Stiff neck and pain when you bend your head forward
• Mental confusion
• Persistent vomiting
• Difficulty breathing or chest pain
• Abdominal pain or pain when urinating
• Convulsions or seizures

For babies and children, fevers are concerning because they are more vulnerable to infections and not as experienced at fighting them off.

The Mayo Clinic recommends reporting fevers to the physician in infants and babies under these conditions:

• Younger than age 3 months and has a rectal temperature of 100.4 F (38 C) or higher.
• Between ages 3 and 6 months and has a rectal temperature up to 102 F (38.9 C) and seems unusually irritable, lethargic or uncomfortable or has a temperature higher than 102 F (38.9 C).
• Between ages 6 and 24 months and has a rectal temperature higher than 102 F (38.9 C) that lasts longer than one day but shows no other symptoms. If your child also has other signs and symptoms, such as a cold, cough or diarrhea, you might call your child's doctor sooner based on severity.
• There's probably no cause for alarm if your child has a fever but is responsive — making eye contact with you and responding to your facial expressions and to your voice — and is drinking fluids and playing.

The bottom line is that fevers are a natural and healthy response to infection. Fevers are generally not dangerous in-and-of-themselves under 103 F. Anti-inflammatory medications (such as ibuprofen and naproxen) and acetaminophen can reduce body temperature for comfort purposes. Contact your doctor if there is any concern about a high fever with the symptoms listed above, or in infants and young children. But for low-grade fevers, perhaps it’s best to be comforted in the knowledge that your immune system is doing its job, and that higher temperatures may actually help with the fight.

References
https://www.mayoclinic.org/diseases-conditions/fever/symptoms-causes/syc-20352759
https://www.scientificamerican.com/article/what-causes-a-fever/