"The best advice is very simple. Read the label. Acetaminophen is safe if you know how much you're taking. And be sure when combining medications not to exceed four thousand milligrams each day."
As with any medication, you have to follow the directions, be safe, and smart.
Except those doses might not be right if you're consuming certain things that interact with those drugs that seem innocuous. Like Grapefruit, for example. If you consume grapefruit and take acetaminophen, more of the drug will get into your bloodstream than expected, and prescriptions doses won't take that into account. You have to be careful taking a lot of drugs if you eat grapefruit, btw, for this reason, not just acetaminophen.
"White grapefruit juice increased concentrations of acetaminophen in mice both 1 hour and 2 hours after feeding compared to controls. In contrast, pink grapefruit juice increased acetaminophen concentrations 2 hours after feeding compared to controls."[1]
Blood concentrations rise because grapefruit slows liver processing. That's not the same as grapefruit increasing the risk of acetaminophen liver damage, which is the OD concern. I'm not saying it doesn't, but I've never read that warning and I've been taking it for fifteen years. You'd want to show the research that states that grapefruit increases acetaminophen toxicity.
They even sell extended release acetaminophen, which prolongs liver processing. Though, I'm not a fan because I think it is rougher on the liver. But health damaging risk is another issue.
"And be sure when combining medications not to exceed four thousand milligrams each day."
That's all very well if people adhere to the instructions but many don't. It's pretty clear why this is so. First, it's an OTC drug and most people associate that with not being as efficacious as drugs that are prescribed by a doctor. Second, people believe OTC drugs to be safe because they are OTC drugs. Third, with the other two factors in mind, given that acetaminophen (paracetamol) is barely an effective painkiller, they opt to up the dose in the hope of obtaining relief.
When I take the drug I'm careful not to take more than 4000mg because of its dangers, in fact I don't ever recall ever taking the maximum daily amount.
I also know the reasons why acetaminophen is dangerous and that further raises my caution. A metabolite of acetaminophen, NAPQI, is toxic to liver cells, it also reduces production of glutathione the agent the liver uses to mop up toxic metabolites. Thus, all's well until the glutathione runs out, after that NAPQI is free to do its damage.
The FDA, doctors and the medical profession need to explain in very simple terms by way of major campaign the reasons for why the drug becomes very dangerous after a certain threshold.
I'm sure an advertising agency could produce a pithy explanation the public would understand (and it should be printed on the box). Irrespective, we urgently need to do something to reduce the thousands of annual acetaminophen poisonings.
I've railed against acetaminophen, aka paracetamol for years. That said, I still take it with care because there's no other drug suitable for the ailments I take it for. Aspirin and other NSAIDs such as ibuprofen are harsh on the stomach, the big guns—the opiates—are totally inappropriate painkillers in all but the most severe pain because of potential for addiction—witness the opioid epidemic—and the newer selective COX-2 NSAIDs, rofecoxib (Vioxx) and celecoxib (Celebrex) have major side effects. Vioxx was banned some years back because it caused heart and related problems in some people and Celebrex has the potential to cause heart issues and is hard on the kidneys.
Essentially, the fallback drug is acetaminophen because there's nothing else. Unfortunately, acetaminophen is an ancient drug discovered in the mid Nineteenth Century and it's been in service for about a century but mainly since WWII. It's classed as coaltar antipyretic which covers a whole range of similar drugs that were or are manufactured from precursors that come from coal. Many of them are related and some are very dangerous (many were withdrawn in the first half of the 20th Century because they literally killed people).
The precursor to acetaminophen is phenacetin which until about thirty years ago was a principal painkiller but was withdrawn from the market after mixtures of it, aspirin and caffeine were found to be rotting people's kidneys out. Phenacetin is also considered carcinogenic.
We still have to rely on this ancient 150+ year old dangerous drug that's barely effective because of a major failing of medical science/pharmaceutical research.
It really is high time we researched much better more effective and safter painkillers and ditched all current coaltar antipyretics, they really aren't that effective and none have been found to be safe.
> We still have to rely on this ancient 150+ year old dangerous drug that's barely effective because of a major failing of medical science/pharmaceutical research.
No it's because we care more about stopping people from getting high than stopping them from being in pain. You said it yourself:
> the big guns—the opiates—are totally inappropriate painkillers in all but the most severe pain because of potential for addiction
Who cares??? It's better to be addicted than suffer. And I have lots of doubts about their addiction potential, because of all the people who have a backwards sense of medicine.
It really depends who you are, but NSAIDs also have their fair share of potential dangers. They are particularly linked to higher risks of heart attacks and strokes [1], but also ulcers and in rare cases other problems.
As for me, whenever I take an NSAID (including Aspirin), my chest feels like it's going to explode. It's not a painful feeling, but it is not a good feeling. It also sometimes gets difficult to breathe. And it's been this way my entire life, so I shun them completely.
As for acetaminophen, the dangers mainly stem from overdose, overuse, and using it with alcohol consumption. Avoid that and it's pretty safe.
Ibuprofen is generally considered safer than Acetaminophen BUT non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen can trigger dangerous stomach acid over production in some patients (source: finding myself in excruciating pain followed by a doctor pushing a camera probe down my throat to examine the damage when this happened to me). That's a minority of patients, obviously, but there are classes of patients who need to take Acetaminophen instead of NSAIDs for various reasons.
Acetaminophen is similar to NSAIDs in many of its beneficial effects but is sufficiently different chemically as to not trigger many of the (rarer) negatives that NSAIDs can trigger.
> The reasons we have acetaminophen with all its risks is because there is nothing better.
There is, but we care more about stopping people getting high than we care about stopping people from being in pain.
My wife had an outpatient surgery, and had muscle spasms from incisions. She was SCREAMING in pain. She was brought in by ambulance (who did not give her anything - sort of understandable because sometimes you need to have the patient identify the pain).
Despite continuing to SCREAM in pain, the nurse refused to do anything or contact the doctor, because she was sure she was a druggy just faking it. It took all my energy not to start throwing punches. (A doctor finally got her pain meds.)
For years pain research and pain alleviation was considered low priority by the medical profession. It strands to reason we need to understand and to continue researching pain before researching painkilling drugs—so we are coming from a low base.
Even after the opioid epidemic and those disreputable Sackler bastards came to worldwide prominence there's been no national initiative like, say COVID research. The problem is that there is not enough research. That's clearly obvious—or it ought to be.
> The reasons we have acetaminophen with all its risks is because there is nothing better.
Of course there are better drugs. But they are not patentable, they are not profitable, and they are not synthesized by chemical factories like the Union Carbide in Bhopal. All of that makes them really unpopular!
This is a talking point I hear a lot that has little basis in fact.
There are many active pharmaceutical ingredients that are natural products, modified natural products, or analogues of natural products. See Metformin and French Lilac.
In fact, a big part of what medicinal chemists do is designing “better” molecules. And some well capitalized pharma companies even come out and say their strategy is “best in class, not first in class”.
Why not take Kratom, or CBD oil? They are extraordinarily effective, no prescription, and very cost-effective. I picked up about 50 doses worth for $20 at a store 2 blocks away, which is closer than the pharmacy, smells nicer, and friendly staff.
It sure is. I’ve heard it argued that Tylenol would never be approved by the FDA were it introduced as a new medication. Even if it were it would be pulled from the market after the first few waves of overdoses. Really doesn’t help that it’s hidden in a bunch of medications and doesn’t mix with liquor.
Quite safe when taken as prescribed or directed though.
"I’ve heard it argued that Tylenol would never be approved by the FDA were it introduced as a new medication."
You're likely right on the grounds that it's not a particularly good painkiller—my own experience is that it's marginally better than nothing (which is also pretty much the official position)—and on its now well defined dangers.
The combined assessments would likely be insufficient for approval.
I got sick Friday (turned out to be Covid - 1st time for me I know of), had a terrible headache all day, still had it Saturday morning, so took one 500mg (extra strength) acetaminophen. It knocked out the headache very quickly and it hasn't come back. So in my case, it was way better than nothing and I wish I had taken it the day before instead of suffering with a heading for over 24 hours. I for one am glad it's around.
You are very lucky, 1000mg (two tablets) has absolutely no effect on my headaches. As for toothaches, I may as well suck M&M's—unlike acetaminophen, they at least taste sweet.
Unfortunately, that's how it goes for many people.
BTW, where I live, all OTC acetaminophen tablets are 500mg (and often come in packets of 100 tablets), and the usual recommended single dose is 1000mg (max 4000mg daily).
Ironically opioids are safer. Opioid overdoes and addiction gets tons of media coverage, but not the thousands of cases of liver failure from a drug marketed as safe, which is anything but , and not even that effective at pain relief either.
Opioids are less acutely dangerous from uses not far over the therapeutic dose, whereas Tylenol is less dangerous for long-term use at the therapeutic dose.
When was the last time that you took 4 grams of opiates to find out if opiates are safer? How about with alcohol? That's the acetaminophen OD dose. The official daily limit is about half of that.
Acetaminophen's best pain relief profile is when it is mixed with aspirin in Excedrin. Neither work that well on their own. Together, they do a great job with virtually no side effect if you dose it as instructed.
And opioids certainly aren't psychologically safer. It can take years of adjustment to come out of depression even from regularly using a drug that indirectly tickles the opiate receptors. Let alone from opiates themselves.
Yeah in medications that have both like Tylenol 3, the dangerous part is the Tylenol and what will send you to the hospital if you just swallow a bunch of pills.
The title got me scared for a bit. Turns out, the problem is that people do not dose it correctly. And also, they often mix products which may contain acetaminophen but the person taking it doesn't know.
I guess that makes sense. There are so many people in my life that I've heard saying "X medicine has done wonders for me, better than paracetamol", but I've had to explain to them that X is just a fancy way of saying paracetamol/acetaminophen.
> they often mix products which may contain acetaminophen
This is the worst thing. Every drug manufacturer likes to take whatever product they’ve been making, stick Acetaminophen in there, maybe some Dextromethorphan… put “Super Severe Cold Annihilator” on the label and let the marketing machine go to work.
I find it amazing that people buy these cocktails rather than literally the cheapest generic versions of their constituent compounds, usually in the same dosages. It’s depressing the education doesn’t seem to be there that these are the same exact things. I’d so much rather take a few pills of drugs I actually need rather than a swig of a bunch of random stuff and wish my kidneys and liver godspeed.
Acetaminophen is a very important drug to have OTC. There's nothing that can replace it OTC, and many people have pain that requires it yet shouldn't rise to the level of seeing a doctor just to obtain medication. Like migraine and short term minor muscle pain.
Also, having it available avoids the risk of doctors over-oveprescribing for complaints that acetaminophen is perfectly suited to handle with much less side effect.
Not ODing on Acetaminophen isn't hard. Read the label. Understand that it doesn't mix with alcohol. Don't take it like an asshole. You have to take over 2 grams to exceed the daily limit for meds like Excedrin, and it takes something like 4 grams (16 Excedrin for example) to be in OD territory.
Recommended doses are something like nothing over 500 mg every six hours.
The vast majority of overdoses are people swallowing a handful while drunk. There's a wide variety of drugs that you can't do that with.
The rule of thumb with acetaminophen is to know the rules.
> The rule of thumb with acetaminophen is to know the rules.
You should not expect everyone to be as chemistry-inclined as you.
My friend recently recommended a Walgreens med. It was generic Zyrtec. I told him that I had been using Zyrtec. He told me it wasn't zyrtec, and when I discussed the active ingredient with him, he just said the Walgreens bottle one works better, because he is ignorant and chemical names are meaningless to him.
Your comment is blatantly obtuse. People don't know the rules, they're not nerds, they don't know the difference between Advil, Tylenol, aspirin, Aleve, etc. Not everyone enjoys memorizing chemical names, and knows that Tylenol=Acetaminophen=Paracetamol=whatever.
You can't buy Nyquil, Robitussin, or Mucinex without getting acetaminophen in it. Recently sick, I scoured a pharmacy for Guaifenesin WITHOUT acetaminophen and was unable to find it, in fact Mucinex nighttime is literally tylenol and a random antihistamine... Mucinex has abandoned its main ingredient for acetaminophen.
A desperate night at the pharmacy will show you that acetaminophen is everywhere. People are not interested in reading chemical names that mean nothing to them, and we should be more interested in health outcomes than saying that someone who can't keep track of chemical formulas deserves liver damage.
I'm not chemistry inclined, let alone a chemistry "nerd". I'm simply literate.
Adults know what they are taking. Children don't. Which is why we have child proof bottles.
Knowing how to take medication has nothing to do with being a nerd. It has nothing to do with enjoyment. You packed in an impressive number of silly accusations into your response. They don't substitute for making a point.
If you can wipe your rear end and pay your bills, you can read a bottle and understand what you are taking. To expect this isn't being obtuse, let alone "blatantly obtuse". Its an expectation of a basic concept of adulthood.
Adults don't chug bottles of dextromethorphan either, because its bad for them. But some children do, because they can in fact read labels and don't care about harming themselves.
You're telling me that it is uncommon for adults to have the OTC drug knowledge of DXM chugging 14 year olds?
The dosage rules are on every bottle.
The no alcohol rule is widely advertised.
Your position on epidemiologically justified public health policy and outcomes, in regard to acetaminophen, isn't upheld by the facts of public health outcomes.
I urge all adults to learn to wipe their ass (know what they are taking).
> Mucinex nighttime is literally tylenol and a random antihistamine... Mucinex has abandoned its main ingredient for acetaminophen
Ummm? Looks like Dextromethorphan is still a listed active ingredient. Sure it has an added antihistamine and Acetaminophen, but that’s hardly “abandoning its main ingredient”.
Mucinex is historically not DXM, it's Guaifenesin, that's what they built their brand on.
Recently they've revised their ingredients because Guaifenesin is a mild stimulant and they know that shoppers are not reading the active ingredients.
It was recently impossible for me to purchase pure Guaifenesin because the pharmacy only carries Mucinex DM/whatever rather than the original product, and all Mucinex day/night products contained Acetaminophen.
Oh my bad, for some reason I thought the main ingredient was always DXM. Yeah I certainly haven’t seen pure Guaifenesin anywhere. How recent was the trend? I could have sworn I’ve seen at least DXM/Guaifenesin Mucinex in the past few years
It sounds like almost all of these issues could be avoided by just legislating that paracetamol can't be mixed into other stuff sold OTC.
Your bog standard cold and flu sachet or whatever can just write on the side "eat me, then one 500mg paracetamol". Then no-one can accidentally eat 10 a day.
I don’t even find it that useful for things doctors usually recommend it (for me anyway). I’ll reach for Naproxen or Ibuprofen for aches and pains. About the only reason I have Acetaminophen in the house is for fever reduction.
I find acetaminophen much better for pain due to injury/tissue damage, while NSAIDS are better for inflammatory pain (for lots of people, the former is more common; they also sometimes come together, but then, its not less safe to use acetaminophen and NSAIDs together than separately.)
I'm a biochemist and I find the distinction arbitrary. Paracetamol/acetaminophen is anti-inflammatory, and it is non-steroidal. That to me is enough to warrant inclusion in the category "NSAID".
It doesn't mean it has the same mechanism of action, the same COX selectivity, the same side effect profile, etc, as all other drugs within the class.
Techically, you're right but it's often grouped with them. I like to view it living in no-man's-land as a cast off from NSAIDs as its chemical origins are so similar to the former. Little wonder the confusion.
I'd add that confusion is only compounded when it's mixed with NSAIDs such aspirin and ibuprofen. Such mixtures are pretty popular.
> Techically, you’re right but it’s often grouped with them.
It is usually distinguished from them, especially as the one OTC painkiller typically usable by people with conditions for which they should not take NSAIDs, and which lacks the issues with long-term use of NSAIDs.
OTOH, with more digging, while most medical sources distinguish it, it is occasionally identified as an NSAID in the literature – ironically, the first source I could find that does that is a paper which both calls it one and contrasts it with NSAIDs, so it seems a bit confused – and it apparently has some (though weak enough compared to the things usually labelled NSAIDs that most sources just straight up refer to it as not being anti-inflammatory) anti-inflammatory effect.
Another entire class of compounds that are not usually called "NSAID" but that you could arguably call that, are 5-ASA/mesalazine and many of its related compounds.
Although I think this would be more controversial than the inclusion of paracetamol. Personally, I think many DMARDs might be considered NSAIDs as well (except by somewhat arbitrary-seeming exclusion).
When I really think about it, I think the nomenclature might just be conventional and not necessarily make much sense.
"The best advice is very simple. Read the label. Acetaminophen is safe if you know how much you're taking. And be sure when combining medications not to exceed four thousand milligrams each day."
As with any medication, you have to follow the directions, be safe, and smart.