But what about Panadol, Anacin and Efferalgan?

August 4, 2011 11:15 AM

Last week Johnson & Johnson announced that it is lowering the maximum daily dose for single-ingredient Extra Strength Tylenol from 8 to 6 pills per day (from 4,000 to 3,000 mg).

The dosage change follows the recommendations posted by the FDA two years ago. The discussion that ensued on Science Based Medicine blog is quite informative. The highlights include the reasons why acetaminophen isn't sold with additives that would prevent liver failure in case of overdose (cost) and what to do if you fail to kill yourself with whisky on the pills and on waking up decide that life isn't that bad after all (go to hospital immediately or you'll eventually succeed).
All in all, while pondering both sides of the optimum therapeutic dose, it's worth remembering that even water can be fatal when taken in excess.

posted by hat_eater (54 comments total)

So interesting. Last year I had some super-painful dental issues, and in order to successfully juggle Advil and Vicodin without going over the daily limits, created an Excel spreadsheet (owmyfuckingtooth.xls, naturally) which helped me calculate exactly how many of each pill I had left to take over the course of the day and how far away I was from the maximum doses of ibuprofen and acetaminophen. This exercise, while vaguely fun and a handy procrastination tool, made me wonder why people don't suffer more liver toxicity from too much ibuprofen.

And apparently the answer is that they actually do. Thanks, hat_eater.
posted by chesty_a_arthur at 11:22 AM on August 4, 2011 [4 favorites]

last sentence: ibuprofen acetominaphen.
posted by chesty_a_arthur at 11:23 AM on August 4, 2011 [2 favorites]

Occasionally, doctors and pharmacists get dosing wrong. I had a minor operation last year and was sent home with Vicodin (codeine plus acetaminophen). The prescription would have had me over the then-daily maximum for acetaminophen by I think 50%.
posted by zippy at 11:40 AM on August 4, 2011

It's being cut in the US, but not in Canada.
posted by smallvictories at 11:40 AM on August 4, 2011 [2 favorites]

One of my cousins attempted suicide as a teenager by overdosing on acetominophen. She nearly succeeded from the liver damage it caused, but she survived. As a long-term consequence of the damage, she suffered a pair of strokes a few years ago, in her mid-30s. She is only six months past her 40th birthday, unable to care for herself, with severe cognitive impairments, although able to walk and talk. She managed to destroy her life, even if she didn't end it completely. I don't think she even intended to really TRY to commit suicide, just to get some attention, as many angsty teens do.
posted by briank at 11:40 AM on August 4, 2011 [3 favorites]

Wouldn't all these limits be body-weight dependent to some extent?
posted by crapmatic at 11:40 AM on August 4, 2011 [1 favorite]

Can someone explain what advantage acetaminophen offers over ibuprofen? It seems like they both do the same thing, except acetaminophen throws in some bonus liver damage. As for limiting overdose deaths, we should just do what the UK does [pdf]
posted by mullingitover at 11:42 AM on August 4, 2011

Damn, briank. That's horrendous. :(
posted by two or three cars parked under the stars at 11:42 AM on August 4, 2011

Can someone explain what advantage acetaminophen offers over ibuprofen? It seems like they both do the same thing, except acetaminophen throws in some bonus liver damage

For me, acetaminophen does the same thing without giving me wicked digestive issues. I'm delighted that ibuprofen is a wonder drug for most people, but I have to use it as a last resort, no matter how many doctors blow me off and tell me to take it with food.
posted by corey flood at 11:49 AM on August 4, 2011 [2 favorites]

Can someone explain what advantage acetaminophen offers over ibuprofen?

Cardiovascular Risk

• NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal.
• Ibuprofen tablets are contraindicated for treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery

Gastrointestinal Risk
• NSAIDs cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal.

Can also complicate the proper administration of blood thinners.

posted by Kirth Gerson at 11:53 AM on August 4, 2011 [1 favorite]

@mullingitover: Ibuprofen and other NSAIDs actually don't do the same thing as acetaminophen. There's one big difference between these meds: acetaminophen is not an NSAID and thus has not effect on inflammation.

Ibuprofen and other NSAIDS, including naproxen (Aleve) and aspirin, can cause gastric irritation and can also decrease blood flow to the kidneys. Acetaminophen does not because it does not stimulate the same receptors that NSAIDs do. Unlike aspirin, acetaminophen doesn't suppress platelet aggregation. In a healthy adult, NSAIDs are usually safe to give, but you can see how they might not be such a good idea for a person with a bleeding disorder, stomach ulcer, etc. Sometimes it's a choice of the lesser of two evils.
posted by pecanpies at 11:56 AM on August 4, 2011 [3 favorites]

Cold water extraction. Really simple.
posted by jcruelty at 11:56 AM on August 4, 2011 [1 favorite]

Er, "no effect," not, "not effect."
posted by pecanpies at 11:57 AM on August 4, 2011

mullingitover: exactly what pecanpies said. Also, I'm diabetic and although I need to be careful of both my kidneys and liver, my kidneys take precedent. As a result I stick to Tylenol and avoid Advil.
posted by deborah at 11:59 AM on August 4, 2011

Also, to put things in perspective, here's an article (actually linked to in the comments) regarding deaths from NSAIDs, aspirin in particular.
posted by pecanpies at 12:03 PM on August 4, 2011

Can someone explain what advantage acetaminophen offers over ibuprofen? It seems like they both do the same thing, except acetaminophen throws in some bonus liver damage

Acetaminophen is a COX-3 inhibitor, which inhibits the sensation pain in the central nervous system. It does not inhibit COX 1 or 2, which mediates inflammation peripherally. Thus, it is good for central pain control, but does not inhibit inflammation at the tissue level.

NSAIDs like ibuprofen block COX 1 and 2 enzymes from forming prostaglandins, which cause inflammation and sensitize nociception peripherally. Unlike acetaminophen, NSAIDs can reduce inflammation and tissue swelling. The downside is that prostaglandins are necessary for maintaining gastric mucous secretions, which is why chronic NSAID use can result in gastric erosion and ulcers.
posted by Acromion at 12:06 PM on August 4, 2011 [18 favorites]

The more I think about this, the more I have to chime in again to say: the real culprit here isn't acetaminophen. It's the pharmaceutical industry in the US and the focus on creating marketable brand name products. If drugs were labelled based on what they actually contained, we'd have far fewer overdoses. People would know that Excedrin contained acetaminophen, because it wouldn't be labelled Excedrin: it would be labeled acetaminophen (and aspirin and caffeine). We shouldn't be surprised that patients don't realize so many meds contain acetaminophen because Big Pharma does all it can to bury that generic name.

/rant
posted by pecanpies at 12:10 PM on August 4, 2011 [5 favorites]

You can't take ibuprofen in the last trimester of pregnancy, either, as it might inhibit the making of some part of the heart or something like that.

I personally find tylenol is usually useless for the type of issues I have and the toxicity is bad news so I rarely even keep it around.
posted by the young rope-rider at 12:12 PM on August 4, 2011 [1 favorite]

I can't find the 'best answer' button but Acromion nailed it. Thanks! Next question, since the UK's approach seems to be much more effective, what's preventing it from being applied here?
posted by mullingitover at 12:16 PM on August 4, 2011

it's worth remembering that even water can be fatal when taken in excess.

Marijuana: Safer than water
posted by crayz at 12:17 PM on August 4, 2011 [1 favorite]

I remember being surprised as a young kid, reading a Consumer Reports article that explained that all those different pain drugs in the store were just different mixes of four basic ingredients: aspirin, ibuprofen, acetaminophen, and caffeine.

I know people worry about the number of violent acts (or sexual acts, choose your poison) kids see growing up in America. I worry more what the effect of having to see through so many different deceptions is.
posted by benito.strauss at 12:20 PM on August 4, 2011 [2 favorites]

I worry more what the effect of having to see through so many different deceptions is.

Not looking.
posted by Mister Moofoo at 12:24 PM on August 4, 2011

Previously on metafilter, a bit on the history of acetaminophen and the 2009 FDA advisory panel recommendation (kind of a self-link).
posted by borborygmi at 12:29 PM on August 4, 2011

We shouldn't be surprised that patients don't realize so many meds contain acetaminophen because Big Pharma does all it can to bury that generic name.

They bury it by putting it right on the label, along with a big warning.
posted by Justinian at 12:31 PM on August 4, 2011

Previously on metafilter

Aaargh! Sorry, borborygmi, I had it open in one of the tabs, I must have accidentally closed it. I totally intended to link to it.
posted by hat_eater at 12:35 PM on August 4, 2011

It's the pharmaceutical industry in the US and the focus on creating marketable brand name products.


Yeah that's definitely part of the problem. Your average joe will not be able to tell you the difference between Extra Strength Tylenol and Rite Aid brand acetaminophen. Not only that, calculating your max dose requires -gasp- math that is beyond the grasp of large percentage of people. I work in a free clinic where approx 40% the local population is functionally illiterate, and most of them identify the pills they take by the color and shape. How can you expect them to keep track of their daily intake of acetaminophen if they are taking, say, a daily dose of vicoden, perhaps a Tylenol for breakthrough pain, and then unknowingly overdose by taking some Nyquil for a cold.

Another large part of the problem is that there are too many different prescription preparations containing various amounts of acetaminophen. The original intent of making tylenol/hydrocodone preparations was to discourage the abuse of hydrocodone, theoretically, by making people sick if they took too much. Didn't really work. People get confused about how much tylenol they are taking. . . many don't realize there is a difference between Vicoden 5/500 and 7.5/750. If the doctor ups your dose and you continue to take the same amount of tylenol otc, then you can get some chronic liver damage over time.
posted by Acromion at 12:35 PM on August 4, 2011 [2 favorites]

It always surprised me how popular paracetamol (the UK name for acetaminophen) was for suicides. It takes days to kill and is a painful and unstoppable end. If you are looking to end it all and have even a scintilla of an inkling that this might be a cry for help then skip the paracetamol and stick to the more traditional sleeping pills mixed with booze. If it works you will slip away painlessly and if it doesn't your long term damage is minimized.
posted by caddis at 12:37 PM on August 4, 2011 [1 favorite]

just different mixes of four basic ingredients: aspirin, ibuprofen, acetaminophen, and caffeine.
BTW, in 1994 they added a fifth to the OTC meds: Naproxen.
posted by fings at 12:38 PM on August 4, 2011

@Justinian: And clearly, that's not working. Since when has the average adult - especially one who's in pain - been known to take the time to read the fine print?
posted by pecanpies at 12:38 PM on August 4, 2011

The problem is less that people don't read the fine print, and more that they don't understand the severity of not taking the fine print seriously. Tylenol is familiar, they make it in baby form, so it must be safe, right?

I found the discussion of the "antidote" additives really interesting. It sounds like it could easily be done, at least in the pill form (the liquid forms would be a bit smelly). If they wanted, they could make a whole new line of "liver protective" Tylenol. It's probably not really the cost; it's the implicit admission that the drug is killing your insides.
posted by zennie at 12:46 PM on August 4, 2011 [3 favorites]

Sleeping pills are harder to get ahold of, though, I thought, for precisely that reason, caddis.
posted by kenko at 1:21 PM on August 4, 2011

wow. all this and not one comment about aspirin...
One time I had something or other that cased pain and doctor perscribed a pain killer from drugstore.
a few weeks later, had a slight pain and took Aleve. Noted on bottle that what the doctor had given me and I paid good money for was the same as 2 and a half Aleves, a lot cheaper.
posted by Postroad at 1:51 PM on August 4, 2011

Postroad: wow. all this and not one comment about aspirin...
One time I had something or other that cased pain and doctor perscribed a pain killer from drugstore.
a few weeks later, had a slight pain and took Aleve. Noted on bottle that what the doctor had given me and I paid good money for was the same as 2 and a half Aleves, a lot cheaper.

Aleve isn't aspirin, it's naproxen. My personal favorite.

Incidentally, you can mix NSAIDs (ibuprofen, naproxen, aspirin) and acetominophen (but don't mix NSAIDs with each other) to get either more effective pain relief than either, or the same pain relief at lower doses of each.
posted by gilrain at 2:01 PM on August 4, 2011

In drug stores, these days, I pay zero attention to brand names. I only care about the chemicals. You can save money in a ton of ways once you start learning everything.

For instance, a lot of people spend tons of money on Benadryl, to control allergies. The only chemical in there (in the US) is diphenhydramine. You know how it makes you sleepy? So do the drug companies, because they also sell it as a cheap OTC sleep aid! When I want Benadryl, I buy a generic brand diphenhydramine sleep aid. It's a ton cheaper. Same chemical. Also frequently labeled as an anti-nausea pill for motion sickness, if you prefer.

My girlfriend used to take Nyquil to help her sleep, sometimes. I warned her that could be bad for her liver. Looked at the Nyquil bottle, found the chemical with the sleepy side effect (doxylamine), and got he started buying sleep aids with just that chemical, thus reducing her acetominophen intake.

I really wish more people shopped for drugs this way. it's safer, it's smarter, and it's cheaper. And you'll learn a lot more about what you're putting in your body.
posted by gilrain at 2:09 PM on August 4, 2011 [18 favorites]

I kind of agree on the marketing thing. This is a sensible way to label pharmaceuticals (though there’s definitely room for improvement). This not so much, it’s not a box of candy.

As a tangent about the discussion of various analgesics, I think it’s interesting that the WHO considers five drugs essential: ASA, ibuprofen, paracetamol, and the opioids codeine and morphine – all of which, of course, have different side effects and even slightly different indications. There’s also the so-called analgesic ladder as a guideline for chronic pain.
posted by wachhundfisch at 2:25 PM on August 4, 2011

Can someone explain what advantage acetaminophen offers over ibuprofen? It seems like they both do the same thing, except acetaminophen throws in some bonus liver damage.

NSAIDs like ibuprofen are also blood thinners, which COX inhibitors like acetapminohpen aren't. So if you have bleeding issues, NSAIDs actually pose relatively serious (and unpredictable) risks.... as I found out before my own bleeding issues were diagnosed.
posted by scody at 3:00 PM on August 4, 2011

Cold water extraction. Really simple.

Simple to screw up the math and fuck yourself up.
posted by hal_c_on at 3:52 PM on August 4, 2011

In drug stores, these days, I pay zero attention to brand names. I only care about the chemicals. You can save money in a ton of ways once you start learning everything.

Yes, indeed. I have not bought Advil in years. I use quite a bit of ibuprofen (headaches), but I always buy it generic. What astounds me is when my dentist prescribes "painkillers" to me after a tooth extraction - it's ibuprofen except the tabs come in 800mg increments and are twenty times more expensive and I have to stand in line at the pharmacy. I mean, why bother. I had some gum surgery by a periodontist recently, and this joker prescribed Motrin in 600 mg caps you had to get at the pharmacist. Dude, skip it. Give me something real, or don't bother.

People just don't read ingredients. Many times you can get the exact same drug OTC, and the only difference is in dosage (if even that).

Of course, you have to be somewhat careful, especially when you're buying online. I was about to buy a 1000 count 200mg ibuprofen for like $10 online, only to read in the reviews that anybody who buys this gets a bottle that's like 2 months from expiration, and of course, there is no way to find that out ahead of time on the website. And then, I'm also somewhat uneasy about certain generics made in places like China - there's plenty of dodgy things going on with production here, I can only imagine what goes on in some even less regulated places. It's not worth your liver to find out.
posted by VikingSword at 4:01 PM on August 4, 2011 [1 favorite]

only to read in the reviews that anybody who buys this gets a bottle that's like 2 months from expiration

Which is fine. I'd take ibuprofen that was 5 or 10 years past expiration without so much as blinking. The expiration date on OTC painkillers is not for safety reasons, it is to make you throw out the pills and buy new ones.
posted by Justinian at 4:57 PM on August 4, 2011 [1 favorite]

Memo: Do not try this with insulin or liquid antibiotics.
posted by Justinian at 4:58 PM on August 4, 2011 [1 favorite]

Which is fine. I'd take ibuprofen that was 5 or 10 years past expiration without so much as blinking. The expiration date on OTC painkillers is not for safety reasons, it is to make you throw out the pills and buy new ones.
posted by Justinian at 4:57 PM on August 4 [+] [!]

Chemicals degrade. I bought some ibuprofen that was near expiration, and it worked for shit.
posted by gjc at 5:43 PM on August 4, 2011

The problem is less that people don't read the fine print, and more that they don't understand the severity of not taking the fine print seriously. Tylenol is familiar, they make it in baby form, so it must be safe, right?

I'd have to disagree. I cannot tell you how many otherwise intelligent adults I've known and/or provided care for who did not realize that Excedrin contained ASA and acetaminophen, Vicodin contained acetaminophen, etc. They understood that taking too much of a certain drug could be dangerous, but lacked the knowledge to realize that they themselves were at risk of overdosing. My 55-year old mother did not realize that aspirin was an anti-inflammatory, and her mother was an RN. The lack of even basic knowledge regarding common pharmaceutical products is overwhelming.
posted by pecanpies at 6:22 PM on August 4, 2011 [2 favorites]

"You can save money in a ton of ways once you start learning everything."

You're one of those Socialists, aren't you? CONSUMPTION is the lifeblood of this country!!

"I bought some ibuprofen that was near expiration, and it worked for shit."

This is the opposite of evidence.
posted by sneebler at 7:21 PM on August 4, 2011 [1 favorite]

Chemicals degrade. I bought some ibuprofen that was near expiration, and it worked for shit.

OTC medications generally do not degrade at a significant rate. This isn't an opinion, it's fact.
posted by Justinian at 7:32 PM on August 4, 2011 [2 favorites]

i'm pretty sure that medicine expiration dates are a worst case scenario--the date indicates how long it will be before 1 pill in the bottle loses effectiveness, according to statistics. they then schedule the date before then to make sure all the pills work.
posted by lester's sock puppet at 7:43 PM on August 4, 2011

CONSUMPTION is the lifeblood of this country!!

What!? It's not! It's a disease!
posted by Kirth Gerson at 4:38 AM on August 5, 2011 [1 favorite]

Isn't the "best used by" date merely when the manufacturer guarantees 100% strength and not a drop dead limit on usefulness?
posted by Enron Hubbard at 7:08 AM on August 5, 2011

Anecdata, but it goes back to advice from medical professionals: Some drugs crap out, such as guaifenesin (expectorant). Some get dangerous, such as (guess what) acetaminophen/paracetamol. And some are pretty shelf-stable, but I don't have a list of which is which.
posted by eritain at 8:21 AM on August 5, 2011

Some get dangerous, such as (guess what) acetaminophen/paracetamol

No they don't.
posted by Justinian at 8:47 AM on August 5, 2011

Anyone want to drop a link or a reference of some sort about expiration dates? Because all y'all seem really confident that they will/won't kill you to death.
posted by the young rope-rider at 8:51 AM on August 5, 2011 [1 favorite]

You can't take ibuprofen in the last trimester of pregnancy, either, as it might inhibit the making of some part of the heart or something like that.

You are thinking of premature closure of the ductus arteriosus; if it doesn't close properly after birth, another NSAID (indomethacin) is often used to close it pharmacologically rather than resorting to surgery.

Anyone want to drop a link or a reference of some sort about expiration dates?

Here's what the Harvard Medical School has to say. As for aspirin, it is acetylsalicylic acid and one of its breakdown products is acetic acid, so if your aspirin smells like vinegar, it is breaking down; if it doesn't you are good to go no matter what the expiration date says.
posted by TedW at 9:17 AM on August 5, 2011 [2 favorites]

Money quote:

So the expiration date doesn't really indicate a point at which the medication is no longer effective or has become unsafe to use [...] Is the expiration date a marketing ploy by drug manufacturers, to keep you restocking your medicine cabinet and their pockets regularly? You can look at it that way.

posted by Justinian at 8:18 AM on August 6, 2011

My piece:

All in all it's in the interests of the patient to prescribe all medications, including OTC meds. It's the doctor's way of stepping up to the plate and saying "yes, I told the patient to take this" and gives the pharmacist an opportunity to do their job (look out for your safety and consult you).

The e-Rx initiatives in the US ride on this assumption that all medications should be prescribed and tracked in databases to prevent death due to contraindications, allergies, etc. And the new Flexible Spending Account rules (no flex spending for OTC drugs that aren't prescribed) reflect this public health concern as well. In some cases it's actually cheaper to get generic extra-strength prescription ibuprofen or what have you, especially if you have a flex account but yeah, if you know better, you can buy 10,000 200mg ibuprofen pills for peanuts at CostCo and take 2-4 at a time depending on your size, pain severity, etc. IANYD

Tylenol is nasty stuff. I'm allergic to Aspirin and have never tried any other NSAIDS; no doctor will recommend it seriously but if I want to try another NSAID I'm advised to do it near an emergency room with a tiny dosage. I'm stuck with Tylenol or narcotics which is kind of a PITA because Tylenol is 100% useless to me; I'd rather have a beer if I have a headache rather than something that makes beer extra toxic :)

Apparently there's a strong correlation between Aspirin allergy, asthma, and nasal polyps. I am mildly asthmatic but not chronically so and do have mild polyps.

There are various theories behind this involving prostaglandin hormones and histamine and what have you...but there is also plenty of evidence that Tylenol damages lung tissue over time and can lead to the development of asthma / allergy symptoms. It halts the production of glutathione in the liver which products the liver and lungs from free radical oxidation. Perhaps people who are allergic to NSAIDS take in an excessive amount of acetaminophen over time, further contributing to asthma symptoms beyond those triggered by genetic makeup...

One quick Google and lazy search result for "Tylenol and Asthma..."

I'm a huge proponent of knowing what you take and laugh at the advisories not to mix various drugs for cough / cold symptoms. Obviously many people will do this incorrectly and poison themselves while more cautious folks can do this to their overall advantage. When I have a cold I will mix and match and am confident doing so, being aware of the various combinations that are used in various formulations. Usually all I really need for a severe upper respiratory infection during the day is guafenesin and pseudoephedrine. They kind of work paradoxically against each other but also complement each other in certain ways and you can sort of figure out when to time your dosages of one or the other.

Typically the cocktails people buy contain at least one thing they don't need for their specific symptoms (Tylenol, phenylephrine [the useless Preparation H replacement for pseudoephedrine], or even dextromethorphan: sometimes you just need guafenesin to make your coughs production and perhaps you shouldn't be suppressing your coughs except at bedtime or if they are completely unproductive.

Tylenol PM is an abomination. So many people take it simply as a sleep aid without any pain to control. Take a diphenhydramine or doxylamine! Many people love Nyquil and as mentioned it's the doxylamine they are after. The rest ain't helping through I do get a mild sleepy buzz off of small doses of dextromethorphan...

It's absurd that they put a liver toxin in most narcotic painkillers in order to "discourage abuse." You think the average abuser knows or gives a rat's? They think "LOL, alcohol is bad for my liver too and I drink that all the time...I haven't died yet." I think Tylenol is horrible and mixing it with alcohol is insane. And also very common and chic in the vicodine/percocet abusing community.
posted by aydeejones at 9:47 PM on August 24, 2011

My mom's a pharmacist and she's got some drugs in her cabinet that are 10 years expired. That might be pushing it quite a bit but yeaaaah, those dates (as in the case of most canned goods) are radically over-cautious and largely decided to favor the manufacturer.
posted by aydeejones at 9:49 PM on August 24, 2011