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Over-the-Counter Painkillers and the Liver
Those with liver disease must be aware that the three most common pain relievers could be hazardous to a compromised liver – even at a reasonable dosage.
Editor’s Note: The information below is for educational purposes only and is not intended to replace, supersede or substitute medical advice.
Whether it is for the flu, a headache, menstrual pain, muscle ache or any other type of discomfort, just about everyone has times when they seek pain relief. Over-the-counter staples for this purpose usually fall into one of three categories: acetaminophen, ibuprofen or aspirin. Unfortunate for those with chronic liver ldisease, all three of these medicines can be harmful to the liver. Because different doctors will favor different types of painkillers, it can be very confusing for someone with liver concerns to know what his or her best choice is. The preferred painkiller – and dosage – will vary depending on each individual, but understanding why each of these medications may be hazardous can help people make informed decisions.
As a general rule, the more advanced a person’s liver disease is, the greater caution is warranted when considering pain relief medications. Similar to how the food we eat and the beverages we drink must be processed by the liver, so too do most medications. By recognizing that drugs exert some degree of strain on the liver, it is easy to see why a severely damaged liver would have a harder time metabolizing medications. In addition, conditions that often result from liver disease make certain drugs particularly hazardous.
Occasional, restricted use of the over-the-counter painkillers listed below may be safe for those with chronic liver disease. However, since each individual is likely to have a different presentation of liver disease – a person must work with a physician in choosing the drug that is least likely to adversely affect his or her liver.
Acetaminophen
Known commonly as Tylenol, acetaminophen is a common, mild to moderate pain reliever. As published in a 2005 edition of the journal Hepatology, U.S. researchers found that over a six-year time span, more than 40 percent of acute liver failure cases were caused by an acetaminophen overdose. High doses of acetaminophen can cause liver injury, even to a healthy liver, so those with fewer functioning liver cells have an even greater risk of harm. In limited dosages, a physician will generally only suggest acetaminophen to someone whose hepatic metabolism is fully functioning.
Unfortunately, overdosing on acetaminophen is much easier than it should be because this ingredient is found in many types of pain-relieving drugs. Acetaminophen is also in several narcotic painkillers like Tylenol with Codeine, Oxycet Vicodin, Lortab and Percocet. Abbreviated on labels as APAP, acetaminophen is also in Anacin 3, Nyquil and thousands of other medicines used to treat headaches, fever and sore throats. If given an okay to take acetaminophen by a physician, make certain to avoid taking more than one acetaminophen-containing drug at a time. Those with liver disease are often advised to restrict the daily amount of acetaminophen to 2,000 mg per day, or even less if severe liver disease is present.
Ibuprofen
A non-steroidal anti-inflammatory drug (NSAID), ibuprofen reduces high body temperature, is an anti-inflammatory and inhibits normal platelet function. Available in products such as Motrin, Advil and Nuprin, ibuprofen is the painkiller of choice for millions of people. However, NSAIDS are known to cause gastrointestinal upset and bleeding. For those prone to portal hypertension (a common liver disease complication), the risk of gastrointestinal bleeding is intensified with NSAIDS. Studies have shown that at certain dosages, ibuprofen can stress the liver and elevate liver enzymes in people with chronic liver disease. As such, ibuprofen must be used with extreme caution (and always taken with food) in the later stages of liver disease.
Aspirin
Sometimes used as a preventative for cardiovascular disease, aspirin reduces fever, relieves pain, is an anti-inflammatory and a blood thinner. Also sold under the brand names Bayer, Anacin and Excedrin, aspirin limits the blood clotting process and prolongs bleeding. In chronic liver disease where the body’s production of clotting factors is naturally decreased, aspirin can increase the risk of bleeding. When taken in high doses (more than 2,000 mg per day) aspirin can cause liver injury.
Besides acetaminophen, ibuprofen and aspirin, there are other pain-relieving options. Especially for those with advanced liver disease, a doctor may suggest a prescription drug to relieve pain that is cleared more by the kidneys than the liver. As those with chronic liver disease do not have any great, totally safe options for pharmaceutical pain relief, make sure to consider non-medication pain treatments such as acupuncture, physical therapy, massage therapy, heat therapy, cold therapy, TENS (transcutaneous electrical nerve stimulation) and biofeedback.
The bottom line for people with liver disease is to consult with their physician before taking any type of pain-relieving pill – no matter how innocuous it may seem. Because the liver is targeted by most drugs, an ailing liver must be prioritized before any pill-popping begins – especially if it’s Tylenol, Advil or Bayer.
http://patients.gi.org/topics/medications-and-the-liver/, Medications and the Liver, Jorge L. Herrera, MD, FACG, Retrieved February 26, 2012, American College of Gastroenterology, 2012.
http://www.everydayhealth.com/health-questions/abdominal-pain/what-can-i-take-for-pain-with-cirrhosis-of-the-liver-4th-stage, What can I take for pain with cirrhosis of the liver (4th stage)?, Sarah Lewis, PharmD, Retrieved February 26, 2012, Everyday Health, Inc., 2012.
http://www.everydayhealth.com/health-questions/pain-management/what-pain-reliever-is-safe-for-the-liver, What Pain Reliever is Safe for the Liver?, Patti Brown, PharmD, Retrieved February 26, 2012, Everyday Health, Inc., 2012.
http://www.hepatitis-central.com/mt/archives/2007/05/is_there_pain_r.html, Pain Relievers and Hepatitis C, Nicole Cutler, L.Ac., Retrieved February 26, 2012, Hepatitis Central, 2012.
http://www.ncbi.nlm.nih.gov/pubmed/16317692, Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study, Larson AM, et al, Retrieved February 26, 2012, Hepatology, December 2005.
http://www.npr.org/blogs/health/2011/01/13/132903273/fda-clamps-down-on-acetaminophen-in-prescription-drugs, FDA Clamps Down On Acetaminophen In Prescription Drugs, Scott Hensley, Retrieved February 26, 2012, NPR, 2012.
http://www.physorg.com/news/2011-01-fda-lowering-pain-reliever-vicodin.html, FDA orders lower doses in prescription painkillers, Matthew Perrone, Retrieved February 26, 2012, The Associated Press, 2012.
http://www.washingtonpost.com/national/fda-moves-to-cut-strength-of-prescription-painkillers-citing-risk-of-liver-damage/2011/01/13/ABt45WR_story.html, FDA moves to Cut Strength of Prescription Painkillers - Citing Risk of Liver Damage, Rob Stein, Retrieved February 26, 2012, The Washington Post, 2012.
About the Author
Nicole Cutler, L.Ac., MTCM is a long time advocate of integrating perspectives on health. With a Bachelor's degree in Neuroscience from the University of Rochester and a Master's degree in Traditional Chinese Medicine from Five Branches Institute, Nicole has been a licensed acupuncturist since 2000. She has gathered acupuncture licenses in the states of California and New York, is a certified specialist with the National Acupuncture Detoxification Association, has earned diplomat status with the National Commission of Chinese and Oriental Medicine in Acupuncture and Chinese Herbology and is a member of the Society for Integrative Oncology. In addition to her acupuncture practice that focuses on stress and pain relief, digestion, immunity and oncology, Nicole contributes to the integration of healthcare by writing articles for professional massage therapists and people living with liver disease.
info. on cirrhoris of liver
So what about Aleve? Sodium naproxen?
I was wondering the same thing, did you ever get an answer to the aleve question? I am curious to know since it isn’t one of the other 3 …?
How about codeine for migraine headache?
My migraine went away when I went off gluten immediatly
I use Tramadol for arthritis.I can take 3 per day. I have Hepatitus C. My doctor has subscribed this for me. Is this harmful?
you mean perscribed. Otherwise, are you getting updates from yur pills?
My doctor has prescribed tramadol for arthritis for me. 3 per day. Is this harmful?
tramadol has acetaminophen in it
Tramadol does not have tylenol in it. It is also called Ultram and is pure tramadol. A medicince called Ultracet, that I have never seen prescribed, has tramdol and acetaminophen.
What about Tramadol (aka Ultram)?
need info on tramadol doctor has me taking
about 10 per day @ 50mg each for sciatica
and back i have hep c and liver disease
with my meld score being “12”
What is a meld score?
I found this during a Google search – MELD SCORE – score turned out to be predictive of prognosis in chronic liver disease in general, and–with some modifications–came to be applied as an objective tool in assigning need for a liver transplant
what about straight codine? Is that harmful in itself to the liver?
Hello, please provide me with some honest information. Unfortunately, I will be using strong opiods like oxycontin or methadone for the rest of my life due to a serious back injury from a fall. I am 55 years old now, have been taking these meds for 4 years and have had hepatitis C for about 25 to 30 years and have grade 2 inflammation, fibrosis stage 1, what could these meds potentially cause for me? thank you…I am not worried, i just want some information…
I am on methadone too. As well as tramadol.
Naproxen can raise blood pressure. I tried it for a short time and instead use Advil. I do not know of anything for pain which is not good for the liver I do know for a fact MSM does not have any known affects. It is very good for inflammation! I purchased ten kilos five years ago and the shelf life is very good if kept in a sealed container. I cannot recommend dosages and do not claim to be a physcian or claim this to be a cure. I only know it has helped me to reduce inflammation.
I use the spice tumeric extract (95% curcumin)300 mg. for reduction of pain and inflamation. It really works. It is not a pain reliever but an inflamation reducer. Try it. My Dr’s have given the OK.
“So what about Aleve? Sodium naproxen?”
Sqeeze one gelcap into a tablespoon of lotion for area pain… works great and relief lasts for days not sure if the liver gets hit with this but you take WAY less pills for pain… so that is a good thing.
Check out magnesium for headaches and spasms.
The specialist supervising my HEPC chemo for cirrhosis therapy wanted me to take up to 2000mg of Tylenol per day to deal with the drugs. My primary care provider flipped out and forbid it instead prescribing a pain medication which did not have any of these three chemicals. Sometimes the experts are wrong.
my doctor has me taking 2-etodolac & 1 codiene with aspirin daily for severe joint pain (arthritis in my back, knees, elbows) & bone spurs in my feet. I have asked if there isn’t something else he could prescribe since this is making me bruise quite easily. He said they all make you bruise. What do you think?
What is the best over the counter pain reliever to take. I have chronic back pain and need something to take.
Many years ago anti – inflammatories were only available on prescription, for very good reason. They are harmful and can kill you. Despite apparently moving forward, pharmaceutical companies often do not research enough and simply change the names of medications that were considered dangerous. No medication is without its risks, some are pure poison.
If I had taken all the drugs that have been poked at me for my various conditions and if I had had all the surgery offered, I would have only half of my body, no child and a life full of side effects.
Do your own research, do not believe advertising, Good luck
I am in the early stages of cirrohis and alcoholic heptitis. I know my doc said no muscle relaxers, no OTCs such as Advil, asprin, acetomenaphine and sodium naproxin (the sodium in the name should warn you immediately). I had have to get “poked” several times in the ER recently and they have given me morphine and diloded, both which I recently learned can be prescribed in pill form. Diloded has been especially effective on my pain, but it is addictive so you have to keep that in mind. It depends on the doctor, I have severe back pain when the belly gets big with all the extra weight and they won’t give me anything outside the hospital due to the addictive factor:{
What about Aleve?
Advil is really bad on the kidneys! No one ever mentions the kidneys, do ignore this when taking Advil.
Was furious to have found that most prescribed painkillers had acetometaphin large quantities, and insisted upon being given oxycodone without acetametaphin. Have much chronic pain. It is complicated to obtain because it requires a triplicate form for prescription. And now my new internist is trying to restrict it by giving small quantities. Have been using it for 10 years and rarely take more than 20 mg a day. When used in a controlled way, does it threaten liver?
I take Aleve. It was the only one that I found that hasn’t yet been added to the list of “bad for liver” pain relievers.
aleve is just another brand name for ibuprofen
Aleve is an NSAID, is it not?
Paracetamol is the recommended painkiller for people with liver disease.
Is there any safe anti-inflammatory ?
same as I was told but no safe anti inflamatory so I was told.
Paracetamol is also known as acetaminophen. That is the last thing people with liver disease need.
Had Liver Transplant in Oct.13 2010 been healty with my Hep.C haven’t had no real pain, but I take percribed meds from Dr. for lower back. As to the pain relivers listed above I take none of them . I have to protect my new liver.
Hi Frank I have a fatty liver and NASH non alcoholic Cirrhosis of the liver In time perhaps I would need a liver transplant ~ please describe the Incission to me
My Dr. gives me Ultram.
It seems that all the synthetically derived pain killing drugs are way more of a problem to those of us with liver disease than opiates. How silly that we are not given the codeine without all the extra frills.
I VE$RY much agree with you sarah , its taboo I think because of op0iate addiction but the synthetics can be much worse eg, methadone worse to come off than heoin itself , so why give it ?
I have been on methadone for 14 years, it is metabolised in the kidneys codeine is the bottom of the barrel of the opiates and is harder on the system than meth,and yes you can get straight codeine with out the garbage.
Advil , alieve , &lbprophin sorry didn’t spell it right. but they’re all goog .I have. hepatitis. c my liver is messed up have problem. with gout. & have diabetes.
Is there any financial help for someone recently diagnosed with Hepatitus C and a fatty liver. I’ve run out of insurance and am very concerned about how I will be able to even me treated for this thing. Thanks.
I don’t know where u live but when I lived in Cleveland the free clinic was staffed by incredible doctors from Universiry Hospitals| why don’t u try a free clinic in your area
What about codeine?
Reading through the comments of liver friendly pain killers, if there is such. Can anyone recommend a drug. I’ve read comments about codeine, but there are
many codeine drugs that contain paraceto=amol or other ingredients.
i am a patient of hepatitisC, I would just like to know what painkillers should i use, that dont affect the liver so much.
I am prescribed Vicodin HP’s which has less acetaminophen660mg & more hydrocodon 10ml. Ive read that recently all Vicodins are being manufactured (by law) with much less acetaminophen in them. Reason being for the sake of anyones liver. But still very habit forming. We just cant win with this.
Im also curious what fellow HCV’ers take and what type & level of pain is experienced on a scale of 1-10. I have all over infused pain of muscles and joints and my liver area gets hard as a rock with pain. Â
I also am prescribed tramadol for arthritus and I am waiting results for my 3rd lot of anti viral treatment for hepc. So this is a big issue for me. I have been told before only to take paracetamol because of my liver disease but have now been given tramadol for my recently developed arthritus in my knee which is bad and affects my mobility. Any ideas please?
HAVE U TRIED SHOTS IN THE KNEE. I HAVE A BAD RIGHT KNEE THT BUCKLES OUT AND HURTS A LOT. I WENT AND GOT SUPRA SHOTS—3 OF THEM AND ALTHOUGH THE PAIN IS NOT COMPLETELY GONE, AT LEAST I AM ABLE TO GET AROUND MUCH BETTER. ASK THE DR TO PUT YOUR KNEE BENT ON A BOLO—PILLOW ROUND/KINDA LONG. I COULD HARDLY FEEL THE SHOT WHEN SHE PUT THT PILLOW! BEFORE THAT–THE DR DID IT WITH MY LEG HANGING OFF THE TABLE WHICH CAUSED ME TO SCREAM WITH PAIN! PUT TRAMADOL/HEPC IN YOUR SEARCH BOX. GOOD LUCK.
I had knee pain and I went to get custom Orthodics for my shoes. With the Orthodics in my shoes and with several tweaks of Orthodics they made for me and may insurance covered my knee is totoally fine
I been told by my doctor my liver is swollen told me stay clear of paracetamol but never said what I could take for pain relief I’m in utter agony
What about Naproxin?