Balancing Act: Drugs that can help and hurt

By: Jason E. Moore

  You’ve seen the headlines: “Tylenol overdoses linked to liver failure.” “Diabetes drug causes liver disease.” “Ibuprofen [causes liver] toxicity in patients with chronic hepatitis C.”

 It’s inevitable. Such headlines set off alarms in people who have a liver disease such as hepatitis C. And they should.

 Many common over-the-counter (OTC) and prescription drugs can cause liver damage, even when taken as directed. There are few drugs more commonly used than Tylenol® and Advil®, yet even these drugs have the potential to harm your liver.

 At the same time, many of these drugs are important therapies and can improve your health and your quality of life.  So, where’s the balance?

 We looked at some of the most common OTC and prescription drugs that can cause liver damage and the risks that you face, as a person with hepatitis C, by taking them.

 Pain Relievers/Anti-Inflammatory Drugs

 This group of drugs, which includes acetaminophen (found in Tylenol) and ibuprofen (found in Advil), contains some of the most commonly prescribed medicines in the world; they are used to relieve minor pain and to treat fevers. Perhaps you’ve read some of the many articles on their apparent ability to cause liver problems in some people. Reported effects of liver injury range from insignificant changes in liver test values to severe and acute hepatitis. Articles abound in the popular press on this possible liver damage and raise serious questions for people with hepatitis C.

 People with hepatitis C are not immune to the aches and pains that everyone else suffers. But are they more prone to liver damage caused by taking common pain relievers than people without hepatitis C?

 The answer to this question is unknown. Usually, studies of such drugs exclude people with chronic liver diseases, so that they are not placed at risk by participating in the study.

 What is known is that the greatest risk from these drugs appears to come from over-dosage and from taking them with alcohol. Taken in high doses, some of these common pain relievers can cause liver damage.

 Anyone who takes large amounts of acetaminophen, for example, will have liver damage in proportion to the amount of the drug taken. Increasing research has also shown that combining acetaminophen with alcohol can increase the risk of liver damage caused by acetaminophen.

 According to Dr. Caroline Riely, Professor of Medicine and Pediatrics at the University of Tennessee, Memphis, College of Medicine, who specializes in Hepatology, chronic alcohol abuse “revs up” certain enzymes in the liver, which then work overtime. These same overactive enzymes convert acetaminophen to toxic substances that can harm the liver. Even doses as small as 2 gm (4 extra strength tabs) can cause serious liver injury.

 Dr. Riely makes another point about alcohol use: “Alcohol is, of course, a drug and can definitely make hepatitis C worse. Folks with hepatitis C should drink not at all, or very sparingly. We can’t emphasize this enough.”

 Dr. William Lee, professor specializing in liver disease, Dept. of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, echoes the potential risks of consuming alcohol and acetaminophen. He suggests that the more common cause of difficulty is patients taking too many tablets in 24 hours. He also warns against taking two or three acetaminophen-containing medications, such as combining cough syrups and pain relievers, at the same time.

 Dr. Lee, who published a 1997 article in the New England Journal of Medicine, gives his bottom line: acetaminophen dosing should be cautious and should generally fall short of the dosage recommended on the packaging, such as 2 grams per day, instead of 4. Nonetheless, Dr. Lee adds that acetaminophen can be used appropriately by people with hepatitis C.

 Aspirin has been shown to be toxic to the liver. In fact, even low-dose (250 mg/day) aspirin therapy has been shown to cause liver abnormalities. However, the liver damage and abnormalities are generally not fatal and are reversible when aspirin therapy is stopped.

 When considering whether to take these common OTC pain relievers, as with most chemicals, the safest route is to avoid these drugs, as they may cause liver damage in some people. At the same time, they can play a useful role in some instances. If taken, they should never be combined with alcohol, and they should be taken at or below the dose recommended on the label.

 Rezulin

 Perhaps you’ve heard of this controversial diabetes drug. It helps the diabetics’ bodies respond better to insulin, which regulates the level of glucose in the blood stream. As of March 1998, the FDA had counted 43 patients who suffered acute liver failure after taking Rezulin for several months.

 As a result, consumer groups have lobbied to have Rezulin removed from the market as unsafe. And doctors are now told to test for liver damage in diabetic people who are taking the drug. While this drug may not always be inappropriate for people with hepatitis C, the risks and benefits of taking the drug should be carefully weighed, with the advice of your doctor.

 Certain antibiotics  (Trovan®, Augmentin, Ciprofloxacin, Erythromycin)

 Certain antibiotics can cause liver damage or other abnormalities. One new antibiotic that has received media attention for its apparent potential to cause liver injury is Trovan®.

 It is used to treat a wide variety of bacterial infections, such as pneumonia, bronchitis, sinusitis, infections in the abdomen and sexually transmitted diseases.

 This drug has been shown to cause very severe liver damage, including liver failure requiring liver transplant, in some people. The reaction is unpredictable and happens only in a very small population of people who take Trovan.

 Nonetheless, because of the severity of drug reaction, doctors have reserved this drug for people who have severe, life-or limb-threatening infections.

 The problem with Trovan, as with Rezulin, is that it is new. When drugs are tested in clinical trials by pharmaceutical companies, the vast majority of patients are healthy. It’s usually only when these drugs hit the market and are widely used that certain peculiar reactions, such as liver damage, affecting only a relatively few people, are revealed.

 Dr. Riely’s advice, “When a new drug comes out, the public should be wary.” Even though people with hepatitis C are at a greater risk of having these particular reactions, when they do occur, people with hepatitis C are likely to have more severe reactions. The best approach: wait until a new drug is widely used (often for several years) before giving it a try.

 Other antibiotics can also cause problems. Augmentin can cause jaundice by slowing the normal flow of bile from the liver. However, this type of reaction is rare. Ciprofloxacin, another antibiotic, can rarely cause abnormalities in liver laboratory tests.

 Ciprofloxacin-induced liver failure has been reported, but the liver damage is thought to be reversible when the drug is discontinued. Finally, erythromycin can also slow the flow of bile from the liver and lead to jaundice. However, erythromycin-caused liver changes are more common than seen with the other antibiotics (nearly 4 in 100,000 people treated with erythromycin reported such problems). The liver injury is reversible, and the jaundice usually subsides in a few weeks.

 Contraceptive steroids

 Some contraceptive steroids, such as the estrogens, can cause changes in liver function. Such changes include decreases in the normal flow of bile from the liver, which causes jaundice, and decreased excretion of bilirubin, a waste product produced in the liver.

 Approximately one in 100,000 Americans has reported this reaction. These liver changes usually go away in the weeks after the estrogens are discontinued. In contrast to the estrogens, progesterone has no apparent effect on liver function.

 Guiding Principles for OTC and Prescription Drug Use

 ·         Protect yourself. Always read the label. Drug labels contain information on the most common and dangerous potential side effects.

·        Follow all directions for both OTC and prescription drugs, especially those concerning when and how much of the medicine to take. Many drugs aren’t harmful when taken in the proper amounts, but can cause serious damage when taken in excess.

·         Don’t combine OTC or prescription drugs with alcohol.

·         Ask your pharmacist. While your local pharmacist won’t tell you what drugs you should or shouldn’t take, he is a great source of information on possible side effects and drug interactions.

·         Consult your doctor. This is the best rule whenever there is a serious question that a drug could harm your liver. The best doctor to ask is one who specializes in treating liver diseases. But, do not assume that your doctor knows everything about all drugs.

·         Research a drug before taking it – ask if it is a new drug and if it has been given without adverse incidents to other patients with hepatitis B or C.

·         Read the labels and inserts included with OTC medicines.

·         Read the inserts provided with prescription drugs. Make sure the medicine you receive is what your doctor prescribed and has the correct dosage indicated on the label.

 Decisions concerning the use of both OTC and prescription medication can be complicated. However, it is possible to strike a balance. Don’t be afraid to ask your doctor or pharmacist questions.

 Educating yourself about the potential problems of taking these medications, while consulting your doctor when questions arise, can help avoid problems that could result from taking the medications meant to improve your health and the quality of your life.