Balancing Act: Drugs that can help and hurt
http://www.hepatitismag.com/features/default.asp?HepStoryID=37
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
TylenolŽ and AdvilŽ, 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 <I style="mso-bidi-font-style:
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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 (TrovanŽ, 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 TrovanŽ.
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
ˇ Protect yourself. Always read the label. Drug labels contain
information on the most common and dangerous potential side effects.
ˇ 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.
ˇ Don't combine OTC or prescription drugs with alcohol.
ˇ 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.
ˇ 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.
ˇ 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.
ˇ Read the labels and inserts included with OTC medicines.
ˇ 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.
You can also report the event to MedWatch, a Federal Drug Administration
medical reporting program. The Web site www.fda.gov/medwatch/report/consumer has
forms that can be downloaded for reporting your event, or you can call the FDA
Office of Emergency Operations at (301) 443-1240.
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.
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