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Avoid acetaminophen as hangover antidote by Mary Helen Yarborough Public Relations The holidays traditionally are full of good celebration and food, and for many, the spirit that can come in various forms of alcoholic beverages. For those who over-indulge on alcohol, a bit of pain relief is in order. But a leading liver expert warns that some pain killers, when taken for a hangover or by people who consume alcohol heavily on a regular basis, can be deadly.   Adrian Reuben, M.D., director of liver studies and a leading member of the Liver Transplant Program, said that the majority of acute liver failure cases in the United States have involved acetaminophen poisoning.   “The problem is that acetaminophen is a component of scores of nonprescription pain killers and people are overdosing without realizing it,” Reuben said. “Many people use the word Tylenol to represent pain killers in general, in a similar way that people use the word ‘Xerox’ to mean photocopying. While using Xerox as a verb might be a nuisance to the manufacturers of competing photocopiers, the misunderstanding of Tylenol in pain killers can be lethal, if individuals do not realize that Tylenol is not the acetaminophen-containing medicine.”   Acetaminophen is found in various products labeled as aspirin-free pain relievers, and it also is found in combination with other drugs, such as the narcotic painkillers Vicodin and Percocet. People who suffer acetaminophen poisoning or toxicity often are taking more than one drug containing acetaminophen without realizing it.   Of the estimated 2,000 acute liver cases a year, 60 percent of them involve acetaminophen poisoning. As a member of the Adult Acute Liver Failure Study Group funded by the National Institutes of Health, which is directed by William Lee, M.D., of Southwestern University at Dallas and former chief of gastroenterology at MUSC, Reuben collaborates in the analysis of cases of liver failure and of their causes for the national consortium.   “Of all the acute liver failure cases involving acetamino-phen poisoning, half are accidental, and the other half are intentional, as in suicides,” Reuben said. “This includes patients who have taken acetaminophen in combination drugs like Vicodin, non-aspirin pain relievers, and Tylenol PM, to mention a few.  Alcoholics represent a group of individuals particularly at risk.”   Taken as directed, acetaminophen is safe for most people, Reuben said. The recommended maximum dose of acetaminophen is no more than 2,000 mg a day, taken as six doses of standard strength (325mg) or four doses of double-strength (500mg) spread out during the day. “That restricted dose should be safe in someone with or without liver disease,” Reuben said.   For the alcoholic, acetaminophen taken in even in small doses can cause acute liver failure, which can be fatal.   Acetaminophen is changed to a toxic compound, N-acetyl-p-benzoquinoneimine (NAPQI) in the liver, which, under normal circumstances, can be made harmless by the liver’s reserve of its natural antidote glutathione.   Acetaminophen becomes toxic when the NAPQI cannot be inactivated and the liver’s own antidote, glutathione, is no match for an excess of the toxin.   “In the alcoholic, the liver produces more of the toxic product but, at the same time, it is not making the necessary supply of its own antidote to counteract it,” Reuben said.   Chronic moderate to heavy alcohol use increases the likelihood of acetaminophen toxicity.  Paradoxically, really large binges of alcohol interfere with the production by the liver of the toxic NAPQI, but to use ‘the hair of the dog that bit you,’ is a foolish and dangerous way to avoid acetaminophen toxicity.”   While alcoholics or people who drink heavily regularly are advised to steer clear of acetaminophen, people who are not well-nourished or are starving also could suffer acute liver failure from acetaminophen, Reuben said.   “In the malnourished, which includes people who have been sick and haven’t eaten for several days, the liver isn’t making its supply of antidote,” Reuben said. “So when this person takes acetaminophen, he or she is vulnerable to sudden liver injury.”   The good news is that the liver is a resilient organ and unless it suffers from overwhelming damage, it can recover completely. If acetaminophen toxicity does become a part of the holiday spirit, the liver can rebound as long as alcohol and all drugs containing acetaminophen are avoided. Eating also is imperative to help supply the liver with the nutrition needed for it to function properly and counteract toxins.   “Nonetheless, the message is to read the small print on medicine labels and be sure that you know what you are taking and how much to avoid an unintended overdose that could ruin your holiday fun and prevent you from seeing 2008,” Reuben said.     Friday, Dec. 21, 2007 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. 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