Paracetamol use during pregnancy – a call for precautionary action
nature.com
nature.com
[edit] > "It is the most common cause of liver injury. Period. Full stop," said Dr. Michael Rieder, a pediatric clinical pharmacologist at Western University in London, Ont.
[1] https://www.cbc.ca/news/health/acetaminophen-toxicity-health...
Without acetaminophen your only option for pain relief without going to much stronger drugs would be the NSAIDS like aspirin or ibuprofen.
While not toxic to your liver, if you take them often enough you’ll end up with GI bleeding pretty reliably.
It doesn't work. It is the leading cause of liver failure in western societies. And yet the "common knowledge" of its utility surpasses those facts among doctors and pharmacists.
They keep prescribing it and adding it to other medicines, but there's no good medical reasons to do so.
There is a massive body of evidence showing that it's far more effective than placebo. There are even recent tentative evidence that show it increases risk taking behaviours and reduce emotional response to various stimulus.
You can find the studies with scihub. Tylenol doesn't seem to work for fever or anti inflammatory purposes either. It's great at hurting and killing people, though, in overdose and chronic use scenarios.
Small changes to a trial can completely blow it up. Same with antidepressants or anything where the trial outcome is a subjective measure by the patient.
What? Not sure what alternate universe we're talking about, but paracetamol definitely works on fever in this one.
That may well be true, but that doesn't mean it's especially dangerous. The number of people injured by a paracetamol overdose is tiny compared to the number of people who take it. Other drugs are significantly more dangerous when you consider per patient injuries.
This is compounded by the fact that paracetamol overdose with alcohol is a common way for people to attempt suicide - all those who are discovered and rescued will end up with acute liver damage. Doctors (in the UK) usually recommend that people who have damaged their liver in this way avoid drinking alcohol for about a decade afterwards.
Really? I thought it was advised to not drink alcohol for life if you had liver damage. I thought the damage was permanent, no?
Saying the damage is caused by regrowth is silly as without it the liver would have failed at the first injury.
Your skin does not regrow if you chop off a large patch. It can only heal damage.
Alcohol is a poison. If you didn't deliberately build up a tolerance to it your reaction is normal.
I read this like you had a chance to build up tolerance earlier
> they can't metabolize it well
Also a possibility orthogonal to tolerance factor.
Not “active dose”, recommended daily limit.
> Each year, about 4,500 hospitalizations in Canada occur due to acetaminophen overdose, and about 16 per cent of these are accidental, Health Canada says.
So this affects only a tiny minority. It’s absurd that the tens of millions of people who use acetaminophen without an issue need to have their access to the drug restricted because of these 700 people.
To be absolutely clear, the maximum recommended dose is 4000mg over 24 hours. That’s eight extra strength pills. According to your article, the people who still accidentally overdose apparently take two pills every 2-3 hours and then forget how many they took. No wonder the vast majority avoid this fate, we simply take one pill instead.
It annoys me to no end when some folks trying to win the Darwin Award make medical professionals change guidelines in a misguided attempt to “protect” us. No, we don’t need that protection. Just keep it available while educating people about concerns around pregnancy and lower doses for younger children.
Everyone involved with writing, editing or contributing to this nothing burger of an article should be ashamed of themselves.
It's also included as a secondary ingredient in a lot of other medicines, which makes it easy to take more than you thought. Additionally, other common drugs (like alcohol) use the same metabolic pathways, so they can dramatically lower the safe limit for acetaminophen.
When you look at the rate of death and serious injury due to overdose, acetaminophen comes out very badly. The only medicines that kill more are opioids.
One other thing is that many compound otc drugs (marketed as 'get through this' for ) also have acetaminophen...
I'll also say that being pregnant is the medical wild card. You shouldn't do, eat, take, catch anything. It doesn't help discriminating between the level of risks you're taking when anything you do is forbidden.
Having such a risky drug at hand mechanically increases the risk of overdose and we should strive to find better alternatives, I think. It doesn't have to be more control, since it won't help you at home and will just make suffering people more miserable, but tech could help here, with delivery or packaging for example. 700 dead people isn't nothing. And putting a 'Darwin Awards' tag on them feels the same as 'pilot blaming' in aviation: not likely to increase safety.
In Spain you can get 1000mg paracetamol pills OTC, so that's 4 of them. It's not that unusual doctors prescripting "one every 8 hours" for acute cases. People are probably not aware that hitting themselves with that dosage could probably hurt them in the long term: next time, you self medicate again.
Any drug where the toxic dose is that close to the suggested dose is going to be dicey when we let people buy it OTC. Notice I'm not saying we should prevent it from being OTC -- as someone who is not a doctor I have no clue on that. Just saying that I don't think it's fair to categorize people who take took much Tylenol without realizing the potential deadliness Darwin Award candidates.
* I'm also going to make an edit to say, you suggest education, but isn't that exactly what this article is doing? If you want people to take warnings seriously, the warnings need to be serious.
Consider that maybe the restriction is why overdoses are so are.
The medical gate-keeping/lobbying for keeping anything effective prescription-only is strong. (Of course the other side is that people will not read the leaflet and take some stuff willy-nilly)
As even the article says, having a fever is also dangerous in pregnancy.
In the UK, for basically any medicine you buy OTC in a pharmacy/drug store, the store assistant will ask you if you're taking any other medication, and will tell you the dosage to take (by reading the packet). It's not fool proof by any means but it does mean that people get _some_ advice.
Compare that to the three alcoholic cirrhotics I am currently caring for (which is a fairly common number where I work), and I personally don’t think acetaminophen is a very big deal for most people.
Also, we (hospitalists in the US) certainly see far more bad outcomes from OTC NSAID use contributing to GI bleeds and heart trouble (I’d say I care for a couple/month on average).
Additionally, it's no wonder that it's a paediatrician speaking, because many Tylenol intoxications are actually intentional in children (suicide). It's one of the most common suicide plan in teenagers.
[1]: https://www.embryotox.de/arzneimittel/details/paracetamol/
This would be corroborated by the fact that siblings of kids whose mothers took Paracetamol during pregnancy also experienced higher ADHD.
As always in these things, effect sizes are small, confounding variables are huge, and much much much larger socio economic factors that we as a society could actually do something about are routinely ignored.
Paracetamol is the therapy of choice for pain and fever during pregnancy. Doctors, pharmacists, etc all recommend it in Germany. Ibuprofen is more problematic.
Without a decent alternative, the best we can probably do is to limit the dose and duration of use. This policy is probably the best for any medication during pregnancy and childhood.
IMO the biggest benefit of studies like this is to discourage pointless use of OTC painkillers. These painkillers are pretty weak anyway so if you old have mild discomfort or find that your pain isn't responding to the drug this is yet another reason to not just 'pop an asprin' (or ibuprofen, Tylenol, etc.) at the slightest bit of discomfort or even taking it regularly without good reason. I have seen even young people just get in the habit of taking ibuprofen, Benadryl, etc. multiple times a week or even daily which just seems excessive.
On the other hand, we are reaching the point where everything is a compromise. If you are pregnant AND working I am going to take a gamble and guess that OTC pain meds are pretty much par for the course.
Depression leading to miscarriage is also a possible outcome.
And on the other end, people who haven’t given birth yet are disqualified for speaking about thing they might actually do. How can one make up their mind, and drum up community support without talking about the issue?
Painkillers are only for treating acute pain.
Chronic pain is fixed by treating underlaying cause (unless you don't have access to health services).
--a random MDhttps://www.nytimes.com/2018/01/27/opinion/sunday/surgery-ge...
[1]: https://www.embryotox.de/arzneimittel/details/ibuprofen/
Increased risks of heart attack and stroke, hypertension, kidney damage.
I've been giving my infant paracetamol and am now having second thoughts about it.
I'm gonna go ahead and continue not giving aspirin to kids.
https://pubmed.ncbi.nlm.nih.gov/11994026/
> The presence of salicylates in the blood or urine of Reye's syndrome patients has not been demonstrated, and no animal model of Reye's syndrome has been developed where aspirin causes the disease. It is clear from epidemiological data that the incidence of Reye's syndrome was decreasing well before warning labels were placed on aspirin products. Reye's syndrome disappeared from countries where aspirin was not used in children as well as from countries which continued to use aspirin in children.
This link with Reyes syndrom is about as valid as good old snake oil to treat ailments. Bad science was not invented just last year.
Paracetamol does not cause such harmful effects if used as directed. It definitely should be used as a first-line treatment (if needed) in case of fever or pain.
Edit: typo
This has never been demonstrated
https://www.theguardian.com/science/2015/apr/14/paracetamol-...
https://www.theguardian.com/lifeandstyle/2019/jun/04/why-par...
Life-threatening liver damage to a tiny minority likely means non-life threatening liver damage to everyone else. Just because everyone else didn't end up complaining to a doctor does not mean no harm was done.
The vulnerable elements of society are often indicators of what will happen to the normal elements, if the pressure is increased—or if the damage gets accumulated over time.
The only option is to keep collecting and evaluating data over and over and make decisions with the best available information.
http://www.survivingnjapan.com/2011/01/how-to-find-tylenol-i...
I don't understand what leads you to believe that a paper that can be filed under "spurious correlation" could be automatically discarded as not being serious.
One of the purposes of scientific articles is to report interesting findings to peers, which serve as food for thought. By definition, the state of the art of any field is perpetually in a "work in progress" stage, and researchers feed off each other's work to progress.
This paper reports an observation. Like all similar papers, now the community is free to look into it and bring some clarity to the topic. This is how progress is achieved.
Well, consumers are doing it completely wrong if they're looking up to papers as established and definite references regarding scientific findings.
Papers do not define reality, at most they only describe the author's perception of reality give their circumstances and current understanding, and reflecting the current state of the art. Thus observations might be off, but still interesting enough to spark further work to build up knowledge and clarify misconceptions.
It's like the parable about the blind men and an elephant[¹]. We might have an academic paper describing a novel species of trees that have a strong correlation with snakes, and consumers would be using that paper to justify shooting at treetops just to be sure they aren't attacked by a snake.
That doesn't mean it 100% establishes a causal relationship. Generally science is more nuanced and it's best not to negate its findings with the 'correlation is not causation' trope.
That is something I guess everyone learns in their first year at university, you can assume peer reviewed scientific work is created by people who got the memo.
Haha. No. (MD with 15y experience in clinical research)
https://www.reddit.com/r/slatestarcodex/comments/q01gwl/comm...
https://en.wikipedia.org/wiki/Post-polio_syndrome
We'll only find out about long-term side effects of Covid... when/if they happen. Should be interesting, to say the least.
I don't see why we this discussion has to be so politically charged. Life as an adult is all about taking risks, and most of the time a risk-less alternative does not exist.
To go back to your example: To make Covid vaccines more risky than say, alcohol, (or another common drug), a lot has to happen. Can it happen? Yes. How likely is it? Very unlikely.
Still people take great risks every day: Drinking alcohol, driving a car, eating unhealthy, taking pain killers, etc.
That risk isn't so great, also not long-term. There's already a lot of evidence and indication for that.
http://www.survivingnjapan.com/2011/01/how-to-find-tylenol-i...
It's heavily advertised and available in every drug store in Japan (you don't even need to go to pharmacies!).
https://www.tylenol.jp/products-tylenol
If you were hunting for paracetamol during the pandemic, it could be that it was all sold out because it has been recommended as the medicine to counter COVID-19 symptoms and if there is anything I trust people in Japan to do it is to be able to stock up on things at a time of emergencies.
If nowhere is the marketing department for Tylenol.
It was created in 1877, before the FDA was in place with such rigorous testing requirements for drugs. It’s safe image has been marketed since then and now represents enough money for the Johnson & Johnson company that they lobby against restrictions on its use.
Reye's syndrome affects fewer than one in a million children a year — Wikipedia. However I do presume that number would go up significantly if more children were given aspirin?
Accidental overdoses of Paracetamol affect about 20 per million people. Calculation: (a) The current population of Canada is 38 million, (b) 700 accidental overdoses per year in Canada: https://news.ycombinator.com/item?id=28735280
https://twitter.com/iaindale/status/1441504448266833920?s=21
How much of the current sexual identity revolution is long-suppressed true identity, and how much is that we have poisoned an entire generation with untested pharmaceuticals, endocrine disruptors, and environmental toxins starting in-vitro and continuing through their entire childhood?
But there are 5 billion people in the developing world about to become middle class... you having fewer kids is going to accomplish nothing. We're already going to have to engineer our way through this.
As countries get richer and women gain better access to education and improved rights, the countries seem to go through an inflection point where suddenly no one wants to have children and the birth rate falls below replacement (2.0, two children to replace two parents)
For us as a species to survive we need to try and stabilise that at 2.0 + some small safety margin (to make up for infertility, people who really don’t want children, or physically can’t).
While we’re bound to one planet (which it looks like is going to be for awhile, “sending people to Mars” is very different from “sizeable % of the total human population living on Mars”) it’s preferable for that stable population point to be as small as possible.
10 billion is a lot, but it looks stable at least. If we bring our replacement rate down more to peak the total population earlier, we have this weird problem where the replacement rate is well below 2.0, so no one is having children, and we suddenly have to convince people to start having more.
It feels like everything else in life; the birthrate would keep yo-yo-ing above and below replacement rate, and we really don’t want it above while it’s so cramped here and we’re messing up fundamental environmental systems that we rely on.
Like everything else these days it seems like it kind of comes back to “well, if you want to do something, first we’ve got to deal with climate instability”. /shrug
The relevant metric is 10 billion at what level of consumption?
Hong Kong style? Maybe. Western developed country style with detached homes with garages, 2 cars, 10k+ (16k+ km) miles of driving, and flying to destinations? I would guess not.