Please ... don't take Tylenol. Ever.

[BroncoBuff]

Originally Posted by bombay

The Doc Abides.

Abides what? I accurately cited impeccable sources that identified dangers, sounded warnings and imposed sanctions against acetaminophen-combination medications. Then Doc came in here throwing wild, over the top insults, saying I had no idea what I was talking about when 99% of what I posted was the FDA actions. He called me (the FDA data) "the most dangerous thing ever posted here."

Whatever. Admittedly some of the WebMD NSAIDs stuff he posted was eye-opening, and kappys confirmed some of those concerns. But don't forget an FDA advisory panel (experts) recommended BANNING these acetaminophen-combination drugs nearly three years ago! Yes, they recommended taking Percocet, Tylenol 3, Vicodin, etc ... OFF THE MARKET ENTIRELY!! That is a VERY big deal. I'll betcha any sum they've never recommended aspirin be banished.


Later Doc tried to play kappys as his supporter, when in reality kappys went out of his way to provide relevant (and welcome) data and info without taking sides.

And what about this from the LANCET article last summer?! He completely avoided these very relevant points:

Originally Posted by Analysis of Lancet article

In 2010 papers in the British Medical Journal (BMJ) and the Lancet showed long-term aspirin use to be the most protective cancer drug yet found.

Gastrointestinal bleeding is clearly an important side-effect of aspirin. But whatever the frequency of bleeding its seriousness does not match that of the diseases aspirin can prevent.

http://www.significancemagazine.org/...nder-drug.html


Sidestepping counter-points is always poor debate, especially counterpoints as powerful as these. FWIW, I think Doc is a doctor ... the CV he gurgitated is well stated. But in addition to being a doctor he's also one rude SOB. I always liked him before, but I don't get the anger and insults, and I don't appreciate them.

[Dr. Broncenstein]

Originally Posted by BroncoBuff

Abides what? I accurately cited impeccable sources that identified dangers, sounded warnings and imposed sanctions against acetaminophen-combination medications. Then Doc came in here throwing wild, over the top insults, saying I had no idea what I was talking about when 99% of what I posted was the FDA actions. He called me (the FDA data) "the most dangerous thing ever posted here."

Whatever. Admittedly some of the WebMD NSAIDs stuff he posted was eye-opening, and kappys confirmed some of those concerns. But don't forget an FDA advisory panel (experts) recommended BANNING these acetaminophen-combination drugs nearly three years ago! Yes, they recommended taking Percocet, Tylenol 3, Vicodin, etc ... OFF THE MARKET ENTIRELY!! That is a VERY big deal. I'll betcha any sum they've never recommended aspirin be banished.


Later Doc tried to play kappys as his supporter, when in reality kappys went out of his way to provide relevant (and welcome) data and info without taking sides.

And what about this from the LANCET article last summer?! He completely avoided these very relevant points:

http://www.significancemagazine.org/...nder-drug.html


Sidestepping counter-points is always poor debate, especially counterpoints as powerful as these. FWIW, I think Doc is a doctor ... the CV he gurgitated is well stated. But in addition to being a doctor he's also one rude SOB. I always liked him before, but I don't get the anger and insults, and I don't appreciate them.

You are the one sidestepping arguments here. Your thread title says "don't take tylenol ever," and you recommend NSAIDs instead. While asprin and other NSAIDs have their place, they routinely cause serious problems. Read my first post. This is the point of my argument. This is the problem I have with your opinion on this matter. You have tried to shift the argument to a different effect of Asprin, particularly regarding a role in cancer prevention. I'm not debating the benifits of asprin. I'm debating the safety of properly dosed acetaminophen vs NSAIDs.

As you stated in your reason to never take tylenol: 400 deaths per year due to acetaminophen overdose.

NSAIDs on the other hand: 16,000 deaths and 100,000 hospitalizations per year at standard doseages.

What part of this is not sinking in? Can you honestly not see where I might have a problem with your origninal post?

I said that tylenol is only toxic when dosed in highly excessive quantities. Kappys (an emergency medicine physician and toxicologist) said that in a healthy adult it takes around 10 grams -- 20 extra strength tablets in one dose -- to cause hepatotoxicity. I called his attention to this thread via a PM. I already knew what he would say. Shall I quote him again?

"Dr. bronc is right when it comes to NSAID's versus tylenol when taken at appropriate doses - NSAIDS cause far more side effects principally being GI bleeding which can be fatal though in most patients has a benign outcome with good management - NSAIDS can also cause a significant percentage to develop renal disease. Contrasting that with the use of normal doses of tylenol which cause some mild liver testing abnormalities of unclear significance is difficult - none of the patients in those studies developed any sort of over liver disease but over decades of use it remains a theoretical concern. Actual human data in the form of cohorts(retrospectively looking at people taking 4 grams a day) does not show evidence of liver injury."

Kappys however didn't go into detail regarding the "good management" aspect of that paragraph. Quite frequently the medical management requires a significant amount of hospital resources including: ICU admission, multiple blood product transfusions, nasogastric tube, multiple IVs / central venous line, foley catheter, intravenous proton pump inhibitors, and serial labs. That's a significant amount of resources for a side effect of a properly dosed medication. There is signinficant risk for complications with the above and that doesn't even begin to account for possible endoscopic or even surgical intervention.

You personal opinion of me is just that. If your ad hominem makes you feel better, then keep after it. I won't get offended. I certainly won't call you names. I will point out if your medical opinion on this football board is dumb and/or dangerous. I'm sorry if that hurts your feelings, but it's my honest evaluation. I would expect nothing less in return if I offered a comparable legal analysis to this football board.

[kappys]

Originally Posted by Dr. Broncenstein

As we have both stated, there is almost no chance for hepatic injury with the proper dose of acetaminophen. Do you think that the diversion trends played any role in the FDA's recommendation to reduce the acetaminophen dose in combined opiate analgesics? More to the point, do you think that knowing the sheer number of people illegally obtaining and abusing these medications had anything to do with the FDA's recommendations?

If I recall correctly when I read the advisory panels recommendations regarding combination products it is mainly the overdose of these medications - whether intentional or unintentional that is the driving force to reduce acetaminophen doses in these combination products.

In case you are interested here is what the 2009 FDA advisory panel found:

Question 1 (Vote)
Do you recommend that the maximum total daily dose (4 grams/day) of acetaminophen in nonprescription single ingredient and combination products be lowered?
11 members voted for A – Yes, I recommend this change and consider it a high priority
10 members voted for B – Yes, I recommend this change
16 members voted for C – No, I do not recommend this change

Question 2 (Vote)
Do you recommend that the maximum nonprescription single adult dose be limited to 650 mg?
12 members voted for A – Yes, I recommend this change and consider it a high priority
12 members voted for B – Yes, I recommend this change
13 members voted for C – No, I do not recommend this change

Question 3 (Vote)
If the current doses of nonprescription products are lowered, do you recommend that the current maximum dosage of acetaminophen (i.e., 2 x 500 mg) be switched to prescription status?
8 members voted for A – Yes, I recommend this change and consider it a high priority
18 members voted for B – Yes, I recommend this change
11 members voted for C – No, I do not recommend this change

Question 4 (Vote)
Do you recommend that pack size limits be implemented for nonprescription acetaminophen products?
2 members voted for A – Yes, I recommend this change and consider it a high priority
15 members voted for B – Yes, I recommend this change
20 members voted for C – No, I do not recommend this change

Question 5 (Vote)
Do you recommend eliminating nonprescription acetaminophen combination products?
2 members voted for A – Yes, I recommend this change and consider it a high priority
11 members voted for B – Yes, I recommend this change
24 members voted for C – No, I do not recommend this change

Question 6 (Vote)
Do you recommend that only one concentration of nonprescription acetaminophen liquid be available?
19 members voted for A – Yes, I recommend this change and consider it a high priority
17 members voted for B – Yes, I recommend this change

Question 7 (Vote)
Do you recommend eliminating the prescription acetaminophen combination products?
10 members voted for A – Yes, I recommend this change and consider it a high priority
10 members voted for B – Yes, I recommend this change
17 members voted for C – No, I do not recommend this change

Question 8 (Vote)
If prescription acetaminophen combination products continue to be marketed, do you recommend that “unit-of-use” packages be required?
5 members voted for A – Yes, I recommend this change and consider it a high priority
22 members voted for B – Yes, I recommend this change
10 members voted for C – No, I do not recommend this change

Question 9 (Vote)
Do you recommend that FDA require a boxed warning for prescription acetaminophen combination products?
25 members voted for A – Yes, I recommend this change and consider it a high priority
11 members voted for B – Yes, I recommend this change
1 member voted for C – No, I do not recommend this change

Question 10 (Vote)
Overall Ranking of Options
Options related to both Rx and OTC products containing acetaminophen have been discussed. You have already indicated whether you consider each individual option a high priority. To further clarify how FDA should focus its resources to decrease the public health burden of acetaminophen liver toxicity,
indicate the single option, including both nonprescription and prescription options, which you recommend that FDA consider its highest priority. If you do not recommend that FDA implement any of the proposed options, please indicate this on the ballot provided.
Nonprescription Products
Note: Options 1a and 1b may be considered a single option or two separate options.
9 members voted for Option 1a and 1b, as a single option.
3 members voted for Option 1a only - Reduce maximum dose of OTC acetaminophen
1 member voted for Option 1b only - Switch current maximum dose of OTC acetaminophen to prescription
0 members voted for Option 2 - Establish pack size limits for OTC products
2 members voted for Option 5a – Eliminate OTC acetaminophen combination products.
7 members voted for Option 6 - Limit OTC liquid formulations
Prescription Products
7 members voted for Option 5b - Eliminate prescription acetaminophen combination products
1 member voted for Option 3 - Require unit of use packaging for prescription acetaminophen combination products
7 members voted for Option 4 - Require a boxed warning for prescription acetaminophen combination products
No member indicated on the ballot, that they did not recommend that FDA implement any of the proposed options.
1 member voted for C – No, I do not recommend this change


As you can see #7 addressed the topic at hand - but there is still quite a bit of disagreement amongst the panel of experts.

[BroncoBuff]

Originally Posted by kappys

Question 7 (Vote)
Do you recommend eliminating the prescription acetaminophen combination products?
10 members voted for A – Yes, I recommend this change and consider it a high priority
10 members voted for B – Yes, I recommend this change
17 members voted for C – No, I do not recommend this change

As you can see #7 addressed the topic at hand - but there is still quite a bit of disagreement amongst the panel of experts.

Wow, great data. 20-17 is very close. But this was very serious, they weren't voting on turkey or roast beef for lunch, they were voting to completely ban Vicodin, Percocet, and the rest ... and the majority voted to take them off the market entirely. Doc, you spent lots of energy in here talking about your many Rx's for Percocet without any problems, good, I'm glad. But how can you so vehemently argue that position - as if it was dispositive on this issue - when such skepticism pervades the medical community? I'm sure there were anesthesiologists still using chlorophorm after it was superceded too, but that didn't mean it was better than ether, or whatever. I'm not questioning your medical judgment, just pointing out it's a bad argument.

The Lancet article wasn't just about aspirin for cancer prevention, as Doc tries to limit it, it literally RECOMMENDED long-term aspirin use, saying the threat of GI bleeding - which is exactly what you guys been talking about in here - was less important: "whatever the frequency of bleeding its seriousness does not match that of the diseases aspirin can prevent." Doc, your beef is that I recommended aspirin. So I'm to assume you have the same beef with the Lancet? They don't know what they're talking about, they're dangerous, right?


I know far less about medicine than you two, but I know how to read these results, reports and recommendations. And based on all this, my decision to avoid Tylenol altogether seems a reasonable one. Certainly not "the most dangerous post ever on this board," plainly an overstatement. It should be noted the distinction between combination drugs and plain acetaminophen is important, these actions concerned combination drugs only. But how do these dangers manifest in other circumstances? If I take two Aleve and four hours later two Tylenol, does that trigger the same danger? That is exactly the kind of question I don't ever want to think about.

My original posts included a reference to my own decision first, then a recommendation others avoid Tylenol, too. I didn't intend that as any more a recommendation than somebody in here saying, "buy a Volvo, they're safer." The thread title is an overstatement I suppose, the kind of quasi-dramatic statement I'm prone to ... but the vast majority of what I posted was cited and sourced, and my 'recommendation,' such that it is, certainly does not reduce the thread to "dangerous."

[BroncoBuff]

Originally Posted by kappys

Question 10 (Vote)
Indicate the single option, including both nonprescription and prescription options, which you recommend that FDA consider its highest priority. If you do not recommend that FDA implement any of the proposed options, please indicate this on the ballot provided.
Nonprescription Products
Note: Options 1a and 1b may be considered a single option or two separate options.
9 members voted for Option 1a and 1b, as a single option.
3 members voted for Option 1a only - Reduce maximum dose of OTC acetaminophen
1 member voted for Option 1b only - Switch current maximum dose of OTC acetaminophen to prescription
0 members voted for Option 2 - Establish pack size limits for OTC products
2 members voted for Option 5a – Eliminate OTC acetaminophen combination products.
7 members voted for Option 6 - Limit OTC liquid formulations
Prescription Products
7 members voted for Option 5b - Eliminate prescription acetaminophen combination products
1 member voted for Option 3 - Require unit of use packaging for prescription acetaminophen combination products
7 members voted for Option 4 - Require a boxed warning for prescription acetaminophen combination products
No member indicated on the ballot, that they did not recommend that FDA implement any of the proposed options.
1 member voted for C – No, I do not recommend this change.

Here's an article on Question #10 kappys posted above (writer mistakenly lumps Rx and OTC votes together)

MedPage Today
Published: June 30, 2009

ADELPHI, Md. June 30 -- An FDA advisory panel voted 36 to 1 to recommend a "black box" warning for prescription medications that combine acetaminophen with another drug. If the FDA follows the advice, it would slap its strictest warning on prescription pain medications that combine acetaminophen with hydrocodone (Vicodin), oxycodone (Percocet), or codeine (Tylenol 3).

"History has been that some of these medications have [seemed] safe and effective and now we're saying they're not," said committee chairman Lewis Nelson, MD, an emergency medicine physician at New York University Medical Center. The panel voted for the warning after two days of hearings on ways to reduce acetaminophen's liver damage risk.

The FDA does not have to follow the advice of its advisory committees, but it usually does -- particularly when there is a substantial majority behind a proposal.

About 42,000 people visit emergency departments each year with acetaminophen overdoses, half of which are accidental. They often occur when a consumer unknowingly takes more than one acetaminophen product.

One advisory panelist attributed 10% of fatalities from acetaminophen overdoses to combination products.

The blue highlight is pretty important I think. Near the end of the last post I asked whether and how frequently these dangers manifested in plain Tylenol, OTC settings, as opposed to the comination drugs. If I'm reading that right, 90 percent?

Originally Posted by Dr. Broncenstein

You personal opinion of me is just that. If your ad hominem makes you feel better, then keep after it. I won't get offended. I certainly won't call you names. I will point out if your medical opinion on this football board is dumb and/or dangerous. I'm sorry if that hurts your feelings, but it's my honest evaluation. I would expect nothing less in return if I offered a comparable legal analysis to this football board.

My feelings are fine, pal. I'm sorry I questioned your credentials, but you repeatedly cited your micro experiences in this macro issue.

Look, the huge number of NSAID deaths sounds very disturbing. A small amount can be explained by their much greater market share, but they're still disturbing. My problem is - I keep wondering - where is the outcry in the medical community? Has the FDA investigated banning aspirin? What are the Lancet and the others missing that you understand?

[Irish Stout]

Make this simple for me guys... what should I take when I have a boo-boo? What should I take when I have a hangover? What should I take when I have a migraine?

Thank you and GB2.

[kappys]

Buff - the panel voted separately on banning combination OTC products and combinations prescription products. Question 10 is standard - for FDA panels in which the voters then clarify their votes by choosing the highest priority agents.

It should be noted that black box warnings are losing quite a bit of luster these days. Previously they were reserved for relatively common severe adverse effects but more and more black box warnings are being added for much rarer or milder issues. It has made the black box somewhat misleading but as a vehicle to keep physicians educated in an era of many drugs it may be beneficial. In addition it helps to keep consumers aware.

As for the Lancet study look at the dose of aspirin used - at low doses there is a protective effect without too much risk fo side effects. Those doses are not usually adequate to treat pain - particularly chronic pain which usually requires a higher dose.

[BroncoBuff]

Originally Posted by Irish McStout

Make this simple for me guys... what should I take when I have a boo-boo? What should I take when I have a hangover? What should I take when I have a migraine?

Thank you and GB2.

Not sure who GB2 is, but my opinion? I'm with Hogan, Aleve is the best OTC painkiller I've used. Careful though, NSAIDs have been known to cause GI bleeding.

All that said, migraines are tricky things ... so don't listen to me, consult a medical professional

[L.A. BRONCOS FAN]

Originally Posted by BroncoBuff

Abides what? I accurately cited impeccable sources that identified dangers, sounded warnings and imposed sanctions against acetaminophen-combination medications. Then Doc came in here throwing wild, over the top insults, saying I had no idea what I was talking about when 99% of what I posted was the FDA actions. He called me (the FDA data) "the most dangerous thing ever posted here."

Yep.

He's still the same "ideology over facts" nutjob who defended GWB for eight years.

[Smiling Assassin27]

Originally Posted by L.A. BRONCOS FAN

Yep.

He's still the same "ideology over facts" nutjob who defended GWB for eight years.

This post should be framed and the thread shown to every member. Somebody start a thread about Kittens vs. Puppies so this fool can wedge more inane, rambling, and totally unrelated Bush-isms. Tool.

[BroncoBuff]

Originally Posted by Smiling Assassin27

This post should be framed and the thread shown to every member. Somebody start a thread about Kittens vs. Puppies so this fool can wedge more inane, rambling, and totally unrelated Bush-isms. Tool.

Politics and painkillers are different topics yes, but LA wasn't comparing the topics. He pointed out what he thinks are the same behaviors in different situations. Just an analogy or simile like: "Of course Boob screws up on the job, he can't even move out of his mother's basement."

kappys, you mentioned the problem with irregular concentrations/strengths in liquid acetaminophen, that one really sticks with me. If the toxic dose in children is less that double the recommended dose, that leaves no room for error. Especially in that it’s a mere “recommended” dose ... who pays attention to recommended? It’s a suggestion, like a speed limit sign,


I’ve argued enough in here ... I’m not a doctor, nor should I play one online. I did not know about the frequency of NSAID problems, had no idea. Why are these dangers largely unknown? Why hasn’t the FDA considered actions/restrictions against NSAIDs? Something’s wrong with that picture. Anyway, the fact I didn’t know about those numbers made me defensive and a (just a wee bit) hostile. Sorry Doc, really.

[BroncoBuff]

Didn't mention this before, but I nearly OD'd on an NSAID in 1981. Anybody wanna hear how it happened?

The story started like so many others, with a dame. This doll
was built ... silky soft hair, cherry-red lips and bazoombas as
far as the eye could see. I sat shirtless as she silently hovered
over me. She exhaled softly in my ear, and I began to shake.
When she started rubbing my back, well that's when I knew I
was a goner.

[Dr. Broncenstein]

Originally Posted by BroncoBuff

Politics and painkillers are different topics yes, but LA wasn't comparing the topics. He pointed out what he thinks are the same behaviors in different situations. Just an analogy or simile like: "Of course Boob screws up on the job, he can't even move out of his mother's basement."

kappys, you mentioned the problem with irregular concentrations/strengths in liquid acetaminophen, that one really sticks with me. If the toxic dose in children is less that double the recommended dose, that leaves no room for error. Especially in that it’s a mere “recommended” dose ... who pays attention to recommended? It’s a suggestion, like a speed limit sign,


I’ve argued enough in here ... I’m not a doctor, nor should I play one online. I did not know about the frequency of NSAID problems, had no idea. Why are these dangers largely unknown? Why hasn’t the FDA considered actions/restrictions against NSAIDs? Something’s wrong with that picture. Anyway, the fact I didn’t know about those numbers made me defensive and a (just a wee bit) hostile. Sorry Doc, really.

There are occasions where NSAIDs are appropriate and worth the risk. Additional steps can be taken to mitigate the risks. That's the art of medicine -- weighing the benefits vs the risks of any proposed treatment. There isn't a medication or surgical procedure that is completely safe.

[L.A. BRONCOS FAN]

Originally Posted by Smiling Assassin27

This post should be framed and the thread shown to every member. Somebody start a thread about Kittens vs. Puppies so this fool can wedge more inane, rambling, and totally unrelated Bush-isms. Tool.

Speaking of "ideology vs. facts" - raise a flag and watch who salutes!

[BroncoBuff]

Originally Posted by BroncoBuff

The story started like so many others, with a dame. This doll
was built ... silky soft hair, cherry-red lips and bazoombas as
far as the eye could see. I sat shirtless as she silently hovered
over me. She exhaled softly in my ear, and I began to shake.
When she started rubbing my back, well that's when I knew I
was a goner.

Nobody wants to hear how I nearly OD'd on an NSAID, really?

It's true, every word Bogie said is true. Except the red lips.

I feel like a raconteur without a racontee.

[bombay]

The Doc Abides.

[epicSocialism4tw]

Originally Posted by L.A. BRONCOS FAN

Yep.

He's still the same "ideology over facts" nutjob who defended GWB for eight years.

Dude. Seriously. Look at your avatar. Now think about the fact that you're trying to one-up a medical doctor on a thread about pharmacology and toxicology.

You might want to pull back on the reigns a bit there.

[Beantown Bronco]

Anytime I feel any pain, I knock down a bottle of NyQuil, sleep for 2 days, and wake up refreshed and pain free.