Hepatitis And Over-The-Counter Pain Relievers: What Are Possible Side Effects?

Hepatitis is an inflammation of the liver tissue. There is a broad spectrum of symptoms that depend on the cause and the severity of the infection, but many people experience abdominal pain, headaches, joint and muscle pain. Furthermore, hepatitis can be a chronic condition and people who live with it experience the same troubles that make the rest of the population reach for pain relievers. However, treating pain in patients with liver injury poses a unique challenge for clinicians. Analgesics (pain relievers) are mostly metabolized in the liver and they can lead to further liver damage. There are two reasons: hepatotoxicity of the medications, and altered drug metabolism in the liver.

Hepatotoxicity of over-the-counter pain relievers: What you need to know

Acetaminophen (Tylenol) is accountable for 39 percent of all acute liver failure cases in the United States. It causes a type A hepatotoxic reaction that happens only when a certain dose is exceeded. Other analgesics, like nonsteroidal anti-inflammatory drugs (NSAIDs), may cause a type B reaction. Type B or idiosyncratic reactions happen unexpectedly and independently of the dose, but only in certain individuals. Underlying liver disease is one of the risk factors for idiosyncratic reactions.

Why are hepatitis patients more prone to adverse drug reactions?

The liver plays a central role in the metabolism of most medications. Physiological changes that accompany liver damage can alter the way liver processes medications. The degree of alteration is hard to predict and depends on the extent of the injury. These alterations range from slight or mild with chronic hepatitis to substantial with liver cirrhosis.

Different mechanisms can lead to the alteration of drug metabolism and elimination. The capacity and activity of the liver enzymes that metabolize drugs might be lowered, as well as the production of drug-binding proteins. These and other mechanisms lead to drug accumulation. The free, unbound, drug in the liver is then present in higher concentrations than expected, since it’s not being processed at a predicted rate. That way it can cause direct damage to the hepatocytes. Another possibility is that the initial substance (medication) is processed at a normal rate, but there's an accumulation of a toxic intermediate or metabolite of the drug.

Due to changes in drug metabolism and elimination, patients with hepatitis and other types of liver damage are more susceptible to the side effects of many medications. However, there are also people with hepatitis who have a fully functional liver with minimally altered drug metabolism. A physician has to asses the degree of liver injury to find a suitable treatment.

Common OTC pain relievers and their side effects

1. Acetaminophen (Tylenol, Paracetamol)

Acetaminophen is the most common cause of fulminant liver failure and at the same time, the most commonly prescribed over-the-counter analgesic in the United States. This might seem like a paradox, but when taken in recommended doses, acetaminophen is one of the safest medications. While the maximum dose is four grams per day in healthy individuals, this dose can be toxic for someone with hepatitis.

In 2006, the American Liver Foundation (ALF) issued a recommendation that the dose shouldn’t exceed three grams per day in people with hepatitis. However, some studies find that the maximum safe dose is two grams a day. This is because the elimination half-life (the time the drug stays in your body) is significantly higher in people with liver damage. With a severe liver injury, it can be 100 percent higher.

The safety of prolonged acetaminophen therapy in patients with liver injury remains a somewhat controversial question. Statistics show that 23 percent of doctors wouldn’t recommend paracetamol for patients with chronic hepatitis. However, that recommendation might not be entirely based on facts. A few studies demonstrated that prolonged therapy with two grams of acetaminophen a day doesn​'t cause any accumulation or measurable liver damage in people with non-alcoholic chronic hepatitis.

Acetaminophen's possible side effects include:

• Nausea
• Loss of appetite
• Rash
• Dark-colored urine
• Jaundice (yellowing of the skin and the eyes)

Symptoms of acetaminophen overdose (might take up to 24 hours to occur):

• Nausea or vomiting
• Increased sweating
• Swelling or pain in the upper right abdominal area
• Confusion

If you have symptoms of overdose, please seek immediate help since the outcome can be fatal.

2. NSAIDs: Ibuprofen (Advil, Mortin, Nuprin)

Ibuprofen is classified as a nonsteroidal anti-inflammatory drug (NSAID). This class of medications also includes aspirin, naproxen (Flanax), diclofenac (Voltaren, Zipsor) and a dozen others. Around 10 percent of all drug-induced liver injuries are related to NSAIDs.

Unlike paracetamol, NSAIDs mostly cause type B reactions — unpredictable, unexpected, and not related to the dose. Patients with hepatitis are considered a vulnerable population, and underlying liver damage is a risk factor for type B drug reactions. This is why they are generally avoided in patients with liver impairment, although safety depends mostly on the extent of liver injury. In patients with severe liver damage, they can increase the risk of complications such as portal hypertension, varices, kidney problems and other hepatitis or cirrhosis associated complications.

Some studies have shown that liver injury had a minimal effect on the disposition of ibuprofen.

Side effects include:

• Gastrointestinal upset and bleeding. Hepatitis patients are already at risk of developing portal hypertension as a complication; portal hypertension can also lead to gastrointestinal bleeding, so taking ibuprofen is an additional risk 
• Nausea or vomiting
• Dizziness and headaches

3. NSAIDs: Aspirin (Anacin, Excedrin)

While the metabolism of aspirin remains unchanged with liver impairment, studies have shown that there is an accumulation of its metabolite. This is because there are not enough plasma proteins that would normally bind this metabolite. A higher concentration of free salicylate increases the chances of hepatotoxic reactions.

Possible aspirin side effects include:

• Abdominal pain and cramping
• Ulcers
• Headache
• Rash

Conclusion

Analgesics can put additional strain on an already vulnerable liver and might cause severe adverse reactions. If you have hepatitis, it’s extremely important to consult your physician before taking any medication or supplement. Many factors need to be taken into consideration, including the extent of the damage and individual changes in body composition. Determining the right dose and medication for pain management in patients with liver damage presents a daunting challenge even for trained specialists.