This is a question that comes up quite often:

What is the safest painkiller to take when one has liver disease?

In terms of Over the Counter (OTC) medications the correct answer is none of the above in advanced liver conditions.

These medications break down into three main ingredients — aspirin, ibuprofen, and acetaminophen. Of the three acetaminophen (Tylenol) is the most dangerous. Acetaminophen overdose is the leading cause of acute liver failure in America. The cause is a reactive metabolite which binds to proteins leading to mitochondrial dysfunction and nuclear DNA fragmentation and ultimately to cell death. Tylenol has the potential toxicity to damage healthy livers, and is even more of a risk to people with liver disease.

Acetaminophen is a common ingredient in many pain relieving medications including Oxycodone, Lortab, Vicodin, Percocet, Nyquil, Anacin 3. It can also be abbreviated on the back of labels as APAP. Many people take its ubiquity as a sign of safeness, which is a mistake.

Both aspirin and ibuprofen are more of a danger in progressed liver cases as they can both lead to increased bleeding, which is a cause of sudden death in liver patients. Ibuprofen (Motrin, Advil, Nuprin), as well as aspirin both inhibit platelet aggregation, though aspirin has a longer lasting inhibition of platelets than ibuprofen. Platelets are the best single marker of the progression of liver disease in Hepatitis C patients (see my dissertation).

The liver has enormous blood flow. If you go to the store and look at liver from a cow it is completely vascularized, it is maroon colored and soft. When the liver gets fibrotic, it gets to be a more orange color and harder. In humans to compensate for reduced blood flow through the liver, the body creates a network of alternative blood vessels called varices. These varices have more of a tendency to bleed than regular blood vessels, and are a major cause of sudden hemorrhage in liver patients.

To sum up, liver patients with portal hypertension, varices, low platelets, or high clotting time should not take either ibuprofen or aspirin, though aspirin has a longer, lasting impact than ibuprofen.  Acetaminophen is far more toxic to the liver than the other choices.

Next blog we will look at alternatives to conventional pain relievers. One hint is that not all of these compounds turn out to be liver friendly as well.

— Dr. Steven Finkbine