• Optimizing Acetaminophen Use in Patients with Risk Factors for Hepatotoxicity: Reviewing Dosing Recommendations in Adults

      Bauerlein, Deanna K; Williams, Allison P; John, Preeti R (Oxford University Press, 2020-11-08)
      Acetaminophen is the most commonly used analgesic and antipyretic in the United States, with more than 60 million Americans using the drug on a weekly basis [1]. In contrast to nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen is associated with fewer gastrointestinal, cardiovascular, and renal adverse drug events and drug interactions. The clearance of acetaminophen also does not change in relation to age, and thus acetaminophen is recommended by the American Geriatrics Society for chronic pain [2]. Following the opioid crisis and heightened awareness by the medical community of the need for multimodal analgesia, adjuncts to opioids such as acetaminophen are being used more commonly to treat acute and chronic pain. Unfortunately, acetaminophen-induced hepatotoxicity resulting from unintentional overdose is the most common cause of acute liver failure in the United States, resulting in 30,000 hospital admissions per year [1]. It accounts for more than 50% of overdose-related acute liver failure and 20% of liver transplant cases [1]. Although adverse effects caused by acetaminophen represent a significant public health concern, the Food and Drug Administration’s (FDA’s) recommendations for maximum daily adult dosing have remained unchanged for decades, with no formal recommendations for dosing adjustments in the presence of risk factors for hepatotoxicity. Given the widespread use of acetaminophen in clinical practice and its association with hepatoxicity, it is imperative that providers be aware of recommendations by experts (hepatologists) for safe dosing in patients with risk factors for hepatoxicity such as alcohol use disorder, cirrhosis, chronic hepatitis C, and malnutrition or the fasting state. This Commentary reviews expert opinion regarding safe dosing in adult patients with these risk factors.