Warfarin and Tylenol

[RI Mom]

When my child began taking Coumadin/Warfarin, I was told by all of the medical professionals that we must avoid Ibuprofen (Motrin) and that Tylenol was the only safe med. for pain relief/fever reduction. Yesterday I received Idrees' Warfarin in the mail and in the package was an insert warning patients about taking Tylenol while on Warfarin. OK...now I'm confused!! The insert stated that Tylenol can make bleeding more of a risk. Has anyone else heard this or been told to avoid Tylenol? What other choices are there that are relatively safe for Warfarin users?

Thanks!

 

[Ross]

Tylenol is the prefered pain reliever/fever reducer when on Warfarin. It doesn't work for me, so I take Ibuprofen and Naproxen Sodium. I say take whatever works, but they are afraid those will eat a hole in your stomach and cause gastro bleeding. Fact of the matter is, all the stuff they have me on is far worse of a stomach eater then those tablets are. They don't say anything about taking them!

The thing with Tylenol is, if taken in large quantities, it can result in a rising INR. Do not exceed recommended dosage.

 

[dick0236]

The thing with Tylenol is, if taken in large quantities, it can result in a rising INR. Do not exceed recommended dosage.

I agree with Ross about the overuse. From what I know, Tylenol can cause Liver damage if overused, but I have not had any doc warn my about using it with Warfarin. I have taken it for 8-10 years for spinal pain, but I try to limit it to 1000mg(two tabs) per day. Seldom take more than 2000mg. My bottle says "8 tabs(4000mg) is the max adult daily limit". Medicine warnings seem to be on the increasee as we are discovering more and more about the long term use of many drugs. Touch base with the pediatrician or cardio for their input.

 

[olefin]

I've taken Tylenol for fever and cardiologist oked for pain if needed.

Suppose I'm very fortunate, I don't need anything for pain. Quit smoking about 45 years ago, up till then I had to take aspirin for headaches... after stop smoking no more headaches. Now days it's a 81 MG aspirin daily but not for pain.

 

[RI Mom]

Thanks for the replies!

I ended up calling the pharmacist who told me that a study indicated that regular users of Tylenol (daily and several times a day) may be more at risk for bleeding while on Warfarin. He thought that occasional use of Tylenol in small doses would not likely be risky. Good news for us as that seems to be the only pain reliever approved by the Dr. for my son to use.

 

[Ross]

Thanks for the replies!

I ended up calling the pharmacist who told me that a study indicated that regular users of Tylenol (daily and several times a day) may be more at risk for bleeding while on Warfarin. He thought that occasional use of Tylenol in small doses would not likely be risky. Good news for us as that seems to be the only pain reliever approved by the Dr. for my son to use.

It's more of a cover your a$$ thing then anything. Like I said, tylenol doesn't do a thing for me, so I use Ibuprofen and Naproxen Sodium. Advil/Aleve.

 

[AgilityDog]

You can use ibuprofen or naproxin sodium with warfarin/coumadin. As Ross says, it just may raise your INR, and it may cause stomach bleeding. But once in a while for pain, especially something like tendonitis or a sprain where tylenol does nothing for inflamation, just use what you need to, and adjust if necessary.

I was prescribed ibuprofen after my first surgery, along with and later in lieu of my pain meds... We were so busy adjusting my INR for the other drugs, and healing, and eating, and exercise, we never noticed any INR effect from the ibuprofen.

 

[drivetopless]

https://secure.pharmacytimes.com/lessons/200301-01.asp

"Acetaminophen (Tylenol)
Of all the potential interactions between warfarin and other drugs, the interaction with acetaminophen is probably the most confusing for pharmacists and patients. The published data on the interaction is conflicting but acetaminophen appears to increase the anticoagulant effect of warfarin in a dose-dependent manner.

Approximately thirty percent of patients stabilized on warfarin ingesting approximately two grams of acetaminophen daily can experience an intensification of warfarin response. An interaction between acetaminophen and warfarin appears more likely with daily acetaminophen doses of greater then 2 grams daily for a week or more. Maximal effects on the anticoagulant response have occurred one to three weeks after starting acetaminophen. Occasional doses of acetaminophen do not appear likely to interact with warfarin.

Patients receiving warfarin should be counseled to limit their intake of acetaminophen-containing products. Patients should also be reminded to check with their pharmacist if they are unsure if a product contains acetaminophen. Many over-the-counter products contain acetaminophen as an ingredient and should therefore be avoided. Aspirin-containing products should not be used as an alternative to acetaminophen. Aspirin is undesirable due to its adverse effects on the gastric mucosa and platelet inhibition effects.

Coagulation parameters should be monitored more frequently (e.g. once or twice weekly) when a patient is starting or stopping chronic acetaminophen therapy. This is especially true if ingesting more then the two gram daily limit."

 

[Ross]

ACETAMINOPHEN INTERACTIONS WITH WARFARIN

Brand Names: ACETAMINOPHEN - Tylenol, Feverall, Acephen, Neopap, Apacet, Children's Dynafed Jr. Genapap, Maranox, Mapap, Panadol, Tempra, Aceta, Aspirin Free Pain Relief, Genebs, Meda, Tapanol, Aspirin Free Anacin Maximum Strength, Extra Strength Dynafed E.X. Redutemp Dapacin, Infants' Pain Reliever, Silapap, Ridenol, Oraphen PD, Children's Pain Reliever, Halenol, Liquiprin, Capital with Codeine, Tylenol with Codeine, Acetaminophen with Codeine, Aceta with Codeine, Fioricet with Codeine, Lortab, Zydone, Hydrocodone with Acetaminophen, Bancap HC, Ceta-Plus, Co-Gesic, Duocet, Dolocet, Hydrocet, Hydrogesic, Hydrophen, Margesic - H, Lorcet, Anexsia, Panacet, Stagesic, T-Gesic, Vicodin, Norco, DHC Plus, Acetaminophen with Oxycodone, Percocet, Roxicet, Roxilox, Tylox, Propoxyphene Napsylate with Acetaminophen, Darvocet N, Propacet 100, Wygesic, and many other brands. There are so many that they could not all be listed here. If you are taking warfarin, you should read the label of any pain relief medication to determine if it contains acetaminophen. If you are unsure, purchase the product at a pharmacy where you can have the pharmacist check the label for you.
Acetaminophen is the safest pain reliever to take with warfarin. It does not cause bleeding of the lining of the gastrointestinal tract as many other pain relievers do.
However, Hylek et al. found that if a person takes more than 26 regular- strength (325 mg each) or 19 extra-strength (500 mg each) over one week, the International Normalized Ratio (INR) may be raised. This will increase the chance of a person bleeding.
Two articles have added insight as to how this may occur. Lehman hypothesized that various enzymes in the liver may be involved in different patients. These have to do with metabolizing the two forms of warfarin and acetaminophen. These may come into play with varying conditions such as in older patients, those with atrial fibrillation and congestive heart failure. This theory could account for why some people are affected and some are not.
Whyte et al. reported their observations in a regional toxicology center. They found that a small rise in the INR is common after acetaminophen poisoning without liver injury. This appears to be caused by inhibition of clotting factor VII. This would account for the interaction between acetaminophen and warfarin.
My opinion is that the theories of Lehman and Whyte do not contradict each other. They are probably both involved in explaining what Hylek observed.
Addendum: Many of you may be familiar with other websites and a story that ran on CNN stating that acetaminophen and warfarin is a harmful combination. Since I wrote this page, I have had an opportunity to speak with Dr. Hylek. She regretted giving the interview, which was edited to make it appear that she was stating that this combination was harmful.
References:
Hylek EM et al. Acetaminophen and other risk factors for excessive warfarin anticoagulation. JAMA 1998;279:657-662.
Lehmann DE. Enzymatic shunting: resolving the acetaminophen-warfarin controversy. Pharmacotherapy 2000; 20:1464-1468.
Whyte IM et al. Acetaminophen causes an increased International Normalized Ratio by reducing functional factor VII. Ther Drug Monit 2000;742-748.
Remember that nothing on these pages should encourage you to start or stop taking any medication. You should consult with your physician. Many interacting medications can be safely taken if the INR is monitored frequently. Stopping an interacting medication can upset the balance between warfarin and other medications.

 

[lance]

Earlier this year I had to take Tylenol for arthritis in my thumb. I did not exceed the daily dose recommended on the package. My INR went up substantially as a result. I test weekly and within that week the INR went from 3.7 to 5.1.
When I googled I found 1 reference to interactions between warfarin and Tylenol. If I remember correctly anything under 1400 mgs perday won't affect INR.