Paracetamol is a common medicine many people abuse for different reason. Dr Adegboyega Akere, a consultant gastroenterologist at the University College Hospital, Ibadan, in this interview by SADE OGUNTOLA, speaks on the several dangers inherent in the abuse of the popular drug.
At what level can consumption of paracetamol lead to liver failure?
The normal therapeutic dose of paracetamol is about 3 gms in a day; that amounts to taking 2 tablets of paracetamol 3 times daily. But taking 4 gms and above can damage the liver. Because Paracetamol is a common drug, some people can use it for suicidal attempt by taking up to 10 gms (20 tablets) of the drug at once.
Taking an amount of paracetamol above 4 gms (8 tablets) at once can damage the liver. It is toxic to the liver and causes liver necrosis, so making the person to go into acute liver failure. The person develops yellowness of the eyes and altered level of consciousness due to liver damage.
When the liver is damaged already or diseased, for example alcoholic liver disease, even a normal daily dose of paracetamolcan actually further damage the liver.
Which one does the damage, using a large dose of paracetamol at once or its persistent use?
A single use of the drug at a high dose, say 10gms, will damage the liver completely causing acute liver failure and subsequently death. Actually taking more than 4gms of the drug at once is injurious to the liver.
Will you therefore say that people that use a combination of many drugs including paracetamol, ibuprofen, iron tablets and so on every day after work are putting their liver at a higher risk of shutting down?
Yes, they are putting their liver at a higher risk of sustaining an injury. Every drug is a chemical compound and most of the drugs we take pass through the liver. Drugs are metabolized in the liver. In fact, some drugs get activated in the liver. The liver transforms them into metabolites that actually does the expected work in the body. So the more drugs people consume, the more they are overworking the liver; and the more they stress their liver. Certainly, people who take akapo are prone to having drug-induced liver injury, and subsequently they can develop liver disease with time.
Aside from paracetamol, are there other drugs that have toxic effect on the liver when taken in high doses?Â
Most drugs can affect the liver when you take an overdose of them and these drugs include antibiotics, anti-tuberculosis drugs, anti-cancer drugs, drugs for treating seizure disorders and so on. This is because most drugs when taken pass through the liver. As such, an over dose of any drug can predispose individuals to developing liver disease which can be acute or chronic.
How often do you see cases of people that have taken paracetamol overdose that come down with liver problem in the hospital?
When you take a large dose of it at once, it destroys the liver. The person develops an acute liver failure which is actually fatal and can lead to death. If you have 10 of such patients, maybe one will actually survive because the cells of the liver are destroyed completely. So, the chance of survival is very slim.
Does it mean that the liver cells cannot regenerate like other cells in other organs do?
Yes, the liver can regenerate quite all right but what happens in the case of an overdose of paracetamol is that cell destruction is overwhelming and sudden. So, the chance of regeneration is very low. Once more than 95 per cent of the cells are damaged at once. It does not have time to regenerate. That is what happens in this case.
But if the damage to the liver cells is gradual, then the liver has time to regenerate. Actually, it takes time before liver damage becomes manifest. That is why it will take some time before a person that takes four tablets of paracetamol everyday comes down with serious liver disease if the individual does not have a preexisting liver disease.
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How common are liver failure and liver diseases in Nigeria?
Acute liver failure results from the death of the liver cells in a person that does not have an existing liver disease and the liver is normal. In this case, the person develops jaundice and becomes unconscious as a result of an insult to the liver.
There is also what is called hepatic encephalopathy. If individuals with an existing liver disease, say chronic hepatitis, liver cirrhosis and any other condition like liver cancer, become unconscious or have altered level of unconsciousness, we say they have hepatic encephalopathy. This is common because it is a common complication of chronic liver disease, especially liver cirrhosis. Liver cirrhosis as a result of hepatitis B virus is common in Nigeria.
But acute liver failure is not as common; it is less common compared with hepatic encephalopathy, which is a complication of many chronic liver diseases.
Are there other common causes of liver failure aside from alcohol use and high doses of paracetamol?
Yes, there are herbs that are toxic to the liver; then viruses like hepatitis A, B and C. Hepatitis B is the commonest in Nigeria. Also, there are aflatoxins, which are toxins released by a fungus that is found in stored grains like groundnut. Aflatoxins, when consumed for long can damage the liver and can also cause liver cancer.
Eating mushrooms is not common around here, but some poisonous mushrooms when consumed can actually damage the liver. This can also cause acute liver failure.
Is there help for people with liver disease and failure in Nigeria? Do we have treatment for them?
There is help, there is treatment for liver diseases. It depends on the stage at which the person is presenting for treatment at the hospital. For individuals with acute liver failure or acute hepatitis, we have treatment that we offer. But even in developed countries, the chances of survival of an acute liver failure is very low. But for someone that has acute hepatitis, chronic hepatitis, liver cirrhosis, there is treatment. There is treatment for liver cancer depending on the stage of presentation.
How do you rate access and quality of treatment for liver disease in Nigeria?
I will rate it high because we can offer so many things even though most of our patients present late at the hospital. By then, you might not be able to do much but even at that we are still able to offer palliative care.
The type of treatment depends on the type of liver disease. Most acute liver diseases can be cured. Also chronic liver diseases can be treated and majority of the patients will still live a normal life. As I said earlier, everything depends on when the patient is presented for care. So, early presentation and adherence to doctor’s instructions are important.
Will you say access to liver disease care is not an issue?
I would say access is not an issue; it is to know where to go. Once you are in the hands of specialists, then you can be sure that you will be given the best of care. There are Gastroenterologists/Hepatologists who specialize in the care of liver diseases, although they are few. But, patients can still have access to them for specialist care.
What is the possibility of getting vaccinated for some of these liver conditions in Nigeria?
There are very few liver diseases that can be prevented by vaccination. These are mainly viral infections, like hepatitis A & B. Unfortunately, there is no vaccine for hepatitis C. Once an individual is vaccinated against hepatitis B, the person is also protected against hepatitis D.
However, there is need to always protect self from exposure to these disease causing agents, even after vaccination. Being vaccinated does not imply being careless with one’s health and get exposed. Currently, every new born in Nigeria is vaccinated against hepatitis B.
Are there foods one should avoid to prevent having a liver disease or liver problem?
Well, every food should be taken in moderation. Generally foods rich in fruits, vitamins and vegetables, less fat are good for the body. Avoid alcohol, do exercise. Avoid eating grains that have been stored for long because of risk of aflatoxin that can cause liver cancer.
It has been observed that some patients with acute hepatitis are being advised to avoid protein completely by some people. This is a wrong advice. In fact, a patient with acute hepatitis needs protein at that stage to help the liver build its membranes that are being destroyed in that acute phase. So, a patient with acute hepatitis needs to take a balanced diet rich in vitamins and minerals.
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