Combination OTC “cold and flu” medications typically contain analgesics (eg, acetaminophen, aspirin), antihistamines (eg, chlorpheniramine, diphenhydramine), antitussives (eg, dextromethorphan), expectorants (eg, guaifenesin), and nasal decongestants (eg, phenylephrine, pseudoephedrine). KH’s chronic prescription medications include a narcotic analgesic combination product that provides 2600 mg of acetamino-phen and 40 mg of hydrocodone. Over the past few days, KH has added two different OTC acetaminophen-containing products including Alka-Seltzer Plus Severe Cold + Flu (650 mg acetaminophen/2 tablets) every 4 hours and Tylenol PM (1000 mg acetaminophen/2 tablets) at bedtime. The clini-cian should obtain a detailed medication history to determine the actual total dose of acetaminophen consumed, but it is likely that KH has ingested more than 6 g of acetaminophen daily over the past 72 hours. This cumulative dosage, coupled with KH’s chronic ethanol consumption (three to four glasses of wine daily), significantly potentiates the risk for acet-aminophen hepatotoxicity. In the USA, unintentional acet-aminophen overdose is a leading cause of acute liver failure. The warnings section on all OTC acetaminophen-containing products clearly state that severe liver damage may occur when consumers: (1) take dosages >4000 mg in 24 hours; (2) use acetaminophen in combination with other drugs containing acetaminophen; or (3) take acetaminophen and drink three or more alcoholic beverages daily. Unfortunately, many consum-ers do not carefully read OTC medication labels, and many do not appreciate the amount of acetaminophen “hidden” in combination prescription and OTC products.
Cathi E. Dennehy, PharmD, & Candy Tsourounis, PharmD
A 53-year-old woman with a history of knee osteoarthritis, high cholesterol, type 2 diabetes, and hypertension presents with new onset of hot flashes and a question about a dietary supplement. She is obese (body mass index [BMI] 33), does not exercise, and spends a good portion of her work day in a seated position. She eats a low-sugar diet and regularly eats packaged frozen meals for dinner because she doesn’t have time to cook regularly. Her most recent laboratory values include a low-density lipoprotein (LDL) cholesterol that is above goal at 160 mg/dL (goal < 100 mg/dL) and a hemo-globin A1c that is well controlled at 6%. Her blood pressure is high at 160/100 mm Hg. Her prescription medications include simvastatin, metformin, and benazepril. She also takes over-the-counter ibuprofen for occasional knee pain and a multivitamin supplement once daily. She has heard good things about natural products and asks you if taking a garlic supplement daily could help to bring her blood pres-sure and cholesterol under control. She’s also very interested in St. John’s wort after a friend told her that it helped allevi-ate her hot flashes and could also help improve mood. How should you advise her? Are there any supplements that could increase bleeding risk if taken with ibuprofen?