DRUGS AND HEPATITIS

Introduction

People with hepatitis and or hepatitis need to be careful taking drugs these may be over the counter (I.e. available without prescription), Prescription drugs or recreational drugs. For people with liver problems drugs that are generally safe can cause problems including liver damage, reduced effect, enhanced effect, prolonged effect. If taking any drugs you are advised to discuss with your doctor/pharmacist. However I strongly advise that you confirm the safety of any drug using a drug reference book. (One recommendation "The Nurses Drug Guide 1995", ISBN 0-8385-6998-6) especially if seeing different doctors (e.g. General Practitioner, Hepatoligist, Dermatologist etc.) as many of these are very knowledgeable in their own field but may not be up to date on current effects/safety on those with liver disease or taking interferon.

Over The Counter (OTC) Drugs

The following are available OTC, in the UK they may not be available OTC in all countries.

Of the drugs listed their safety (or otherwise) is referring to their occasional or short term use. When used long term for chronic pain, at a higher than normal dose these drugs may not be as safe (or otherwise) as indicated here. If you need to take any of these OTC drugs long term or at dosages higher than normal please consult a doctor before doing so.

Acetaminophen (Paracetamol, Tylenol)

This is a common pain killer for mild to moderate pain and is also effective in reducing high body temperature. Acetaminophen can cause liver damage if taken in overdose and/or for long periods. It is therefore recommended that in adults no more than 4 doses per day are taken and not for longer than 10 days without medical supervision.

Liver damage occurs from acetaminophen when the liver is depleted of glutathione which normally detoxifies the drug by binding to potentially dangerous intermediate metabolites. When this pathway is saturated the resulting free intermediates cause liver damage.

The antidote for acetaminophen is N-acetyl-cysteine (Trade names: Airbron, Mucomyst, Mucosol, N-Acetylcystene ) given by IV or orally. N-acetyl-cysteine repletes glutathione and hence prevents damage. In the case of overdose this must be given within 10 to 12 hours of poisoning but is ineffective if a delay of 16 to 20hrs has occurred. Also the amino acid Methionine is an antidote if taken at the same time or soon after ingesting acetaminophen.

In the UK there is a brand of acetaminophen called Pameton that contains the antidote methionine and so makes overdose impossible and it only costs a little more. The amino acid methionine is also available in capsules from health food shops. It may be wise for those with liver damage if ingesting acetaminophen to use the antidote containing brand (Pameton), or if methionine was taken concurrently with the acetaminophen as it would ensure that the metabolic pathway for acetaminophen metabolism was working as well as possible and so reduce any possible liver damage to a minimum. Note, it has been pointed out to be that taking N-Acytyl-Cysteine would be more effective and safer than taking methionine.

From the information I've seen of all the OTC pain killers acetaminophen is probably the safest pain killer to take for people with hepatitis provided it is ONLY taken occasionally and at normal dosages. E.g for the occasional headache, Interferon side effects etc. Taking acetaminophen with NAC may reduce any chance of damage to a minimum.

Aspirin

This was one of the first pain killers and is used for mild to moderate pain, it is also effective in reducing high body temperature, is anti-inflammatory and inhibits blood coagulation. Aspirin may also cause abnormalities in liver function tests. The odd aspirin is probably OK but if taking interferon or if in the later stages of liver disease more care is needed due to aspirin increasing blood coagulation time. I would advise if suffering from hepatitis it is best to discuss taking aspirin with your doctor.

Ibuprofen (Neurophen, Advil)

This is one of the newer OTC pain killers for mild to moderate pain, is also effective in reducing high body temperature, is anti-inflammatory and inhibits blood coagulation. Ibuprofen is reported to be better for joint and muscle pain than other OTC pain killers. Ibuprofen can cause a transitory rise in ALT and cases of toxic hepatitis have been reported from its use. Of all the OTC pain medications this is probably has the highest risk of causing problems. If suffering from hepatitis it is best to discuss use of ibuprofen with your doctor.

Codine & Dihydrocodine

These opiate drugs are only available OTC in combination with other drugs such as acetaminophen (paracetamol). Taken as such and for occasional pain they are OK although my drugs book states that it should be used with caution in those with hepatic impairment. However more caution should be used if taken with interferon as taking opiates and interferon concomitantly (at the same time) should be avoided.

Morphine

This is generally only available with kaolin as an anti-diarrhoeal and used as such is safe. However if suffering from diarrhoea and have hepatitis please see a doctor immediately especially if taking interferon as this could be a sign of a more serious infection. However caution is advised if taken with interferon. Taking morphine and interferon concomitantly should be avoided.

Anti-Histamines

There are too many of these to list here (at present) and I would advise discussing taking these with your doctor. However it has been reported, but I have seen no actual research, that anti histamines can reduce the side effects of interferon.

Cough Mixtures

Again there are too many to list here so you are advised to check the ingredients and discuss with your doctor. However if taking interferon you should avoid theophyline derivatives, unfortunately many cough mixtures contain these so a discussion with the available pharmacist is advised.

Indigestion Tablets

In general these are safe generally containing calcium carbonate, magnesium oxide etc. However the newer brands such as Tagamet that contain cimetidine are contraindicated for cautious use in those with hepatic impairment. Discuss the use of these new preparations with your doctor.

Recreational Drugs

The drugs discussed here are generally used for non medical purposes. However some of these drugs are illegal in many if not most countries. The illegality has in general inhibited research on them and there is very little information available. The following section represents my best efforts, however due to the lack of information from reliable sources (especially the illegal drugs) do not regard this section as necessarily accurate. I strongly advise you to avoid these drugs. However since hepatitis can be caught through drug use (IV, cocaine snorting tubes) and some may be prescribed I include them here. Be it on your own head!

Before continuing, the subject of purity must be discussed. When a drug is obtained from a pharmacist you obtain a pure and known dose of the drug, however because the source of a recreational drug is generally not pure there may be other contaminants and adulterants present. For legal things such as coffee, tea, brandy, beer etc there are many other toxic chemicals present but these tend to be fairly consistent in a brand but may still be stressful to the liver. In illegal drugs such as amphetamine (speed, wizz), cocaine (Charlie), heroin (smack), MDMA ("E", "X") there many be many unknown and toxic adulterants from sugar via toilet cleaner through to ground glass. You are advised to avoid illegal drugs for this reason alone. However if you decide to take these drugs make sure you have a reliable supplier and know what your taking.

Alcohol

In cases of acute hepatitis alcohol must not be consumed.

In cases of chronic hepatitis, consumption of alcohol is a bit like pouring alcohol on a smouldering fire and should be avoided. Some doctors say it's OK to have a very occasional drink but most others recommend complete abstinence. The consumption of a large amount of alcohol in a single session damages your liver. In the same way, the consumption of a small amount of alcohol regularly is bad for those with hepatitis whereas alcohol in small amounts in the general population has been shown to be beneficial to health. It is therefore recommend that you avoid all alcohol but if you do decide to continue to drink: don't get drunk; limit your consumption to rare occasions and above all be sensible.

Alcohol also temporarily causes abnormal results in liver function tests, i.e. raised ALT, AST. It is therefore important to not consume ANY alcohol for several days before giving blood. If you have consumed alcohol in the days before giving blood for tests you should inform your doctor of how much alcohol was consumed and when. Failure to do this may cause your doctor to make clinical decisions based on inaccurate results from liver function tests.

In addition some new studies have shown that consumption of alcohol drastically reduces the effectiveness of interferon.

If you have any alcohol dependency you are advised to seek help and support as hepatitis and alcohol can be an explosive combination.

Amphetamine, (Speed, Wizz) & Methamphetamin (Crystal, Crank)

If prescribed under medical supervision theses drugs are probably safe for people with hepatic dysfunction. However if taken for recreational use the lack of sleep they may induce and the extra stress on the body is not a good idea. Unless there is a medical reason it is advised that amphetamines should be avoided.

Caffeine (Coffee, Tea, Cola's, Sone OTC Painkillers...)

Caffeine is not contraindicated for those with liver disease so taking caffeine in OTC preparations (depending on any other drugs present) poses the same risk to those with hepatitis as the general population. The drug is however metabolised in the liver, this may place more stress on the liver than if it was not consumed (?). However if caffeine is taken to excess or late at night this may cause stress on the immune system due to insufficient sleep, exhaustion and this should be avoided.

In coffee there are many other compounds present and their metabolism may stress the liver so excessive consumption should be avoided. A switch to tea or even cola may be preferable if you cannot resist your morning cup of coffee.

Cocaine (Charlie, Crack)

Cocaine is hydrolysed in serum so probably does not pose a risk if taken for medical reasons or is available in its pure form. However the stimulant effect, late nights, desire to take more etc pose a risk to the immune system and the use of cocaine for non medical reasons should be avoided.

Heroin (Smack)

Pure heroin taken under medical supervision for pain relief is OK if used with caution for those with hepatitis. Heroin taken for recreational purposes with the (high) risk of impurities can cause problems specially when injected. Heroin and other opiate derivatives are also contraindicated for anyone taking interferon.

L.S.D (Acid, Trips)

In itself, this drug, effective in very low doses is probably non toxic to the liver. After taking LSD the majority is metabolised and excreted within 2 hours after consumption. However in people with impaired liver function it has been reported that this may take longer so the effect of the drug may be more powerful. Taking LSD is probably not advised if taking interferon, as interferon has a tendency to make you depressed and this may be exacerbated or enhanced by the LSD and cause a bad trip(?).

Marijuana (Dope, Mary Jane)

It has been known for marijuana to be "spiked" with PCP (Angel dust) so once again, be it on your own head.

The metabolism of this drug has been reported to place a strain on the liver however it is also been reported that marijuana can also sometimes help in increasing appetite, suppressing nausea and relieving other symptoms of hepatitis or side effects of interferon. However attention is drawn to the following article which may indicate that marijuana may inhibit the action of interferon.

Genital warts do not respond to systemic recombinant interferon alfa-2a treatment during cannabis consumption. Dermatologica, 1991, 183(3):203-7.

Abstract: The case of a 22-year-old man suffering from genital warts is described. The lesions responded completely to recombinant interferon alfa-2a only after discontinuation of cannabis consumption. Cannabis was detected using the enzyme immunoassay/1-trans-tetrahydrocannabinoid method in urine. Southern blotting of frozen genital wart biopsy material revealed papillomavirus type 11 DNA, the amount of which increased significantly during interferon treatment. The final clearing of lesions after discontinuation of cannabis consumption implicates that the drug-induced impairment of cellular immunity was reversible. It is concluded that drug abuse and especially cannabis consumption may play some role in the world-wide increase in genital papillomavirus disease and in the high number of recalcitrant courses of genital warts.

MDMA (Ecstasy, "E" or "X")

This has the same contradictions as amphetamines. It has been reported that taking between 60-120mg of MDMA once every 2 to 4 weeks can have an antidepressant effect similar to prozac however consumption of larger doses or if taken more than once per week may cause a permanent depletion of seritonin in the brain and make depression worse. In addition most MDMA or "E" on sale is generally MDA, MDEA, LSD, Methamphetamine, amphetamine or combinations of the above.

There have also been reports of severe liver damage and fatalities occurring after ingestion of MDMA.

It is recommended that MDMA is avoided.

Nicotine

Nicotine has no general medical use and is a poison. However it is sometimes found in treatments to assist in the treatment of nicotine addiction. E.g. nicotine patches, gum etc.

Nicotine is generally found in tobacco products and the nicotine and the many other chemicals in tobacco are stressful to the liver and have many associated health risks (cancer, heart attack etc). It is strongly advised that you try to stop smoking / chewing tobacco. If you feel that nicotine gum or patches may be useful to you in achieving this please discuss with your doctor especially if taking interferon.