09/02/2025
Widespread belief holds that the popular over-the-counter painkiller paracetamol (acetaminophen) does not cause stomach ulcers, but a new study from the United Kingdom puts that in doubt. General practice records from 1998 to 2018 in the UK show that, among 180,000 people aged 65 and older who received prescriptions for paracetamol, the risks for peptic ulcers, bleeding from ulcers, and any type of lower gastrointestinal (GI) bleeding were increased by 20% to 36%, compared to more than 400,000 people not prescribed the drug. Paracetamol use was also associated with increased rates of other health problems including heart failure, chronic kidney disease and hypertension.
"Despite its perceived safety, acetaminophen (paracetamol) is associated with several serious complications," Kaur and colleagues wrote. "Given its minimal analgesic effectiveness, the use of acetaminophen as the first-line oral analgesic for long-term conditions in older people requires careful reconsideration."
Although paracetamol's safety has largely been taken for granted (apart from often fatal liver damage caused by overdose) the authors noted that evidence to the contrary has been accumulating. A decade ago, Britain's National Institute for Health and Care Excellence suggested that the agent does, in fact, modulate the same cyclooxygenase-related pathways as nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, with the potential for adverse GI effects. And the institute formally dropped paracetamol from its recommended treatments for osteoarthritis, both for safety and efficacy reasons.
After matching and adjustment for covariates, Kaur and colleagues calculated the following hazard ratios (HR) for users versus non-users:
• Uncomplicated peptic ulcers: HR, hazard ratio 1.20, 95% confidence interval (CI) 1.10 to 1.31
• Peptic ulcer bleeding: HR 1.24, 95% CI 1.16 to 1.34
• Lower GI bleeding: HR 1.36, 95% CI 1.29 to 1.46
• Heart failure: HR 1.09, 95% CI 1.06 to 1.13
• Chronic kidney disease: HR 1.19, 95% CI 1.13 to 1.24
• Hypertension: HR 1.07, 95% CI 1.04 to 1.11
These risks increased with the number of prescriptions. For example, hazard ratios for patients with nine or more paracetamol prescriptions reached 1.39 (95% CI 1.22-1.58) for uncomplicated peptic ulcers, and 1.44 (95% CI 1.29-1.60) for peptic ulcer bleeding, relative to paracetamol non-users. Regarding the apparent adverse renal effect, the researchers cited previous studies suggesting that the drug can cause acute tubular necrosis with long-term use.
The study did come with an important limitation: "there is no provision for recording over-the-counter prescriptions" in the database, the researchers acknowledged, and it is possible that users (and non-users, too) also bought paracetamol on their own. But in Britain, patients 65 and older receive paracetamol for free when it is formally prescribed. Another limitation was that paracetamol use following that first 6-month period was not tracked in the study.
Studies like this leave me baffled as to why there is not more mainstream interest in proven natural treatments for pain, especially in osteoarthritis. Boswellia, curcumin and willow bark are key examples of safe herbs with efficacy in OA established by multiple randomised controlled trials.
For more information see: https://www.medpagetoday.com/painmanagement/painmanagement/113139?xid=nl_mpt_morningbreak2024-11-27&mh=645d82b33a6ed4235607f5cdac7078eb&utm_source=Sailthru&utm_medium=email&utm_campaign=MorningBreak_112724&utm_term=NL_Gen_Int_Daily_News_Update_active
