Everything that starts in the mouth passes through the liver, including prescription, over-the-counter (OTC) and recreational drugs. Because of this, experts recommend that people with hepatitis B and other liver diseases use caution when taking medications. A liver that doesn’t have cirrhosis can usually metabolize medications that are taken as directed, assuming alcohol is not consumed around the same time. A cirrhotic liver may have difficulty metabolizing certain medications, thus your medical provider may reduce your medication dose.

Excessive acetaminophen (Tylenol) is the leading cause of acute liver failure in the U.S. Despite research showing that low doses of acetaminophen is safe for most patients with liver disease, many people avoid taking it. If you are concerned about taking acetaminophen, talk to your doctor.

Some Facts About Acetaminophen 

Acetaminophen is one of the most commonly used nonprescription medications. In the U.S., approximately 50 million people take acetaminophen every week, and more than 25 billion doses are sold yearly. Known as paracetamol in Europe, acetaminophen is effective for headaches, fever and mild pain. It is harmless at low doses and one of the safest drugs there is, even for those with liver disease. However, acetaminophen can cause liver injury and death from acute liver failure at amounts just twice the maximum recommended dose of acetaminophen. Slightly more than 300 people die annually from it.

Why would people take too much acetaminophen? Roughly half of acetaminophen deaths are the result of suicide. The rest are unintentional overdoses. The big problem with acetaminophen is that it is added to many medications, including remedies for colds, headaches, pain, sleep, sinus problems, cough and menstrual discomfort. People may not know that they are taking acetaminophen, let alone too much of it.

So how do you take acetaminophen safely?

  • Talk to your medical provider about the right dose for you.
  • The maximum labeled daily dose for a healthy adult with no liver disease is 3,250 mg, divided over 24 hours. Your doctor may prescribe as much as 4,000 mg in divided doses. Liver enzymes elevations have been seen at that dose, albeit rarely. It’s best to take the lowest dose you can, and 3,000 mg per day has a clean safety record for adults. Experts at Hepatitis C Online recommend 2,000 mg daily (in divided doses) for patients who don’t have advanced liver disease; 1,000 mg daily for those with cirrhosis. All patients, especially those who are pre- and post- liver transplant, should ask their medical providers for a recommended dose. 
  • The abbreviation “APAP” is often used on labels of drugs that have added acetaminophen. Be sure that your total APAP dose includes all sources of this drug. APAP is added to over 600 other medications, including pain meds, sleep meds, cold meds, cough meds, sinus meds, etc. You can check to see if a drug contains APAP here: www.getreliefresponsibly.com
  • Follow dosing instructions precisely. Never take more than 1,000 mg in a single dose.
  • Start small. A single dose ranges from 325 mg, 500 mg, 650 mg or 1,000 mg; some people have good results at the lower doses.
  • Do not take acetaminophen if you drink alcohol, especially if you have hepatitis B or another liver disease.

Acetaminophen’s reputation may lead you to switch to non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, etc), and naproxen (Aleve). However, acetaminophen has a better safety record. Regular use of NSAIDs at normal doses can cause stomach bleeding, kidney problems, and other medical concerns, and when people die from these, the cause of death isn’t directly attributed to NSAID use. Additionally, these complications occur at normal doses, so these deaths are listed as adverse events, not overdoses.

Data about NSAID deaths are scant. The most recent study is from 1999, reporting 16,500 annual NSAID-related deaths in the U.S. In the same year, approximately 300 people died from acetaminophen overdose; half of those were suicides.

Last Reviewed: March 4, 2019