Medicines

Key points

  • All drugs, even over-the-counter ones or ones bought on the internet, can have harmful side effects
  • Herbal and dietary supplements are causing an increasing proportion of severe liver injury
  • The liver processes many medicines and supplements
  • People with liver disease need to be very careful about which medicines they take and how much
  • Always talk to your doctor about all medicines or supplements you are taking or want to take, including herbal medicine
  • Liver disease stops the liver from processing chemicals properly so you may not be able to take some medicinesfor other health conditions

How will liver disease affect my medications?

People with liver disease can still take medicine. But if you have liver disease, you need to be very careful.

If you take the wrong medicine or too much medicine, you can do more damage to your liver.

Always talk to your doctor before you take any medicine, herbal medicine or supplement.


Over-the-counter pain medicine

Paracetamol is the active ingredient in Panadol, one of the most popular over-the-counter pain relievers. It is used in a variety of conditions to relieve headaches, muscle and joint pain, pain during menstruation, and to reduce fever.

Taking more than the recommended dose of paracetamol can seriously damage the liver. If you have liver disease or another health condition, talk to your doctor about how much paracetamol you can take safely.

A lot of paracetamol overdoses are accidental, as many people do not realise that there are more than 200 products that contain paracetamol. These include combination painkillers and many over-the-counter medicines for coughs and colds or sinus congestion.

Here is how to look after your liver with pain medicine:

  • Always read and follow the dosing instructions from your doctor or the medication label
  • Never mix medicine with alcohol
  • Be careful about mixing different products that contain paracetamol. By taking more than one pain reliever or cold remedy at a time, you may accidentally take more paracetamol than is safe
  • If you take other medicines, talk to your doctor or pharmacist about how the drugs might mix with each other
  • Only take pain relievers when really necessary

Some people develop liver injury from taking nonsteroidal anti-inflammatory drugs, another type of over-the-counter pain medicine. These medicines, including Nurofen, can also cause injury to the stomach, the gut and the kidneys.

The following lists are substances that could be harmful to your liver. It is best to talk to your doctor before taking them. Liver reactions to many of these substances are rare, but can be severe.

Medicines that can be harmful to the liver

  • Analgesics (pain relief medicine): NSAIDs (celecoxib, diclofenac, ibuprofen, naproxen), paracetamol
  • Antiepileptics (epilepsy medicine): Carbamazepine, lamotrigine, phenytoin, valproate
  • Antimicrobials (antiobiotics for an infection): Amoxicillin + clavulanate, azithromycin, ceftriaxone, ciprofloxacin, erythromycin, flucloxacillin, fluconazole, isoniazid, levofloxacin, minocycline, moxifloxacin, nitrofurantoin, pyrazinamide, rifampicin, roxithromycin, terbinafine, trimethoprim, trimethorpim + sulfamethoxazole
  • Antineoplastic drugs (cancer medicine): Bortezomib, cyproterone, flutamide, imatinib, ipilimumab
  • Antiretrovirals (HIV medicine): Darunavir, rilpivirine, ritonavir
  • Cardiovascular drugs (heart medicine): Amiodarone, hydralazine, methyldopa
  • Immunodolulatory drugs (medicines that affect the immune system): Azathioprine, intereron-beta, leflunomide, mercaptopurine, methotrexate, TNF inhibitors
  • Psychotropic drugs (mental health medicine): Agomelatine, chorpromazine, duloxetine
  • Other: Allopurinol, andorgenic steroids, disulfiram, propylthioura il, NOACs (rivaroxaban, dabigatran)

 

Herbal and dietary supplements that can be harmful to the liver

  • Anabolic steroids and bodybuilding supplements
  • Aloe vera
  • Artemisia
  • Atractylis gummifera
  • Black cohosh
  • Callilepsis laureola
  • Cascara
  • Cassia cinnamon
  • Chaparral leaf
  • Chrysanthemum
  • Comfrey
  • Crotalaria
  • Curcumin and tumeric
  • Echinacea
  • Garcinia cambogia
  • Gardenia
  • Germander
  • Green tea extract
  • Greater celandine
  • Heliotropium
  • Jin bu huang
  • Kava / Kava Kava
  • Kombucha tea
  • Ma huang
  • Mistletoe
  • Plantago seed
  • Red peony root
  • Senecio
  • Skullcap
  • Traditional Chinese medicine
  • Valerian root
  • Weight loss supplements

Tips for looking after your liver

Here is how you can look after your liver health:

  • If your doctor prescribes a long-term medication, ask for a liver test before you start the medication and after the first few weeks of taking the drug to determine how your liver is tolerating it. Follow up with regular liver tests all through your treatment
  • Always read and follow the dosing instructions from your doctor or the medication label. Never take more than the recommended dose. Be sure to think about other medications that you may be taking at the same time and tell your doctor
  • Never mix medication with alcohol. Alcohol increases the risk of possible liver damage
  • Be careful about mixing different medications that contain paracetamol. By taking more than one pain reliever or cold remedy at a time, you may accidentally take more paracetamol than is safe. Talk to your doctor about how to take paracetamol safely if you have liver disease
  • Avoid certain herbal supplements (see list above) as well as certain vitamins in high doses as they have the potential to cause liver damage. For example, high doses of vitamins E and vitamin A may be harmful
  • Avoid grapefruit, grapefruit juice or supplements with grapefruit bioflavonoids if you are taking certain medications. The chemicals in grapefruit (both rind and pulp) can interfere with the liver enzymes that break down many drugs. A variety of different medications – including some anti-depressants, blood pressure medications, cholesterol-lowering drugs and tranquilisers – have been shown to have potentially serious interactions with grapefruit products. For more information, talk to your doctor or pharmacist
  • Be aware that use of body building supplements and anabolic steroids as well as some weight loss supplements can cause serious liver injury
  • Avoid the use of any form of recreational or ‘street’ drugs because they can put you at risk of contracting hepatitis B or C and can cause serious harm to your liver. Even a single ‘experiment’ could lead to a potentially life-threatening liver disease. If you do use drugs, make sure you use sterile drug-use equipment (e.g. syringes, cookers, filters, water, tourniquets, pipes, straws) and never share any of it

 

References

Nash E, Sabih AH, Chetwood J, Wood G, Pandya K, Yip T, Majumdar A, McCaughan GW, Strasser SI, Liu K. Drug-induced liver injury in Australia, 2009-2020: the increasing proportion of non-paracetamol cases linked with herbal and dietary supplements. Med J Aust. 2021 Sep 20;215(6):261-268. doi: 10.5694/mja2.51173. Epub 2021 Jul 17. PMID: 34272737.

Therapeutic Guidelines. Liver Disorders: Drug-induced liver injury

Reviewed November 2022

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