title: Beware of paracetamol use in alcohol abusers: a potential cause of acute liver injury.
abstract: There may be under-recognition of acute liver injury following reported therapeutic use of paracetamol in alcoholics. We present the case of an alcoholic patient who developed acute liver injury suspicious for chronic paracetamol toxicity on two occasions. The likely contribution of chronic paracetamol was not recognised at her second presentation, reflecting a need for increased awareness of this potential cause of acute liver injury. The biochemical hallmark of the syndrome is the 'towering' aspartate-aminotransferase (AST), often in the thousands; transaminases above 500 U/L should never be dismissed as secondary to alcoholic liver disease alone. Whether alcoholics are at increased risk of toxicity from therapeutic doses of paracetamol remains controversial, although many cases have been described for over 30 years. Randomised controlled trials to date have failed to show significant hepatic derangement in newly abstinent alcoholics exposed to short courses of paracetamol. We argue that these studies do not reflect the realities of paracetamol use in this population. In addition, alcoholics are at risk of accidental 'staggered overdoses', or repeated supra-therapeutic ingestions. In cases of suspected paracetamol toxicity, administration of the antidote n-acetyl cysteine (NAC) should be considered, even when the patient's serum paracetamol level is normal.
authors.affiliation: Medical Detoxification Unit, Kenepuru Hospital, PO Box 50-215, Porirua, New Zealand. geoff.robinson@ccdhb.org.nz.
authors.forename: Achala
authors.initials: A
authors.lastname: Manchanda
authors.forename: Christina
authors.initials: C
authors.lastname: Cameron
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Robinson
mesh_terms: D000082:Acetaminophen / Q000633:toxicity*; D000410:Alanine Transaminase / Q000097:blood; D000437:Alcoholism / Q000150:complications*; D018712:Analgesics, Non-Narcotic / Q000633:toxicity*; D001219:Aspartate Aminotransferases / Q000097:blood; D056486:Chemical and Drug Induced Liver Injury / Q000150:complications* / Q000175:diagnosis / Q000209:etiology; D005260:Female; D006801:Humans; D008099:Liver / Q000187:drug effects; D008875:Middle Aged
chemical_list: D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen; D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase