When it doesn’t help to check the label

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Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

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50 Responses

  1. Avatar Mad Rocket Scientist says:

    Our Pediatrician gives us a Tylenol & IBU dosing chart at every visit & circles or highlights the current dose as per the weight they recorded during the exam. It’s a simple thing, but it makes a difference.Report

  2. Avatar Brandon Berg says:

    On the topic of dosing, why is it that a lot of OTC medications will indicate the same dosage for some ridiculous range of sizes and ages, like “adults and children over 6?” How can the same dose be appropriate for people whose weights differ by a factor of four or more?Report

    • Avatar J@m3z Aitch in reply to Brandon Berg says:

      If they’re old enough to work in a factory, they’re old enough to take an adult dose of Tylenol (and they’re going to need it, too!).Report

    • For some medications, the safety doesn’t really vary much over a certain age or size. Once you’ve reached a certain physiologic threshold, your body can process what is essentially an adult dose.Report

    • Avatar George Turner in reply to Brandon Berg says:

      I’ve always been curious if many cases of cirrhosis, which only affects a fraction of alcoholics, is the result of constantly taking analgesics while the liver is hammered with alcohol and alcohol byproducts. Now most all analgesics say “Do not take with alcohol”, but I doubt that was always the case, and drunks just don’t care anyway.

      Of course, I also think some of the warnings over drinking anything during pregnancy must be overblown, since all Europeans used to drink like fish all day long, and at their historic levels of alcohol intake, every skeleton in a medieval cemetery should be showing clear signs of FAS, and they don’t.Report

      • Any given person’s response to medication, risk of adverse effects, etc is related to all manner of vagaries peculiar to that particular patient. But within general, broad safety parameters most people should have minimal risk of complications.Report

      • Avatar Kim in reply to George Turner says:

        Plenty of Europeans didn’t drink “like fish”. When wine’s your standard, it takes a lot of work to get enough to keep one person sloshed for a year. Plus, most folks were poor.Report

      • Avatar George Turner in reply to George Turner says:

        Yet even the Russian serfs, who were dirt poor even by the standards of poor Europeans, managed to stay sloshed much of the time. I think it’s just a matter of priorities (and cheap booze).

        Even if only half of Europeans drank like fish, or even 10%, old graveyards should be overflowing with skeletons showing clear signs of fetal alcohol syndrome.

        We could get better data on the issue just by recording the daily drinking habits of Hollywood party girls, yet some might find it unethical to connect them to science, even as lab animals.Report

      • Avatar BlaiseP in reply to George Turner says:

        Beer and wine were heavily regulated. You didn’t just make beer and wine, you had to buy it at a licensed tavern. Same with breadmaking, you needed to bake your loaves in the lord’s ovens.Report

      • Avatar J@m3z Aitch in reply to George Turner says:

        A common drink was “small beer.” It was a very low alcohol content beer, drunk because it was safer than water. A normal adult could drink quite a bit of it without getting drunk.Report

      • Avatar zic in reply to George Turner says:

        @jm3z-aitch is on the money here. People from cities didn’t used to drink cold water the way we do now, it made you sick. They drank beer, the cooking/fermentation process sanitized the water. They drank tea and infusions. Even children drank beer.

        This is also why tea is a common beverage in China; again, too many bacterial contaminants in the drinking water. Boiling it to make tea helps sanitize it.

        Source for claim #1 is the experts at Plimoth Plantation, where I used to work, and was given a bottle of ‘small beer’ to drink with my mid-day meal.

        Source for claim #2 is the book “Farmer’s of Forty Centuries” by F. H. King, a report on his travels in China to observe agricultural practices in the early 1900’s.Report

  3. Avatar Kazzy says:

    “Now, my own practice actually has dosing instructions for all children on our website. But sometimes parents don’t know that, or lack the English skills to properly parse the chart. So often enough I get woken up because, per the package instructions, I am being asked to dose Tylenol.”

    Question 1: Does checking the online dosing instruction count as “asking the doctor”?
    Question 2: If the answer to question 1 is “Yes”, how many people know this? Even Kazzy “What’s the worst that could happen?” NewParent would probably think checking the website would not suffice.Report

  4. Avatar George Turner says:

    What would be simpler is to eat up a bit more shelf space and have the Tylenol packed in different bottles whose dosages vary by the weight range of the patient.

    10-15 lbs. 15-25 lbs. 25-40 lbs, 40-65 lbs. 65-100 lbs. 100-150 lbs. 150-250 lbs.Report

    • Avatar Kazzy in reply to George Turner says:

      Yea, until you get a hefty guy standing there saying, “Well, maybe I weighed 265 at my last doctor’s appointment, but I’ve only gone to McDonalds three times since then and I did walk up those 7 flights of stairs the other day. I’ll get the 150-250 bottle.”Report

  5. Avatar Jaybird says:

    Say what you will about Warburg’s Tincture, but at least it didn’t mess up your liver.Report

  6. Avatar BlaiseP says:

    Thank you for this sensible post. If only there were some way to automatically flag all the unscientific and innumerate harum-scarum on the Internet as Dangerous Bullshit, as anti-malware software flags dangerous websites, it would make me much happier.Report

  7. Avatar Anne says:

    Thanks for this Russell, for years I have avoided Tylenol and discourage those I love from taking it and warn them about it. I really don’t want to come off as crazy (Like the anit-vaccine coalition) I personally know someone who died from Tylenol complications granted there were other factors, other illness and alcohol consumption that led to this persons death but that is exactly why it scares me so. The amount of other OTC cold remedies that contain it, prescription pain killers that contain it, I have also heard that if you are fasting (be it diet, from illness, anorexia) this heightens the danger of toxicity as well. And the question of maximum dose per day so if someone is treating chronic pain it seems to me way to easy to inadvertently hurt your liver. So I avoid it like the plague. Why is it used so ubiquitously if there are these dangerous complications.? Please feel free to tell me I am an over reacting nut job from you I can take that 🙂Report

    • Avatar George Turner in reply to Anne says:

      I found it staggeringly odd that Tylenol was sold over the counter even though a miscalculation of its dosage is fatal (oops, forgot that I already took two before dinner), while Prilosec was prescription only, yet so safe that you could actually eat the pills till you were too full to eat another one.Report

      • Avatar Jaybird in reply to George Turner says:

        I’m still trying to wrap my head around why they add it to painkillers in order to prevent abuse… because, presumably, we’d rather deal with people without livers than people addicted to opioids.Report

      • Well, George, along those very same lines I wonder why the incredibly safe emergency contraceptive pills were held up for so very long, given that it is essentially impossible to do real harm to one’s self with them.Report

      • Avatar morat20 in reply to George Turner says:

        As I understand it, George — and by “as I understand it” I mean “something I vaguely recall hearing, so take it with a heaping spoonful of salt”, Tylenol snuck in before the FDA really got tough on such things — and moving it off the OTC label runs into both public and lobbyist pressure. Serious pressure.

        I don’t think it’d be approved OTC in the doses it’s historically had, if it was invented today.

        And as nasty as it is, bluntly speaking — so few (relative to the number of people who take it) actually die that no one’s going to call to do more than reduce dosages, add warning labels, etc.

        I don’t envy the FDA their jobs. They have to juggle recommendations for drugs based on minimal to no independent research, which might or might not have long-term effects that weren’t looked for (like, oh, lengthy use proton pump inhibitors for gastric reflux leading to heart problems decades down the line) against a sick public where this drug may make a sizeable change in quality of life or save lives if approved.

        And that doesn’t even get into OTC stuff. (And then there’s the fun off-label stuff, which generally sorta just…grows up around a drug as doctors get used to it, and I don’t think the FDA really regulates that much at ALL).Report

      • Avatar J@m3z Aitch in reply to George Turner says:

        Morat’s probably right. I’ve been told that OTC Primatene Mist, for asthma, is more dangerous than newer prescription drugs, but was approved under older, lower, standards.Report

  8. I don’t suppose you could be convinced to get some kind of messaging service that could at least ask the patient if they want to leave a message or page you?

    Because just giving patients your direct pager number seems like madness.Report

  9. Avatar DavidTC says:

    The other bee that got buzzing in my bonnet after hearing the “TAL” episode regards multi-symptom products, such as Nyquil or Tylenol Cold and Flu. I hate them. Not only are people who take them often getting medications for symptoms they may not have, but they may not realize which medications they’re even taking.

    I think I’m one of the few people who _will not_ purchase any sort of ‘combination’ medication unless I absolutely can’t avoid it. (Especially ones with acetaminophen in them. I already know how to deal with a headache, thanks.)

    I buy pills with one active ingredient, so I don’t have to worry about any of that combination nonsense. If I really need two ingredients, I’ll take _two different pills_. Amazing idea, I know.

    It’s one thing to not be able to make complicated medical decisions, but it’s another thing to be so stupid we buy random mixtures of medication and take them semi-randomly without any consideration for each other, instead of looking at the damn active ingredient and googling exactly what it does. But the medical establishment has trained us well to be very stupid, so they can shove brand names in our face.

    Although I’m a little baffled as to why there’s not a simple cheat sheet for that. Someone should make a little web page with the twenty of so ‘cold’ medications on it, and what exactly they do. Same with headaches, and stomach problems, and other such things.Report

    • Avatar Reformed Republican in reply to DavidTC says:

      I tend to buy the combos, but I buy the combos specifically for the symptoms I am experiencing, and I read the labels to know what I am getting.Report

    • Avatar dragonfrog in reply to DavidTC says:

      The only combo I buy is codeine + aspirin or ibuprofen + (amusingly) caffeine. I do that only because it’s the only way to get codeine without a prescription here. I understand the caffeine is there, not because it’s thought to be useful in any way for pain, but because it brings the number of ingredients high enough that the tablets are no longer considered “mostly” codeine.Report

  10. Avatar Mike Schilling says:

    I do not understand why Tylenol has become a preferred analgesic to aspirin, which may upset your stomach but won’t destroy any vital organs.Report

    • In my experience, aspirin just doesn’t work.Report

      • Avatar J@m3z Aitch in reply to Pierre Corneille says:

        How about ibuprofen?Report

      • Avatar zic in reply to Pierre Corneille says:

        That’s funny, because in mine, acetaminophin doesn’t work. After I my bike accident as a teenager (broken jaw, damaged neck, fractured head), they had me take aspirin for the headaches that plagued me. Worked, but I developed ulcers from it. Tylenol was next, and it did Nothing. At. All.

        Ibuprofen wasn’t on the market, only other remedies were narcotics. So I ended up self-medicating with pot, which actually did help with what was becoming an ongoing battle with migraine. Not so good for the grades or academic accomplishment, but I’m not sure I’d have been academically successful after that brain smashing no matter what I did; took a long time to get the gears operating again.

        But a lot of the decision on what to take actually depends on the problem; inflammation or nerve pain or fever pain, etc. After my son broke his collar bone a few years ago, they told him not to take anything, particularly ibuprofen, because it interferes with healing. My grandmother return to something close to normal after 20 years of ibuprofen at arthritis doses (they stopped because of looming kidney damage). I’m a lot more reluctant to take anything then I used to be; a little pain doesn’t hurt me, I’ve grown used to it, and because it’s inflammation pain, there seems to be a rebound problem (the excedrin headache) which seems akin to some sort of addiction to me.

        Yoga, exercise, working my brain hard, staying out of strobing light, and avoiding trigger foods work better then most pills. And if I’m sick, chicken soup, elderberry juice and sleep.Report

    • Avatar morat20 in reply to Mike Schilling says:

      Reyes syndrome. Tylenol is what you give kids, because you’re not supposed to take aspirin if you’re under what, 14?

      So what do you grow up taking for headaches, bad bruises, sports injuries, and other aches and pains? Tylenol.

      So what do you take as an adult? The stuff you’ve ALWAYS taken,.Report

  11. Avatar Mike Schilling says:

    What I like about Nyquil is that it makes me sleep. I presume it would be safer to achieve that with a single-ingredient medication like bourbon.Report

    • Ever try melatonin? It has made my life much easier.Report

      • Avatar Mike Schilling in reply to Will Truman says:

        Never thought about it, really. I don’t have trouble sleeping except when I have a fever, which makes my mind race in a really exhausting fashion. The Nyquil both relieves that and knocks me out, which is a great combination.Report

      • Avatar Glyph in reply to Will Truman says:

        1/2 a Benadryl will usually do the trick for me.Report

      • Avatar BlaiseP in reply to Will Truman says:

        Bananas are damned near the perfect source for melatonin.Report

      • Melatonin is the perfect source of melatonin, in my experience.

        My sleeping difficulties are mostly self-induced. Caffeine and nicotine too late in the day.Report

      • Avatar BlaiseP in reply to Will Truman says:

        I dream. A lot. Serious, hard-core dreaming. The only thing which works for me when it gets out of hand is to cut way down on meat, especially red meat.Report

      • Avatar BlaiseP in reply to Will Truman says:

        Ecch, I have this theory about these dietary supplements. Probably completely unfounded but it was my mother’s theory. If nature produces it in a fruit or veg, consume it as-generated. It’s got to get through the digestive process, lots of these chemical formulations don’t survive gastric acid.

        But I’m no nutrition scientist. An old wives’ tale it might be, but my Mom was a clever wife, anesthesiologist and pretty fair chemist, ruthlessly scientific.Report

      • Avatar dragonfrog in reply to Will Truman says:

        I occasionally use melatonin when I have trouble sleeping. I find it almost too effective – it takes me a couple of runs at it to fall asleep.

        I’ll start physically falling asleep so fast my mind hasn’t made the usual gradual transition from wakeful to sleepy thought patterns, and my body will essentially start falling asleep faster than my mind. I get a sort of mild panic reaction to my body going numb so suddenly, and startle awake. I have to put some effort into not fighting the unusual sensation of falling asleep ‘ahead of myself’.Report

      • Avatar ktward in reply to Will Truman says:

        One of my many lovely peri-menopausal symptoms was trouble sleeping. (Never had trouble sleeping before, not ever, regardless of stress factors. Heck, I slept like a baby even through an ugly divorce, though that’s no doubt a different convo for other reasons …)

        Anyhoo. I tried melatonin. I slept better/longer, but it gave me weird, seriously disturbing dreams which I later learned was actually a thing with melatonin supplements. “Melatonin Dreams”. Fortunately, my doc gave me ambien. Worked like a charm, no weird dreams.Report

    • Avatar Lyle in reply to Mike Schilling says:

      Of course that was the old remedy, either straight, or put in some tonic designed to fix whatever ails you. Most of the old nostrums appear to have had alcohol as the real active ingredient. I do recall my parents when I was little and had a bad cough, that the doctor said give him some whiskey to stop it.Report

  12. Avatar Elliott Mason says:

    As a parent the thing that drives me mad about kid-medication dosage instructions on the box is the INSANELY wide ranges that are supposedly taking the same dose.

    I downloaded the (recommended by my doctor) mg-per-kg dosing chart and do my calculations instead of giving her 5mL forever (even when that becomes a dose with no apparent effect) and then switching to 10mL. It may be because I’m a geek, but I have no trouble drawing a 6.25mL dose and giving it to her. Also, I prefer instructions in mL, not ‘teaspoons’, dammit. I constantly surprise the clinic staff by referring to medications as ‘ibuprofen’ and ‘loratadine’ and ‘diphenhydramine’ instead of their brand-names, which are all anyone there ever says to me when suggesting uses.

    In the UK, ibuprofen with codeine in it is available over the counter in pill form. Such a civilized country. Since Tylenol does almost nothing for me except lower fever (no analgesic effect), we don’t bother to keep it in the house at all.Report

  13. Avatar Darwy says:

    I always read the labeling to see what’s in OTC medicines, precisely because it is so easy to double (or triple) up on a medication. (Granted, I also have an education that included pharmacology and pharmacokinetics)

    You feel like @ss, you take tylenol because you’ve got a headache, NyQuil for the sneezing, sniffling etc.. and bingo – you’re in danger of drug induced liver injury. You get up 7 hours later to go to work, and take some DayQuil and Sudafed…. ditto.

    I asked a pharmacist once about the dosage for my son – and I got a snippy, “Well what does the bottle say??” My son was 2, but large for his age (his weight put him up in the 3-6 age dose, but I wanted to be sure the dose I had calculated was correct. At 5 he’s nearly 50 inches tall, 60 pounds, wears a youth size 1 shoe and has a head circumference of 21″.

    I put down the medication and went to another pharmacy that wasn’t staffed by douche canoes, and bought the same product and got confirmation that the dose he received was weight appropriate.Report

  14. Avatar Miss Mary says:

    I enjoy the TAL piece when I heard it. It totally freaked me out when I heard the infant Tylenol was so strong though. I gave that to my kid!Report

  15. Avatar ktward says:

    … Nyquil or Tylenol Cold and Flu. I hate them. Not only are people who take them often getting medications for symptoms they may not have, but they may not realize which medications they’re even taking.

    A-men to that. To this day, I remind my adult kids not to buy that stuff. Congested? Take Sudafed. Allergies? Take zyrtec or claritin or whatever works, but take the non-D version. Headache/fever/aches/pains? Take ibuprofin, whatever brand is cheapest at the local store. Any combination of these conditions means one must take more than one pill [gasp!], but there’s NO reason a person should take meds they don’t need, no matter what the marketing says. And no acetaminophen! Otherwise healthy peeps have zero reason to ever use that shit.

    My 20+yo kids get this. My senior parents who I’m currently caring for? A nightmare. I have to watch them like the proverbial hawk, because they’re both already taking a litany of Rx meds for various conditions. Unfortunately, my Papi must take Tylenol for his arthritis — he’s got it bad — because every other NSAID is contraindicated with his other Rx drugs. It’s a dangerous dance, though, which is why, among other reasons, he regularly gets tested for liver and kidney function. Yay for Medicare.

    Anyhoo. Unlike 20 years ago when I was parenting young kids, it’s soeasy anymore to look this stuff up on the web, I have a hard time imagining how much of a dumbass a parent must be to wake their Pediatrician up in the middle of the night with this kind of stuff.Report

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