tylenol bottles

Q. I was very upset to read your response to a question about the blood thinner Coumadin. You listed several drugs that may interact with Coumadin; one of them was Tylenol.
I am a heart valve patient. My cardiologist is one of the most respected doctors in the country. He told me never to take any drug without clearing it with him first.
The one drug I am allowed to take without asking a doctor is Tylenol. After I read your column I became alarmed. I spoke to two cardiologists, an infectious disease doctor, a neurologist, an ophthalmologist, and two pharmacists. ALL said Tylenol was not incompatible with Coumadin.
You should do more research before responding to such inquiries. Please print a correction.
A. We are sorry we alarmed you. Most physicians realize that aspirin and other anti-inflammatory drugs can cause problems in combination with Coumadin. Despite research going back 30 years, few are aware that acetaminophen (Aspirin Free Anacin, Panadol, Tylenol) can also interact with this anticoagulant.
Although it is safe for a patient on Coumadin to take Tylenol occasionally for a headache, regular use (more than a few days) could increase the risk of hemorrhage.
A study published in the Journal of the American Medical Association (March 4, 1998) showed that people who take fewer than three doses (six 325 mg tablets) per week have little to worry about, but just four tablets a day for a week result in 10 times the danger of bleeding. More recent studies in the European Journal of Clinical Pharmacology (March, 2011) and Pharmacotherapy (June, 2011) confirms this link in some patients.
Anyone taking Coumadin should be aware of all potential incompatibilities. We’re sending you our FREE Guides to Food, Drug and Coumadin Interactions which describe many of these problems in greater detail.

Join Over 120,000 Subscribers at The People's Pharmacy

Each week we send two free email newsletters with breaking health news, prescription drug information, home remedies and a preview of our award-winning radio show. Join our mailing list and get the information you need to make confident choices about your health.

  1. S
    AZ - Arizona
    Reply

    All I want to know is: how much dosage should I take of Tylenol while on warfarin or coumadin?

  2. Raven
    Surrey, BC
    Reply

    I am 81 and am on Warfarin for A-Fib. Lately I have developed a uterus bleed and it has become painful to even walk…went on Tylonol Arthritic to manage the pain …my I&R has gone from 2.5 to 5.2 In one week… dangerously high considering I already am having a bleeding problem. So am agreeing with you that it may not be as compatible for me at this time.

    I will see my doctor after another I&R with no Warfarin to see if it has come down and talk to my pharmacist about this today. I agree…monitor carefully.

  3. Ed
    NC
    Reply

    Pharmacotherapy. 2011 Jun;31(6):591-7. doi: 10.1592/phco.31.6.591.
    Effect of acetaminophen on international normalized ratio in patients receiving warfarin therapy.
    Hughes GJ1, Patel PN, Saxena N.
    Author information
    Abstract
    Warfarin is known to have extensive interactions with many classes of drugs. The literature suggesting a relevant interaction between acetaminophen and warfarin is inconsistent. Considering the ubiquitous use of acetaminophen, a review of the effects on international normalized ratio (INR) in patients taking warfarin was necessary. Thus, we performed a search of the PubMed (1966-November 2010) and International Pharmaceutical Abstracts (1970-November 2010) databases to review the available literature addressing an acetaminophen-warfarin interaction and its possible mechanisms. A sample of case reports, in addition to all English-language studies were evaluated, and relevant references were examined for additional articles. Reports of nonwarfarin coumarin anticoagulants were excluded. Published documentation reporting an interaction between acetaminophen and warfarin is limited. Small prospective studies of various designs and case studies describe aberrant INR results in patients using acetaminophen while receiving warfarin. These INR elevations typically involved acetaminophen ingestion of at least 2 g/day for several consecutive days. In several small prospective studies, INR results were elevated to a statistically significant extent that would require a change in warfarin dosing and monitoring in clinical practice. The mechanism for this interaction remains to be elucidated yet is suggested to occur through alterations in hepatic metabolism. The use of moderate-to-high doses of acetaminophen while receiving warfarin results in supra-therapeutic INRs in some patients. The characteristics that may predispose a patient to this interaction are unclear, yet the widespread use of acetaminophen calls for enhanced clinician awareness and reinforcement of patient education about this interaction.
    PMID: 21923443 [PubMed – indexed for MEDLINE]

    from: http://www.ncbi.nlm.nih.gov/pubmed/21923443

  4. Frank
    California
    Reply

    I am responding to the person who said “The one drug I am allowed to take without asking a doctor is Tylenol.” (Wrong.)
    “After I read your column I became alarmed. I spoke to two cardiologists, an infectious disease doctor, a neurologist, an ophthalmologist, and two pharmacists.” (All of whom you spoke to NEED to either conduct more research OR go back to Med School for passing along FALSE INFORMATION that can cause internal bleeding and possibly Death. )
    “You personally should conduct more research before responding to such inquiries.” (The only correction has been answered by peoplespharmacy.com which is a website giving you more precise intel than ALL of your Doctor’s and Pharmacist’s combined = Coumadin and Tylenol are Extremely dangerous together.)

    I wont lie, I was told the exact same thing ie: that it was safe to take Tylenol with Warfarin/Coumadin = WRONG. The only pain killer that IS SAFE is oxycodone in low mg as needed. I currently take 4 mg of Warfarin a day for blood clots for over a year now and a few other meds. I was in excruciating pain the other night and tried to take a couple old Percocet I had 2 nights in a row. These had 5 mg of oxycodone and 325 mg of acetaminophen. On the 2nd night I woke up around 3 am and it felt like I was being stabbed in my right kidney with a knife. So my Doctor said the only thing safe that he is aware of is oxycodone (alone) in low dosages. Ie: 10-20 mg at a time as needed.

    So point is, unless you want to risk internal bleeding or possibly your life, avoid any OTC pain killers at all costs. Especially Tylenol/Acetaminophen.

    Regards, Frank.

  5. Bessie
    Edinburg, Tx
    Reply

    My cardiologist tells me I can only take Tylenol for leg and hip pain because I take Coumadin, I have a defibillater and pace maker. So if I shouldn’t take Tylenol what can I take for pain?
    Thanks

  6. LeRoy
    Baltimore
    Reply

    I am using Coumadin to battle effects of. Antiphospholipid Syndrome. Since you are saying that I cannot take Tylenol,what do I take for a head ache, or back pain, or leg pain since there is such a restriction on what pain relievers I CAN use, what do YOU suggest that I take?

  7. KATHLEEN G.
    Blackfoot Idaho
    Reply

    I have been on coumadin for 3 months 3mg and my protime levels keep changing. I now have very bad headaches and my stomach hurts. This is also with my knee pain and hip pain. I am unsure what to do as I do not like taking meds at all ..my coumadin pills also have been raised to 5 mg to thin my blood more. I also have pupura on both lower legs and feet.

    • Mae
      Georgia
      Reply

      I am a retired RN. I am on warfarin be cause I have A-Fib and have had two TIAs
      I would never take aspirin with warfarin.
      My MD Rx’d Hydrocodone with acetaminophen for rib pain after I fell and had a
      hairline fracture on one rib. I told the pharmacist that I should not take the RX, but she said
      I would have to take the med for months before it would be harmful.
      I went against my better judgement and took the med for two days and then started
      having rectal bleeding. Of course the MD advised me not to take any more.
      I make this a rule, no aspirin, acetaminophen or nsaids, no matter who tells me to do so.
      Sometimes, the patient knows best!!!!!

  8. sheryl l.
    Reply

    What can you take for hip pain if you take Coumadin and a 81 mg asprin? thanks
    PEOPLE’S PHARMACY RESPONSE:
    People taking the anticoagulant warfarin (Coumadin) are caught on the horns of a dilemma. Most OTC (and many prescription) pain relievers in the NSAID class such as ibuprofen, naproxen, diclofenac, etc can be damaging to the digestive tract. If you are taking warfarin, that means a bleeding ulcer is a distinct risk.
    We would discourage all NSAID use, including drugs like Advil or Aleve.
    You will need to ask your MD about other options. Meanwhile, you may find our Guide to Alternatives for Arthritis of interest.
    https://store.peoplespharmacy.com/guides/alternative-treatments-for-arthritis.html
    But be careful with herbs and spices. Even something like turmeric (curcumin is the active ingredient) may increase the risk for bleeding.

  9. DAW
    Reply

    Question: If one is taking Coumadin and you have pain in hips and or knees just WHAT can you take for relief from arthritic pain?

    • Rose
      Dutch Caribbean.
      Reply

      I am on Acenocoumarol Sandoz, but having a hard time getting it regulated, every time I am tested my blood is either too thick or too thin. I have AFib, I am also a diabetic, and have high blood pressure. I am on various medications, all precribed by a Dr. But having so much pain in my body from Athritis and difficult to find a really safe pain killer to take along with the blood thinners. It is about 4 months I have been on the blood thinners, it is still being adjusted as the right dosage have not been established as yet, anyone else experienced this.

      Thank you

  10. Sheila S
    Reply

    It’s true: if you read the information that comes with the warfarin/Coumadin, Tylenol (acetominphen) is indeed among the drugs that are contraindicated. I agree that it’s sad that so many doctors are in the dark as to which drugs are incompatible, and that patients must be more educated over what they can and cannot take.

  11. APJ
    Reply

    I recently had two stents placed and have been told that I must take Plavex for a year. I am taking 3,000 mg of acetaminophen daily for failed back surgery pain and am wondering if this presents a similar exposure to excessive bleeding in my brain as described in this article?

  12. cpmt
    Reply

    After I read this I am wondering if the problem I had in the hospital recently was do to the combination of both drugs given to me together. Thank you for the information.

  13. Tom
    Reply

    I have been on Coumadin (warfarin) for four years and being monitored by the University of Michigan Health System’s anti-coagulation clinic. I have been told an occasional dose of acetaminophen (max 1000g per day) should not affect my blood levels. Continued daily use could cause a problem.

    • Rocky
      Hermitage, PA
      Reply

      I have been on Warfarin for over 10 years because of 2 DVTs. Recently I had 2 herniated discs and was prescribed Percocet. Because I did not want to take these on a daily basis, I switched to Tylenol Extra Strength. My INR levels escalated to 7.9. My orthopedic surgeon and general practitioner had no idea why it was elevated even though I had informed them of everything I was taking to include the Tylenol Extra Strength.

      I then called my pharmacist and she informed me that the Tylenol may elevate the INR. She said she would check and get back to me. After doing some research she called back and stated that it is definitely the Tylenol. When I went back on the Percocet and discontinued the Tylenol my INR dropped to 2.5 and stayed in range.

      Many doctors and specialists DO NOT know that Tylenol, when taken several times/week or more will increase the INR in some people, especially taking the extra strength Tylenol. An occasional dose, however, does not seem to affect my INR.

What Do You Think?

We invite you to share your thoughts with others, but remember that our comment section is a public forum. Please do not use your full first and last name if you want to keep details of your medical history anonymous. A first name and last initial or a pseudonym is acceptable. Advice from other commenters on this website is not a substitute for medical attention. Do not stop any medicine without checking with the prescriber. Stopping medication suddenly could result in serious harm. We expect comments to be civil in tone and language. By commenting, you agree to abide by our commenting policy and website terms & conditions. Comments that do not follow these policies will not be posted.