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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.
Sandra
New Hampshire
I have been taking two 500 Mg. of Tylenol once per day and only a couple of times per week. My INR was higher 3.8, and Warfarin was adjusted. Last time 3.0. I have been pretty steady at 2.5 until taking Tylenol. Have pain in knees, and it really helps so what do I do? I will not take opioid drugs.
Dawn
Tempe, AZ
**CORRECTION
My previous post indicated, incorrectly, that my mom’s INR increases when she takes more than 1.5g of acetaminophen for 4 or more consecutive days. It SHOULD have indicated the INR increase as occurring when acetaminophen is taken for 4 or more consecutive days at a daily dose of 3g or more (6 pills @ 500mg/pill). My mom’s records actually show that her INR does not move out of range when daily dosage is 2.5g or less for more than 3 consecutive days. Essentially, based on the information I have tracked and kept over the past few years (specifically since starting Warfarin a couple yrs ago until now), it seems viable to manage her pain with acetaminophen as long as she doesn’t take more than 5 pills every day (@ 500mg per pill). My suggestion to others is to keep a daily diary of medications (if no changes, just put something to indicate no change, such as ” or NC, but be sure to include any new or different OTC meds so you have something to reference should your INR be out of range. It may not help in your case, but it can’t hurt and, as happened in my mom’s case, it was highly revealing.
Dawn
Tempe, AZ
Due to AFib, a previous TIA, and a blood clot following acute renal failure about 2 yrs ago, my mother started taking 27.5 mg of Warfarin per week. Since then we have had difficulty managing her INR within the goal range of 2.0 to 3.0, with her INR being as low as 1.2 all the way up to 4.7, even though we carefully manage vitamin K and are very consistent with the dosage. However, she had suffered from compression fractures on two occasions since beginning Warfarin, and each time we have used Extra Strength Tylenol in combination with oxycodone/acetaminophen for pain relief, with the goal of minimizing the use of oxycodone/acetaminophen whenever possible to avoid addiction/withdrawal and constipation.
About a week and a half ago, my mom finally started to have less pain from her most recent comp. fracture (that happened about 6 weeks ago); this led to decreasing the narcotic use and increasing the use of Tylenol for pain management per our goal as stated above. However, 5 days ago my mother woke up with blood on her teeth and gums, which has not happened before, and earlier this week her INR was 4.7. We were told by the dr. office staff that the high INR was due to the oxycodone and that Tylenol does not affect INR. After reading the information here and then reviewing my mom’s health and medication history (including INR results), it now seems clear to me that her use of Tylenol at a daily dosage of more than 1.5g (6 pills @ 500mg/pill) for more than 3 consecutive days caused her INR to skyrocket. Additionally, I believe her high INR is the likely cause of her bleeding gums.
This is upsetting, especially since we were explicitly told just a few days ago that acetaminophen had nothing to do with her INR fluctuations. On a positive note, I now believe I can effectively manage my mom’s pain without throwing her INR out of range simply by regulating her acetaminophen intake to avoid her taking more than 1.5g/day for more than 3 days in a row.
So… THANK YOU because I really appreciate having this apparently obscure but highly relevant information (and my mom thanks you as well).
Joan
salem nh
I am on warfarin and suffer from arthritis pain daily. My doctor said Tylenol in small amounts is ok so I want to know what else is safe to take if everyone is saying that Tylenol is dangerous. We all feel like dropping the warfarin in order to help with the pain everyday. So we are stuck between a rock and a hard place. Does anyone out there have the answers for us?
Jeff
IL
My doctor says basically nothing can be done. I am allowed Tylenol but although he told me it was safe I keep reading about INR increases. I expect the the amount of warfaren can be lowered thus keeping the level safe
Georgie
OH
I am having a horrible problem because of warfarin. I have constant pain from severe arthritis, and pain management Dr gives me opioids, which I cannot take due to dizziness. My PCP said I could take Tylenol and so started that recently and now learn that’s not right either. Rheumatologist prescribed Celebrex which interferes w/warfarin too. He said it was the only Rx I could take but also learned from computer AND pharmacist it’s no good either. If all these drugs thin blood, why can’t we just take them and discontinue this miserable warfarin???
Zipora
Boston ma
Very interesting info. I have been on Coumadin for the last few months for an Afib condition. I fell and fractured my sternum. I took Tylenol for the pain not knowing the interaction. Anyway, I was of town and had to go the ER because the pain did not subside, and I had black and blue marks on my body. My INR was 5. They stopped the Coumadin for two days and gave me another pain med, Norco.
Well, my INR returned to a normal value of 2.4, and I am recovering from the fractured bone. No one ever warn me not to take Tylenol wth Coumadin. It shows that physicians don’t know all the effects of drugs. I figured out the drug interaction on my own but the People’s Pharmacy confirmed it .
Brigitte
British Columbia
I agree the Tylenol is definitely not compatible with warfarin. This is the 2nd time my mom has taken Tylenol arthritis every day for pain on her doctor’s recommendation, and both times, her INR went up from normal range 2.4 to out of range 3.4. Last time, it went to 3.7. I am going to try to educate her doctor at the next appointment. I hope he listens this time.
S
AZ - Arizona
All I want to know is: how much dosage should I take of Tylenol while on warfarin or coumadin?
Raven
Surrey, BC
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.
Ed
NC
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
Frank
California
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.
Terry Graedon
What we have read is that there is a big difference between taking an occasional acetaminophen and taking it nearly every day with regard to its interaction with warfarin. The occasional pain reliever is probably safe. Chronic use should not be assumed to be safe.
Here are a couple of abstracts: http://www.ncbi.nlm.nih.gov/pubmed/21923443
http://www.ncbi.nlm.nih.gov/pubmed/23736105
http://www.ncbi.nlm.nih.gov/pubmed/26058438
http://www.ncbi.nlm.nih.gov/pubmed/21191575
http://www.ncbi.nlm.nih.gov/pubmed/19779704
gloria
I is happening to me. I take Coumadin for a heart valve and I have had a cold this week with headache and bodyache. I have been taking Tylenol – maybe 2 or 3 500 mg capsules per day. My INR normally around 2.5 was 3.7!
I have also been taking some cough meds. So not sure if Tylenol alone or combination, but my INR is very high.
My doctors have also told me ok to take Tylenol. Need to rethink that! Maybe one now and then only.
Lee
No, no, no, no. I don’t understand how providers do not know this. Cardiologist definitely should as they are usually the main ones to RX coumadin for cardiac issues and hx of thrombi, etc. although some PCP’s also do.
I am an RN and one of my duties is monitoring pt.’s with their INR’s and managing their warfarin dosing per ordered protocol through our facility. Although aleve, advil, ASA and other NSAIDS and salicylates will effect and interact with the warfarin by working synergistically (together) with the warfarin by increasing the pt.’s risk of bleeding, the tylenol or products that contain acetaminophen (tylenol) Increase risk and raise the INR to dangerous level (critical values).
The other products above listed do not raise the INR but just increase the risk of bleeding more. Even more scary is that pt.’s will tell us that the pharmacist told them the tylenol is fine with it. This is rare though. This is not a secret. We all can get this info. All it takes is diligence and research. Read the evidenced base articles and reputable sites re: this information.
Bessie
Edinburg, Tx
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
Lee
If you’re asking me, then I can’t tell you what to take because I am not your provider and you aren’t my patient. I can tell you what we tell our pt.’s. First off. Regular use of Tylenol, Advil, Aleve or NSAIDS have been proven to increase risk of cardiovascular disease and MI’s (heart attacks). None of our cardiologists like to see any pt. take these on a regular basis regardless if they are on warfarin or not.
In regards to having to take Tylenol, I would have to say that life happens and sometimes we have to take things to ease the pain. Providers, most of them, do not like to prescribe pain medications that are addictive so would rather see the pt.’s on OTC meds instead. We know that life happens. What I tell the pt.’s is be consistent with your regimen and it is easier to keep INR in check that way because we dose around their lifestyles.
In a perfect world no one drinks, smokes, takes harmful meds, etc. but this is not a perfect life. If a person takes Tylenol twice a day about 2-3x/wk then keep that consistency. We can change the dosing around that lifestyle. When they start taking tylenol 3x/day everyday or increase that then we see the INR go up because it is used to being dosed around that other schedule and now the pt. is adding and deviating from the regimen that it is being dosed around.
Same thing with reducing that Tylenol because they don’t need it as much. We will see the number go down. Alcohol, the same concept. If you take warfarin and have a drink every night and are able to keep INR in check because it is part of the regimen then that is fine but when a person decides to have an extra one then the INR will go up and vise versa. Doesn’t have one like normal then it might trend down that week or the next.
It usually takes a good 2 days to get full effect with the warfarin when any changes in meds/regimen are made because of the half life in the system of the med. CONSISTENCY is key for a more controlled INR. Also, it is best to take it at night because you are done with your day. Labs are taken during the day, right? Well if one takes the warfarin in the day and then go to the lab and get a high INR then we know that it will likely go up more because of the 2 day full effect thing. If they take it at night then we tell them to hold their dose so it won’t go up more.
PLEASE ALWAYS CHECK WITH YOUR OWN PROVIDERS BECAUSE EVERY PROVIDER MANAGES IT A LITTLE DIFFERENT. NEVER HOLD YOUR WARFARIN (NOT TAKE IT) OR ADD MORE THAN YOU WERE TOLD UNTIL YOU TALK WITH YOUR PROVIDER OFFICE.
LeRoy
Baltimore
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?
KATHLEEN G.
Blackfoot Idaho
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
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!!!!!
Lee
This site is not saying not to take Tylenol. It is just saying that there can be a possible interaction to where it will raise the INR. Everyone has pain. See my comment on Kathleen from Idaho. Life happens. We take those things. Consistency. I don’t tell any of our pt.’s not to take something. I educate them so they are aware of the effects it can have on them and their warfarin, INR’s, etc…Also liver and other co morbidities that they may have.
Warfarin is metabolized through the liver and so is Tylenol. All meds, whether OTC or prescribed or natural products, have some side effects. Depending on our health and use, other medications we are taking, etc. This isn’t a perfect world. Just educate or ask questions. That is how we learn. :)
sheryl l.
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.
DAW
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.
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
Sheila S
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.
APJ
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?
cpmt
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.
Tom
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
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.