April 12, 2011
Acetaminophen may boost blood pressure
For people with cardiovascular disease who need relief from aches and pains, acetaminophen (Tylenol, generic) has long been touted as a safer alternative to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. A small but important Swiss trial warns that it may not be. This work doesn’t mean you should ditch acetaminophen if it helps you, but does suggest you should give it the caution that it — and every medication — deserves.
A closer look at acetaminophen
The Swiss team set out to fill a surprising gap in medical knowledge: the effect of acetaminophen on blood pressure among people with coronary artery disease. This includes folks with angina (chest pain with exercise or stress) along with anyone who has had bypass surgery or angioplasty or who has been diagnosed with cholesterol-clogged arteries.
The researchers asked 33 men and women with one or more of these problems to take either 1,000 milligrams (mg) of acetaminophen or an identical placebo three times a day for two weeks. Then, after a two-week break, each volunteer took the other treatment. The amount of acetaminophen used in the study is a standard daily dose for pain.
When the participants took acetaminophen, average systolic blood pressure (the top number of a blood pressure reading) increased from 122.4 to 125.3, while the average diastolic pressure (the bottom number) increased from 73.2 to 75.4. Blood pressure stayed steady when participants took the placebo. These increases aren’t large. But they indicate that acetaminophen, like NSAIDs, somehow affects the cardiovascular system.
A larger, longer trial would have given more reliable results. It would also have been unethical, since none of the participants were in pain. That means they couldn’t reap any benefit from acetaminophen, but could only be harmed by it.
The sudden removal of the popular painkiller Vioxx from the market in October 2004 over concerns that it caused cardiovascular problems put all pain relievers under the spotlight — except acetaminophen. It avoided the “black box” warning about increased risk of cardiac problems that the FDA now requires on the labels of all NSAIDs. And the American Heart Association later recommended it as a safe alternative to NSAIDs.
Acetaminophen is easier on the stomach than aspirin and other NSAIDs, and is probably a good option for people who take warfarin (Coumadin, Jantoven, generic) or clopidogrel (Plavix). But because it is so widely used and perceived as safe, people tend to take it without thinking, one reason acetaminophen is a leading cause of liver failure and transplantation in the United States.
If you have some form of cardiovascular disease, it makes sense to take acetaminophen rather than an NSAID for a fever, headache, pulled muscle, or other occasional problem. But if you need relief every day for pain from osteoarthritis or rheumatoid arthritis, acetaminophen may not be a better option than an NSAID — it doesn’t work that well against inflammatory pain and, like an NSAID, may slightly elevate blood pressure.
The key message from this study is that acetaminophen isn’t free from cardiovascular side effects. It is worth a try as a first-line drug for pain relief, but if it doesn’t control your pain, it is reasonable to switch to an NSAID.
Does laser treatment work for toenail fungus?
Q. I’ve tried a lot of things for a fungal infection in one of my toenails, but it just won’t go away. What do you know about a new treatment that uses laser?
A. Two lasers using different types of laser energy have attracted attention as treatments for fungal infection of the toenails, a condition called onychomycosis (pronounced oh-nee-koh-my-KOH-sis), which can also affect the fingernails: Noveon and the PathoLase PinPointe FootLaser. The theory is that a precisely directed laser can eliminate the fungus without harming the surrounding nail tissue. The underlying technologies are already in use for other conditions, including cataract surgery, dental work, and hair removal. Although there is some laboratory evidence that lasers can squelch fungal organisms, clinical studies in humans thus far are limited.
There is no study comparing laser to other widely used treatments, and its long-term effects are unknown. While the PathoLase PinPointe laser has been approved by the FDA for the treatment of toenail fungus, Noveon has not yet been approved for this specific purpose, despite showing some promise in research studies.
The desire to find a cure for onychomycosis is understandable. Fungal infection can cause a toenail to thicken and look crumbly, discolored, and distorted. The nail can become difficult to cut and a source of embarrassment. Worse, it may be painful and make walking difficult. In people with diabetes or a suppressed immune system, toenail fungus may progress to more serious infections.
How to prevent toenail fungus
Fungi thrive in moist environments, so it’s important to keep your toenails short and as clean and dry as possible. Here are some tips:
- Dry your feet and toes thoroughly after showering or bathing. If you have a hair dryer, use it on a low setting to dry your toes.
- Always wear shoes in locker rooms, in public showers, and around public pools.
- Whenever possible, wear synthetic socks that wick moisture from your feet; if your feet sweat a lot, change your socks during the day.
- Wear shoes that fit well and are made of breathable materials.
- Avoid tight-fitting socks and stockings, which can trap moisture between your toes.
- Don’t pick the skin around your toenails.
- Use antifungal spray or powder in your shoes or on your feet.
- Keep your pedicure instruments clean and disinfected, and if you use a pedicure salon, make sure your pedicurist does the same.
- Don’t try to cover up the infected toenail with nail polish. It will trap moisture and worsen the infection.
The fungus is notoriously difficult to eradicate. Fungi are very hardy microorganisms. They can invade the nail through a tiny crack in the skin or even a small separation between the nail plate and nail bed. There are many over-the-counter nail creams and ointments, but none of them are very effective. Topical ciclopirox (Penlac) works somewhat better than a placebo, but it’s not a cure. So far, prescription oral antifungal medications have the best track record, though they’re not an easy fix. They must be taken for at least six to 12 weeks, and they can have side effects such as a rash, diarrhea, and liver damage, so users must be monitored by a clinician. If treatment succeeds, a new fungus-free nail will grow out to replace the old one, a process that may take several months. Even after successful treatment, the fungal infection may return in as short a time as a year.
The interest in laser treatment is growing partly because it does not have the side effects of oral medication. It’s painless and takes only 10 minutes per toe. But the cost (roughly $1,000) is not covered by any health insurance, and, more important, there is little information about its long-term safety and effectiveness. For the time being, I suggest that you save your money and explore currently approved therapies under the care of an experienced clinician.
— Celeste Robb-Nicholson, M.D.
Editor in Chief, Harvard Women’s Health Watch