The Truth About Tylenol - DTNS Weekend Edition

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2:09Dr. Gerry Tolbert: Welcome to another edition of the Daily Tech News Show Weekend Edition. And this is a topic that actually Dr. Nikki asked if we should cover. and then we decided that if we were going to cover it, we might need to get a medical doctor versus someone who studies goat skulls. And not that Dr. Nicky couldn't have done a great job with this topic, but I'm very pleased to welcome to the show to discuss a little bit of the technology and science behind what's going on with Tylenol in the United States. Dr. Jerry Tolbert, thank you for joining us. Thanks for having me. You are an actual doctor, right?

2:48Dr. Gerry Tolbert: A medical doctor.

2:50Tom Merritt: Correct. I'm a family doctor. I've been practicing for about 18 years at this point, close to 20, if you count medical school.

2:56Dr. Gerry Tolbert: Yeah. And a lot of people will know you from the podcast you do with Scott Johnson.

3:00Tom Merritt: Yes, we do a show called The Medical Show. We talk about all kinds of different topics and how they affect the everyday lives of everyday people. So I know a lot

3:08Dr. Gerry Tolbert: of people around the world, especially in the United States, watched the press conference in which the president and the secretary of health said that you should be aware of Tylenol. There was a lot of things said in the press conference, but there was also an actual government document issued. And that's what you would pay attention to as a doctor, right?

3:33Tom Merritt: Absolutely. Beyond all the sturm und drang of the political side of things, the scientific side of things from the FDA and from the Health and Human Services, that stuff is the stuff that really hits the road for doctors. It's the stuff that we have to actually pay attention to so that we can affect our everyday practice and make sure that we're doing things that are safe for our patients.

3:52Dr. Gerry Tolbert: So what's in that document, since that's the important part, and what's the science behind what's in that document?

3:59Tom Merritt: So there are three major components to that report. The first is the use of a medication called leucovorin, which helps with folic acid metabolism, which is a, if you've ever heard of folate or folic acid that comes from food. That is a component of nerve cell development. And so when we are growing as an embryo, we have to have folic acid in order to function correctly. That is also true later in life. And what we've discovered and what science has shown is that there are certain symptoms of autism that respond to that folic acid improvement and leucovorin helps make that happen inside the brain.

4:33Tom Merritt: So what they've said is leucovorin now has an FDA approval for use in certain types of autism for certain language specific symptoms that go along with autism in order to treat some of the verbal component of that dysfunction. It helps with the verbal skills, verbal expression. So speaking that goes along with certain facets of autism. So if somebody is on the autism spectrum and they have verbal deficits, they may have the type of verbal deficit could respond to that medication. And now scientists are allowed to, and doctors are allowed to, use that medication to see if patients would have that response.

5:14Dr. Gerry Tolbert: Were you not allowed before, or is this just more of a stamp of approval, don't be worried kind of thing?

5:19Tom Merritt: More the second than the first. We could use it, but most insurances wouldn't pay for it. And so the cost would be prohibitive in a lot of cases. And so it is sort of a combination of both.

5:28Dr. Gerry Tolbert: Okay. But that's not Tylenol, which is what everybody else was talking about. I assume there's a couple more bullet points we got to get to here.

5:36Tom Merritt: Absolutely. The second half or the second point was that we as physicians should be paying attention to how much Tylenol pregnant patients are taking during their pregnancy. It was kind of a restatement of an existing scientific idea. We know that acetaminophen, which is the main ingredient in Tylenol, is a relatively safe medication in pregnancy. There are lots of studies over many decades that have shown that, that this was reaffirmation that we need to be careful because there may be other things that we have not studied yet that could be impacting the development and growth inside the mother during pregnancy.

6:11Tom Merritt: And that is very important when we talk about pregnancy in general. There is always stuff that we don't understand because we don't like to experiment on pregnant women.

6:24Dr. Gerry Tolbert: So in other words, it's not don't take Tylenol, but what does it mean as a doctor then for you? Are there warning signs that you need to look out for? What is the practical effect of that bullet point?

6:38Tom Merritt: The answer is yes, there are things that we need to look out for, but most of it is stuff that we should already be doing. You should be limiting the dose. Tylenol is actually a very dangerous drug. In the past, people would say, oh, well, you just throw the dose of Tylenol at them and whatever sticks, that's the dose that you're supposed to use. That's a joke from Scrubs. The truth is that's not true. More than four grams of Tylenol in a day can be very damaging to the liver, especially, and more than 10 grams of Tylenol in a day. So each tablet is 500 milligrams. So two tablets is one gram. So if you take 10 tablets of Tylenol in a day, you are exceeding the actual normal dose that you should be taking, the safe dose that you should be taking, and it can cause liver damage and in fact can cause liver failure.

7:19Tom Merritt: And above 10 grams, more than a third of patients that consume more than 10 grams will have total liver failure and can potentially even need liver transplants. So it is a long-term damage that cannot be undone in some cases.

7:30Dr. Gerry Tolbert: So it does sound, I know you said it was a reaffirmation, but it sounds like there's not much new in that one other than, hey, reminder, Tylenol can be a problem.

7:39Tom Merritt: Accurate. It is difficult to say what the actual effects are based on the current literature. The science behind how acetaminophen is affecting development is pretty difficult to ascertain because we have to be very careful. We can't do controlled studies. A lot of times we have to do retrospective looks and that can make it a lot more difficult to control for other confounding factors. So we just don't know if the associations that we see actually prove causality, just like a lot of other things in science.

8:09Dr. Gerry Tolbert: And then there was a third bullet point.

8:11Tom Merritt: The third bullet point was a creation of essentially a grant system for the Autism Data Science Initiative. Essentially, they're looking at how can we study autism from other angles? Rather than looking at it as much from proteomics and genomics, they're looking at it from environmental factors. That's what they really want people to focus on based on what the paper says. It's hard to say what it's going to actually end up being, but it's basically just an allocation of funds for that kind of research.

8:43Dr. Gerry Tolbert: Okay. And so that seems like the one that would impact you the least since you're not involved in that. You kind of answered this along the way, talking about leucovorin and folic acid and the fact that there are already these things to be careful of with the administration of Tylenol. Is there other science beyond what's in this that you are thinking like, well, you also need to be aware of that?

9:08Tom Merritt: For Tylenol specifically, yes. There's ongoing research into the root causes of autism across the board, mostly genetic factors, because that's what we've learned over the last several decades is a primary cause, but as well as what other behaviors and symptoms similar to these verbal issues that are going to be treated with Leucovorin could be potentially improved with certain supplementation or other medications. And even things as extensive as things like gene therapy, which is much further down the road. There have also been studies of Tylenol and its metabolites that have already been done.

9:39Tom Merritt: And those are ongoing, looking at how they cross the placenta, what the levels are in mom versus what the levels are in baby. And what we found so far is that those levels do correlate pretty well. So the amount that we give mom is kind of the amount we're giving baby. And so once we get to a certain point around 15 to 17 weeks of gestation, the baby is going to be more sensitive to that Tylenol because they develop their own liver system that can process the Tylenol. So before that point, they don't have the same enzymes that mom has and the byproducts of Tylenol don't cross the placenta. So it's a little bit safer in that first trimester than it could be in the third trimester.

10:16Tom Merritt: But we haven't seen any real major adverse effects that we can really nail down and show a causal relationship with. So we're still in that gray zone of it's probably safe, but we just need to be careful. Gotcha.

10:26Dr. Gerry Tolbert: So how do you approach this issue yourself? And I know you're a family doctor, so this is something that you probably will be asked, but it's not like you're in the delivery room necessarily?

10:39Tom Merritt: Absolutely not in the delivery room, but I have delivered a whole lot of babies and I do a lot of prenatal care because people will come to us long before they get to the OB. And in the area where I am, it's a fairly underserved area. So there are a lot of patients that were the first contact. So when we talk about it, we talk about it in the sense of safety. We talk about thresholds. And so for most folks, if you're staying below three grams of Tylenol, you're going to be a day, you're going to be in the safe zone. And if you can get below that, If you can do a single dose, one gram of Tylenol, that is going to be a much safer.

11:11Tom Merritt: And remind me again why three grams is the level. So four grams is the danger zone. We're trying to stay below the line. So three grams is kind of acceptable. For liver damage or for anything? All of the above. All of the above. Okay. Because it does cross the placenta in a way that is going to be, it's not one to one, but it is proportional. And so because of that, we don't want the baby to get more Tylenol. And babies get a Tylenol dose that when they're born, once they're out of the womb, they're going to get a dose that is 10 milligrams per kilogram, roughly. That's kind of the calculation we use.

11:45Tom Merritt: And so smaller babies need less Tylenol. It's kind of size dependent. And there's a max dose there. And that three grams in mom tends to stay below that max dose for babies in terms of what we understand how it crosses the placenta.

11:58Dr. Gerry Tolbert: Because it's spread out amongst the whole system. It's spread out amongst two people, basically. Yeah, yeah, yeah. Yeah, that makes sense. And I'm asking this question because I'm trying to ascertain somebody's mindset when they come to you. If I'm protecting my liver, am I also protecting my baby from autism?

12:17Tom Merritt: Most of the time you're protecting your baby from the downstream effects of Tylenol. It's

12:22Dr. Gerry Tolbert: not necessarily going to be autism, but you're protecting them from anything that may be

12:27Tom Merritt: happening because of the Tylenol or because of its metabolites.

12:29Dr. Gerry Tolbert: Yeah. Now, what about somebody who doesn't respond to the lower dosages?

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15:40Tom Merritt: The problem in pregnancy, and this is where this gets really, really difficult, is that there are dangers to taking medications like aspirin and ibuprofen and naproxen, which are over-the-counter pain relievers, those fall into what's called non-steroidal anti-inflammatory drugs. Those can be very dangerous during multiple phases of pregnancy. And we know that already. We've already shown that in multiple different studies. So the limitations of what is safe for baby are much higher. They're much more stringent. And so Tylenol was kind of the only option that most pregnant women had for pain relief.

16:14Tom Merritt: If we're talking about something that requires much more pain relief, we have to start looking at either alternative methods or moving to drugs that are a lot stronger and have a lot more potential risk to them. So that's why we have to be careful on both sides. We don't want to limit Tylenol completely and not have an option. We also don't want to overdo it and have problems.

16:34Dr. Gerry Tolbert: What do you say to someone who comes to you, they're pregnant, and they are worried about any amount of Tylenol now because they've been watching the news, but they may not have been watching it as closely or reading the bullet points? How do you handle that?

16:54Tom Merritt: The short answer is I try to reinforce the fact that Tylenol is mostly safe if used correctly, and it's about that threshold. It's about using it in a way that is going to be safe for you and safe for baby and still effective for treating the symptoms that you're trying to treat. And if there are alternatives, then we can absolutely use those first. But if Tylenol is the appropriate choice, we want to make sure that we're not throwing the baby out with the bathwater, that we are actually saying there are safe ways to use these medications. There's an old saying by Paracelsus, at least it's attributed to him, that the difference between a medicine and a poison is the dose.

17:28Tom Merritt: And so what we have to be very careful of is what's that threshold? What's that line? So we're not going to cross that. If we can avoid it at all costs, we're not going to cross that threshold, but we will still use the tools that we have in appropriate ways. in appropriate ways. Right, not inappropriate, but in a way that is appropriate.

17:50Dr. Gerry Tolbert: Exactly.

17:51Tom Merritt: And in a way that is going to be safe and effective. And if we have to go outside of those bounds, we're not going to do that lightly.

18:00Dr. Gerry Tolbert: Now, tell me if I have this right, because I'm not sure I do. There is a level above which Tylenol is just dangerous for your liver. and of course if you're pregnant dangerous for not only your liver but your baby's liver especially after 15 weeks as you were explaining and so the question of whether there is a risk of autism above there seems to be sort of a side note like well you don't want to damage your liver anyway so maybe not worry about the autism and worry about the liver and you get both for free even if the autism one is true or not. That is a valid statement.

18:40Tom Merritt: Okay. So I got, I have that right. Yeah, absolutely. I agree with that. I think that's a great way to say it. I might even file that away and use it myself.

18:47Dr. Gerry Tolbert: Okay, good. Yeah. No, I wasn't sure. So I'm happy to hear that because I think people really want to get into the conversation of like, well, does it or doesn't it? And if I'm getting this right, We don't know. And we need to study that. But there are guidelines we can follow that keep it from being a concern. Absolutely.

19:09Tom Merritt: It is going to be less of a concern and it is going to be easier to study if we're using it appropriately than if we either step away from it completely or we go full force and try to ignore the recommendation. That modicum of restraint to use it correctly and to look at the science rather than getting emotional or becoming concerned about politics is absolutely the key to using anything that we use correctly. That's true for all the medicines we use. And that's why when we talk about medications, just in general, there are certain sort of protocols that we follow. If it's a new medicine, you have to be careful because we don't have decades of aftermarket data.

19:48Tom Merritt: With Tylenol, we literally have decades of aftermarket data. We know what happens from watching people in real life. that kind of data can't be used to figure out causality as easily because statistically it's just not the same kind of data, but it is absolutely useful in pointing us in the right direction. Like, is it even a possibility versus is it something that is just outside the realm of possibility?

20:11Dr. Gerry Tolbert: Well, this has been extremely helpful in helping me understand this issue better. And I hope that is true for everyone listening as well. If folks want to get your insight on more than just this topic, where should they go?

20:25Tom Merritt: So I am usually at Dr. Tolbert on most social media platforms. If I'm not at Dr. Tolbert, I'm at G Tolbert. They can also check us out on the medical show. The URL is the medical dot show for Scott and my podcast. And that's probably it. Otherwise, I'm kind of just out there talking about things, usually just walking around the office spouting random scientists.

20:49Dr. Gerry Tolbert: Fantastic. Dr. Jerry Tolbert, thank you so, so much for taking the time to talk to me, man. This is really good. Yeah. Thanks for having me. It was awesome. And thank you folks for supporting us at patreon.com slash DTNS, giving us the ability to have these kinds of conversations and bring them to you. Let us know what you think. Feedback at dailytechnewsshow.com. We'll see you with the regular show on Monday.

21:15Tom Merritt: the dtns family of podcasts helping each other understand i'm in club hopes you have enjoyed this program

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