MAYO CLINIC HEALTH LETTER

MAYO CLINIC HEALTH LETTER

Reliable Information for a Healthier Life

VOLUME 31 NUMBER 12 DECEMBER 2013 Diverticular ful attack caused by the inflammation
disease of a diverticular pouch (diverticulitis).
Inside this issue
Fiber as therapy An attack of diverticulitis only
HEALTH TIPS . . . . . . . . . . . . . . . . . . 3 o­ ccurs in a small percentage of people
Taking a breather. For many older adults, being told they with diverticular disease. In most in-
have small pouches (diverticula) along stances, it can be treated successfully,
NEWS AND OUR VIEWS . . . . . . 4 the wall of their large intestine (colon) but complications sometimes develop
Storing up brainpower for later — diverticular disease — comes as a that warrant hospitalization or surgery
years. Post-meal walking reduces surprise. But it’s a common surprise. It’s — and may even be life-threatening.
blood glucose. estimated that 60 percent of Americans
have diverticula by age 60, and that Weak spots
PERICARDITIS . . . . . . . . . . . . . . . . . 4 percentage keeps climbing with age. Diverticular pouches (diverticula)
Heart inflammation.
Most people learn they have diver- most commonly form in the last portion
LOWERING ticular disease as a result of a colon of the colon (sigmoid colon) before it
BLOOD PRESSURE . . . . . . . . . . . . 6 exam done for another reason, such as turns into the rectum. However, among
Devices that help. screening for polyps and colorectal Asians, they often develop in the first
cancer. However, some people learn part of the colon (ascending colon).
ACETAMINOPHEN . . . . . . . . . . . . . 7 of their diverticular disease after a pain-
Generally a better choice. Diverticula develop at points where
blood vessels run through the colon wall
SECOND OPINION . . . . . . . . . . . 8 to supply the inner layers of colon tissue.
The areas around these vessels are
Coming in January

IMPLANTED PACEMAKERS
Ticking away at progress.

FECAL INCONTINENCE
With help, often treatable.

BELCHING AND GAS
Reducing air in the system.

THE MYSTERY OF HEALTH
Salutogenesis.

Diverticular pouches (diverticula) most commonly form in the last portion of the colon
(sigmoid colon) before it turns into the rectum.

thought to be weak points. It’s suspected sea, constipation or diarrhea, and ■ Liquid diet — Switching to a clear
that something causes an abnormality in ­occasionally urinary problems. Painless liquid diet for a few days gives your
how colon muscles propel stool through rectal bleeding is also associated with colon a rest and may help inflammation
the colon. This results in increased pres- diverticulitis, and usually isn’t associ- and infection to heal. A gradual return
sure in the sigmoid colon, possibly caus- ated with inflammation or pain. to more normal eating — and eventu-
ing weak spots to balloon out. ally a high-fiber diet — can proceed
Diagnosis usually includes a review after symptoms improve.
It’s not fully understood what causes of symptoms, a check for abdominal Uncomplicated diverticulitis usually
the initial colon abnormality. However, tenderness and blood tests, such as a resolves with appropriate treatment.
it’s known that diverticular disease is white blood cell count, that looks for However, complications can still emerge.
common in industrialized cultures. In signs of infection. A computerized If symptoms worsen or don’t improve
addition, diverticular disease was un- ­tomography (CT) scan is considered the within two to three days or if it becomes
common before 1900. These observa- optimal method for visualizing your difficult to take fluids by mouth seek a
tions, coupled with research, indicate ­colon and looking for signs of inflamma- prompt reassessment.
that modern living may result in risk fac- tion, infection or other complications.
tors for diverticular disease, including: Surgery warranted?
■ Lack of dietary fiber — This contrib- Another consideration is whether Complications of diverticulitis are
utes to small, hard stools that take longer hospitalization is necessary. Most peo- serious and can be life-threatening.
to pass, and are more difficult to pass. ple can follow up with treatment at They include development of an in-
Although not proved, this appears to be home. However, hospitalization may fected, pus-filled pocket (abscess), rup-
one of the most likely contributors to be appropriate for more severe diver- ture of an inflamed diverticulum into
sigmoid colon changes that set the stage ticulitis, diverticulitis with complica- the abdominal cavity causing peritoni-
for development of diverticular disease. tions — or for those who are older, who
■ Lack of exercise — Research has have weakened immune systems or MAYO CLINIC HEALTH LETTER
shown an association between vigor- who have other significant diseases.
ous exercise and a reduced risk of Managing Editor Medical Editor
d­ iverticular disease. The reduced risk Milder bouts Aleta Capelle Robert Sheeler, M.D.
resulting from exercise is enhanced by For about 75 percent of those with Associate Editors Associate Medical Editor
high-fiber intake. Carol Gunderson Amindra Arora, M.B.,
■ Obesity — One study found that an attack of diverticulitis, the condition Joey Keillor B.Chir.
obesity raised the risk of diverticular is considered mild (uncomplicated). Medical Illustration Editorial Research
disease by about 50 percent more than Michael King Deirdre Herman
not being obese. The risk of diverticular It’s thought that diverticulitis devel- Operations Manager Copy Editing
bleeding also was increased. ops when pressure in the colon or irrita- Christie Herman Miranda Attlesey
■ Aging — It’s not known why age tion of colon tissue causes inflammation Administrative Assistant Donna Hanson
increases risk, but it may be due to a of one of the diverticular pouches. A Beverly Steele Julie Maas
decrease in the strength and elasticity microscopic perforation may develop
of your bowel wall. at that site, possibly causing the pain of EDITORIAL BOARD
a diverticulitis attack and leading to
A flare up ­inflammation of the colon wall. Protec- Shreyasee Amin, M.D., Rheumatology; Amindra
Diverticular disease — meaning the tive mechanisms within the abdomen Arora, M.B., B.Chir., Gastroenterology and Hepatology;
can typically seal off the perforation. Brent Bauer, M.D., Internal Medicine; Julie Bjoraker,
mere presence of pouches — generally M.D., Internal Medicine; Lisa Buss Preszler, Pharm.D.,
produces no symptoms. Typically, di- In addition to nonprescription pain Pharmacy; Bart Clarke, M.D., Endocrinology and
verticula become a problem when in- medication, treatment of uncompli- Metabolism; William Cliby, M.D., Gynecologic
flammation or infection develops. When cated diverticulitis usually involves: Surgery; Clayton Cowl, M.D., Pulmonary and Critical
that happens, it’s called diverticulitis. ■ Antibiotics — A course of antibiot- Care; Mark Davis, M.D., Dermat­ ology; Michael
ics is usually prescribed to kill off any Halasy, P.A.-C., Emergency Medicine; Timothy
The prominent symptoms of diver- infection that may have developed. A Moynihan, M.D., Oncology; Norman Rasmussen,
ticulitis are pain and tenderness in the recent study has suggested that antibi- Ed.D., Psychology; Daniel Roberts, M.D., Hospital
lower left side of the abdomen. The otics may not always be necessary with Internal Medicine; Robert Sheeler, M.D., Family
pain is often intense and comes on sud- mild diverticulitis. However, Mayo Medicine; Phillip Sheridan, D.D.S., Period­ on­tics;
denly. However, it may sometimes be Clinic doctors still recommend antibi- Peter Southorn, M.D., Anest­ hesiology; Ronald Swee,
less severe, fluctuating and gradually otic therapy for those with mild diver- M.D., Radiology; Farris Timimi, M.D., Cardiology;
building over days. In addition, signs ticulitis and an elevated white blood Matthew Tollefson, M.D., Urology; Debra Zillmer,
and symptoms may include fever, nau- cell count or fever. More research is M.D., Orthopedics; Aleta Capelle, Health Informa-
needed to determine who, if anyone, tion. Ex officio: Carol Gunderson, Joey Keillor.
may be able to avoid antibiotics. Mayo Clinic Health Letter (ISSN 0741-6245) is
published monthly by Mayo Foundation for Medical
Education and Research, a subsidiary of Mayo
Foundation, 200 First St. SW, Rochester, MN 55905.
Subscription price is $31.52 a year, which includes a
cumulative index published in January. Periodicals
postage paid at Rochester, Minn., and at additional
mailing offices. POSTMASTER: Send address changes
to Mayo Clinic Health Letter, Subscription Services,
P.O. Box 9302, Big Sandy, TX 75755-9302.

2 www.HealthLetter.MayoClinic.com December  2013

tis, bowel obstruction from scarring and of diverticular disease, or help prevent Health tips
narrowing, or an abnormal connection recurrence of diverticulitis. Primarily,
(fistula) between the colon and anoth- this involves gradually adopting a high- Taking a breather
er organ. fiber diet by eating plenty of fruits, veg-
etables, whole grain products, beans Deep-breathing exercises can
Complications usually require intra- and legumes. help maximize oxygen exchange,
venous antibiotics and often surgery to facilitate relaxation and reduce
remove the affected portion of colon It’s recommended that men and stress. They can also act on the
and reconnect the healthy colon ends. women over age 51 get 30 grams and centers in your brain that lower
An operation may sometimes be done 21 grams of fiber daily, respectively. blood pressure.
on an emergency basis, such as for peri- There’s no evidence that foods such as
tonitis, or scheduled for when the acute seeds, nuts or popcorn increase the risk The following exercise can
inflammation has settled down. of diverticulitis. help get you started:
■ Get comfortable — Wear
An emergency operation may in- A fiber supplement such as methyl- clothes that are loose at the waist,
volve more than one procedure several cellulose (Citrucel) or psyllium (Metamu- and either lie on your back or sit
months apart, and may include tempo- cil, others) may help boost your fiber comfortably in a chair with your
rarily creating an opening for stool to exit intake. Aiming for a total of 30 to 60 feet resting on the floor.
(colostomy) as a bridge to full repair and minutes of moderate exercise most ■ Take position — If lying down,
function. Laparoscopic surgery using days may also be beneficial. rest one hand on your abdomen
small incisions and thin instruments is and one hand on your chest. If
commonly performed in less extreme Although there doesn’t appear to be sitting, place your feet flat on the
circumstances. Recovery is generally a direct link between diverticular dis- floor, relax your shoulders and
quicker with laparoscopic surgery. ease and colon or rectal cancer, occa- put your hands in your lap.
sionally what appears to be diverticuli- ■ Basic breathing to start — In-
After recovery tis may turn out to be colon cancer. hale through your nose, as this
It’s estimated that about 30 to 40 Because of this, your doctor may recom- filters and warms the air. Exhale
mend a colonoscopy after you’ve recov- through your mouth. Concentrate
percent of those who have recovered ered from a bout of diverticulitis. ❒ on your normal breathing for a
from uncomplicated diverticulitis will few minutes.
have one or more attacks in the future. Life-threatening complications of diver- ■ Inhale deeply — Inhale while
Additional attacks are generally similar ticulitis include development or rupture slowly counting to four or for
in severity to the first attack and aren’t of an infected, pus-filled pocket (abscess). about four seconds. Expand your
associated with increased risk of com- abdomen slightly as you inhale.
plications. Although some believe that As you breathe in, imagine the air
subsequent attacks are more likely to flowing to all parts of your body,
result in peritonitis and complications, supplying you with cleansing,
current studies don’t support that belief. energizing oxygen.
■ Exhale slowly — You may wish
If attacks remain uncomplicated, to hold the air in your lungs for a
they’re treated in the same way as the few seconds. Next, exhale to a
first attack. An anti-inflammatory drug count of four, as your abdomen
mesalamine (Delzicol, Pentasa, others) contracts. Imagine tension flow-
may be helpful to prevent diverticulitis ing out of you along with the ex-
in those with mild but frequent attacks haled breath.
that don’t quite meet the requirements ■ Repeat — Pause for a mo-
for surgery, and who don’t want to re- ment. Repeat this exercise for one
main on antibiotics. to two minutes until you feel
calm. If you experience light-
With recurrence, doctors may as- headedness, shorten the length
sess the severity of your attacks, their and depth of your breathing. ❒
frequency and your risk of developing
complications in the future. If the risk
is high, surgery to remove diseased co-
lon segments may be recommended.
This typically cures the disease.

It’s generally felt that improvements
in lifestyle can prevent the progression

December 2013 www.HealthLetter.MayoClinic.com 3

News and our views Pericarditis

Storing up brainpower for later years Heart inflammation

Multiple studies have looked at the influence that brain-stimulating activities There’s a sharp pain by your heart, and
may have on brain health in later years, and most have found a positive the pain seems to be spreading along
association. Researchers are trying to understand what drives that associa- your arm and neck. Breathing deeply
makes the pain worse, but you do get
tion. One recent study — published July 23, 2013, in some relief from sitting up and leaning
Neurology — looked at whether mentally stimulating forward. You wonder, would this be a
activity somehow helps delay the consequences of heart attack?
cognitive decline that might otherwise occur from
brain changes associated with dementia. Anytime you experience new symp-
For the study, 294 older adults were asked to rate their participation in toms of chest pain, seek emergency
brain-stimulating activities — such as reading books, writing and doing medical care. Symptoms such as these
other mentally involved activities — from childhood to their current ages. In may indicate inflammation of the lining
addition, tests to assess memory and thinking skills were given annually over of the heart (pericarditis). It’s not life-
about six years before their deaths. At autopsy, their brains were examined threatening, but it shares symptoms of
for any diagnostic signs of Alzheimer’s disease and other brain diseases. problems that are, such as heart attack
Even after accounting for those disease-related brain changes, research- and blood clots in the lungs.
ers found that older adults who reported higher levels of mental stimulation
from childhood, through middle age and into late years also had slower A prompt medical evaluation of
rates of cognitive decline. In short, the findings support the idea that more chest pain is the only way to know
frequent mental stimulation across one’s life span may create a sort of resil- what’s wrong. Fortunately, although
ience — also known as cognitive reserve — in the brain. symptoms of pericarditis are a justifi-
Mayo Clinic experts say more research is underway to better understand able cause for alarm, they can often be
this resilience and what factors contribute to it. Many questions remain, includ- successfully treated with basic anti-
ing whether resilience is something people are born with or something that’s inflammatory medications.
developed through lifelong mental stimulation and other lifestyle choices. ❒
The rub
Post-meal walking reduces blood glucose The pericardium is made up of two

When it comes to keeping blood sugar (blood glucose) in check, exercise is thin membrane layers that surround
one of the best forms of medicine. Yet, some people aren’t able to regularly your heart like a sac. The pericardium
squeeze in a 30- to 60-minute walk. It turns out they may not always have to. helps limit heart expansion and helps
the heart work efficiently.
A recent study indicates that 15-minute walks occurring
30 minutes after meals appear to be just as effective at 24- Between the membrane layers is a
hour glucose control as going on a sustained, 45-minute lubricating fluid that smoothes the rub-
walk once daily. bing of the layers together as the heart
expands and contracts with each heart-
The research, published in Diabetes Care, involved 10 beat. Pericarditis occurs when those
older adults who had fasting blood glucose readings that membrane layers become inflamed. The
put them at risk of developing type 2 diabetes. On three separate occasions, pain associated with pericarditis is
each participant spent 24 hours living relatively normally, followed by 24 thought to result from the inflamed peri-
hours of normal living plus either treadmill walking for 45 minutes in the cardial layers rubbing against each other.
morning or in the evening, or walking for 15 minutes a half-hour after each
of three daily meals. Most of the time, pericarditis occurs
All forms of exercise provided roughly equal glucose improvement. In in an acute form, meaning it comes on
addition, walking for 15 minutes after each meal lowered the post-meal quickly and lasts a few weeks or less.
spike of blood glucose when compared with taking a longer walk. The most common symptom is sharp,
Mayo Clinic experts say the bottom line is that moderate exercise and stabbing chest pain behind the breast-
physical activity are almost universally beneficial for health. This study helps bone or in the left side of your chest
prove that there are many ways to incorporate exercise into your life. A post- that occurs even when you’re at rest.
meal walk is a great time to walk the dog or perform an errand on foot. ❒ However, acute pericarditis can also
cause chest pain that’s dull, achy or
4 www.HealthLetter.MayoClinic.com December  2013 pressure-like.

The pain of acute pericarditis may temic lupus erythematosus (SLE) or in- Most people with acute pericarditis
travel into your left shoulder and neck. flammatory bowel disease. respond well within one week to these
It often intensifies when you lie down or ■ Prior chest radiation for lymphomas treatment measures, but recurrence
inhale deeply. Coughing, taking a deep and lung or breast cancers. weeks, months or even years later isn’t
breath or swallowing food also may ■ Other problems such as kidney fail- uncommon.
make the pain worse. Sitting up and ure, tumors or trauma such as an auto- Evaluation and treatment may get
leaning forward can often ease the pain. mobile accident. Pericarditis can also more involved with recurrence — or if
Other than pain, signs and symptoms occur in the weeks after a heart attack an underlying cause is discovered,
may include difficulty breathing, a dry or heart surgery. complications develop or symptoms
cough, feeling sick with fever and chills, don’t respond to standard treatment.
and an overall sense of feeling weak. Calming inflammation Additional treatment options include:
Autoimmune diseases — such as rheu- If nonviral causes of acute pericar- ■ Oral corticosteroids. These were
matoid arthritis — can trigger pericardi- ditis have been ruled out — and com- more commonly used in the past, but
tis, and when they do it’s usually coupled plications aren’t a problem — treat- they’re now only selectively used in
with a flare of autoimmune symptoms. ment can usually occur at home. Initial situations such as when NSAIDs and
therapy attempts to control pain, re- colchicine fail to work or if an autoim-
duce inflammation and reduce the risk mune or inflammatory disease is the
of recurrence. Therapy may include: underlying cause of pericarditis. Steroid
Sorting it out ■ Nonprescription naproxen sodium use may actually increase the risk of
Acute pericarditis can usually be (Aleve, others), or possibly another recurrent pericarditis.
nonsteroidal anti-inflammatory drug ■ Treatment of an underlying cause,
diagnosed based on symptoms and lis- (NSAID), such as indomethacin (In- such as antibiotics for a bacterial infec-
tening with a stethoscope for a charac- docin). Aspirin also may be an option. tion or therapy for an autoimmune or
teristic sound made by inflamed peri- Your doctor may recommend that you inflammatory disease.
cardial membranes rubbing together. also take a medication to reduce stom- ■ The draining of fluid from the peri-
An electrocardiogram (ECG) to mea- ach acid while you are on NSAIDs, cardium. This addresses a complication
sure your heart’s electrical impulses since they can increase your risk of called cardiac tamponade that occurs
also may aid in diagnosis. gastrointestinal problems. when too much fluid accumulates be-
■ Colchicine (Colcrys), an anti-in- tween pericardial membrane layers. The
Additional testing is often performed flammatory drug often used to treat fluid puts pressure on the heart so that
to rule out a heart attack, which may gout. This may be added to the NSAID it can’t pump properly, leading to drops
cause up to 15 percent of acute pericar- drug, particularly if pericarditis symp- in blood pressure that can be fatal.
ditis cases. A chest X-ray or echocardio- toms are severe or recur. It appears to Draining of the fluid is an imaging-
gram is usually performed to look for reduce risk of recurrence. guided procedure that involves care-
potentially harmful complications of ■ Temporary restriction of strenuous fully inserting a needle or catheter into
pericarditis — such as pericardial effu- activity, as this may increase the risk of the pericardium and draining out the
sion, which is a buildup of fluid within recurrence. excess fluid. ❒
the pericardial membranes.

About 70 to 80 percent of the time,
acute pericarditis is attributed to a viral
infection — or no underlying cause can
be found. Since this low-risk situation
is so common, your doctor may — based
on your symptoms, test results and
medical history — elect to forgo more
extensive testing.

However, if doctors suspect a treat-
able — and possibly more worrisome
— underlying cause, additional blood
testing may be done. Additional evalu-
ation may also be performed if your
symptoms don’t improve after one week
with standard treatment. Less common
underlying causes may include:
■ Infections, including tuberculosis.
■ Autoimmune or inflammatory dis-
eases such as rheumatoid arthritis, sys-

December 2013 www.HealthLetter.MayoClinic.com 5

Lowering a diastolic reading of 79 mm Hg or be- thereby allowing blood to flow easier
blood pressure low. Between ideal blood pressure and and with less pressure.
hypertension is prehypertension, a cat-
Devices that help egory that isn’t quite hypertension, but One device that takes advantage of
increases cardiovascular risk. this effect is the Zona Plus, which re-
Your blood pressure is elevated enough tails for around $400. This hand-held
to require treatment. Your doctor is sug- Deep-breathing devices device calibrates the strength of your
gesting a medication to lower it. You’ve Stress typically causes rapid, shal- grip, then guides you to a proper grip
already made some improvement with tension for two, two-minute bouts of
lifestyle measures, but that hasn’t done low breathing from the chest, which in continuous gripping on alternating
enough. Yet, you’d rather avoid taking turn reinforces the overall feeling of hands. These sessions are performed
a drug. Are there other options? stress. Deep, slow breathing from your five times a week.
diaphragm is more relaxing and acts
Maybe. New options for modest re- on centers in your brain that lower Research on handgrip devices is
ductions in blood pressure are portable, blood pressure. somewhat limited, but the evidence so
at-home medical devices. Whether these far indicates that regularly using them
devices are worth the investment in time A device approved by the Food and can result in around a 10 percent de-
and money is a personal question. Some Drug Administration called Resperate cline in systolic and diastolic blood
people may find them helpful, while is designed to train deep breathing. Re- pressure. If you have a systolic reading
others may be able to achieve similar sperate retails for around $300. of 140 mm Hg, that’s a decline of about
results without purchasing a device. 14 mm Hg. It’s recommended that
The device includes a strap that goes people with blood pressure at or above
Pumped up around your abdomen to sense your 180/110 mm Hg avoid isometric exer-
Blood pressure is the internal force breathing pattern, and an electronic cise until their blood pressure is better
interface with headphones. Resperate controlled. More information about the
that blood exerts against the walls of analyzes your breathing pattern and device is available at www.zona.com
your blood vessels. Although a certain creates tones to guide your breathing or by calling the company at 866-669-
amount of force is needed to pump pace. On average, you’ll need to use 9662 (toll-free).
blood, too much force over time makes Resperate for about 15 minutes, three ■ Doing it on your own — In lieu of a
the heart work harder to pump blood to four days a week to sustain a signifi- Zona Plus, a simple, spring-loaded grip
and gradually causes damage to blood cant lowering of your blood pressure. device from a sporting goods store may
vessels and many internal organs such suffice. Choose a grip device that feels
as the heart, brain and kidneys. Studies generally show that regular like it takes about 30 percent of your
use of Resperate may provide an aver- grip strength to operate. Grip the device
Hypertension is defined as being age systolic blood pressure reduction for two minutes in one hand. After that,
140 millimeters of mercury (mm Hg) of about 4 mm Hg. Still, not every study give yourself a minute or two to rest,
or higher for your top (systolic) number on Resperate has shown benefit. To then grip the device for two minutes in
in a blood pressure reading, and 90 mm learn more about the product, go to the other hand. Repeat that sequence
Hg for your bottom (diastolic) number. www.resperate.com or call 800-220- one more time. Perform this at least
1925 (toll-free). three times a week for eight to 12 weeks
Ideal blood pressure is a systolic ■ Doing it on your own — There’s no to test if this mode of exercise is effective
reading of 119 mm Hg and below and evidence that using the Resperate de- at lowering your blood pressure.
vice is better than regularly practicing
relaxed deep-breathing exercises on Take-home message
your own without the aid of a device. The best role for these devices is
See “Health tips: Taking a breather” on
page 3 to try a deep breathing exercise. always as an addition to making impor-
tant lifestyle changes if you have mild-
Zona Plus, left, and a simple, spring-load- Handgrip devices er elevations of blood pressure. Main-
ed grip device are strengthening tools Gripping an object and holding the taining a healthy weight, reducing
that may help lower blood pressure. sodium intake, getting regular exercise,
grip is a form of nonmoving (isometric) not smoking, reducing stress and con-
exercise that may affect a number of suming alcohol in moderation, if at all,
body functions related to blood pres- can each lead to a similar or greater
sure. This type of exercise appears to decrease in blood pressure than can be
help calm the fight-or-flight responses achieved by using a device. ❒
of the nervous system and may help
improve function of blood vessels,

6 www.HealthLetter.MayoClinic.com December  2013

Acetaminophen ever, staying within the daily dose contain acetaminophen. In addition to
p­ arameters is critical to avoiding possi- pain relievers and fever reducers, acet-
Generally a better choice ble liver damage. Those parameters may aminophen is found in many nonpre-
be even lower if you have liver disease. scription combination products that
Acetaminophen is one of the most com- have more than one active ingredient
monly used pain relievers. When used Players in a liver cascade to treat different symptoms. Examples
properly on its own, acetaminophen Your liver acts like a large filter, and include cough and cold medicines, flu
(Tylenol, others) is often the safest pain remedies, some allergy medicines, and
reliever choice. The maximum dose for one of its major functions is to neutralize sleep aids.
adults in a 24-hour period is generally toxic substances. Normally, the liver
4,000 milligrams (mg), but some manu- clears your blood of drugs, alcohol and Among combination prescription
facturers are voluntarily setting the potentially harmful substances before drugs, acetaminophen is often paired
maximum dose levels even lower. they can do damage. These trapped sub- with opioids, such as codeine (Tylenol
stances are then broken down and ren- with Codeine, others), oxycodone (Per-
Acetaminophen is found in a lot of dered inactive by liver cells. cocet, Roxicet, others) and hydroco-
combination medications, both non- done (Vicodin, Norco, others).
prescription and prescription. So it’s When taken properly,
possible to unwittingly use more than acetaminophen is the safest Final word
one acetaminophen product, which Concerns about acetaminophen
increases your risk of getting too much pain reliever choice.
of the pain reliever. come down to knowing how to use it
If too much acetaminophen is tak- safely. Basically, when taken as direct-
Fortunately, you can take simple en, the usual breakdown process ed, it’s the safest nonprescription pain
steps to reduce that risk. Those steps changes and a small amount of a toxic reliever choice available.
along with recent lowering of acet- compound is produced. This compound
aminophen amounts in some nonpre- can be extremely harmful to liver cells Proper use of acetaminophen isn’t
scription products and in prescription if it’s not detoxified by a liver compound associated with stomach bleeding and
combination drugs are important fac- called glutathione. heart attack associated with other non-
tors in the safe use of this pain reliever. prescription pain relievers. ❒
Typically, a healthy liver has an
What sets acetaminophen apart a­ dequate store of glutathione to do the Keep it safe
Many nonprescription products are job — if acetaminophen amounts don’t
exceed 4,000 mg in a 24-hour period The Food and Drug Administra-
nonsteroidal anti-inflammatory drugs on a regular basis. If there’s consistently tion has asked prescription drug
(NSAIDs). These include ibuprofen (Ad- more acetaminophen than that, the manufacturers to standardize and
vil, Motrin IB, others) and naproxen liver’s stores of glutathione can become lower acetaminophen levels in
sodium (Aleve). While NSAIDs provide depleted, allowing the toxic compound combination drugs to no more
pain relief and help reduce inflamma- to accumulate and destroy liver cells. than 325 milligrams of acetamin-
tion, their use is associated with some ophen in a tablet or capsule.
risks, especially at higher doses or when Serious liver damage — even liver
taken for longer periods of time. Risks failure — can result from excessive To further reduce your risk of
include the possibility for stomach ­intake of acetaminophen. The dangers taking too much acetaminophen:
u­ lcers and bleeding or kidney problems. of liver damage can be even higher if ■ Read the label — Prescription
you have liver disease or drink three or labels may list abbreviations for
In addition, heart attack and stroke more alcoholic drinks a day while tak- acetaminophen such as APAP. If
risk may increase with NSAID use, ing acetaminophen. in doubt, ask a pharmacist.
e­ specially if you’ve had a heart attack ■ Keep track — Don’t take more
or have established cardiovascular The problem with combos than one product that contains
­disease. Cardiovascular risk is lower Let’s say you take acetaminophen acetaminophen at any given time.
with aspirin products because aspirin If it’s necessary to take two or
reduces risk of blood clotting. Even so, for a late-day headache, thinking you’re more products containing acet-
the risk of stomach bleeding can still well below the 4,000 mg threshold. If aminophen, use a log to keep
be a concern when taking aspirin. you’re also taking a cough and cold track of how much and how often
medicine that same day and a prescrip- you take the medications.
Unlike these other pain relievers, tion painkiller for back pain, you may
acetaminophen doesn’t raise the risk of not realize you’ve crossed the threshold.
stomach bleeding or heart attack. How-
More than 600 medications — both
nonprescription and prescription —

December 2013 www.HealthLetter.MayoClinic.com 7

Second opinion

Q My doctor is concerned about Tennis elbow is an irritation of tendons where they attach to the outer part of the elbow.
my resting heart rate, which is
89. For now, he wants me to try to get players because swinging a tennis ■ Wearing gloves or extra padding on
in more activity and lose a little extra ­racket improperly or excessively can a handle to reduce grip tension and
weight to try to lower it. Why should involve many of the factors that put you reduce the impact of using the tool.
heart rate be a concern? at risk of the injury, including: ■ Trying to lift items without gripping.
■ Making a repeated motion with the For example, when doing strengthening
A There’s some new data from a wrist, either lifting it up or twisting it exercises, use body bands that you can
large, well-done study in the out when the palm is down wrap around your hand rather than grip.
Netherlands that suggests a high resting ■ Prolonged or tense gripping, such ■ Using rollers on bags and suitcases.
heart rate may signal trouble ahead in as carrying a suitcase or even gripping ■ Using the best tool for the task and
the form of heart failure. a toothbrush using the tool appropriately so that the
■ Full extension of the arm, coupled tool does more of the work and your
The study, which involved more with force wrists and forearms do less. ❒
than 1,800 otherwise healthy older ■ Holding the wrist firm while exert-
men, found that those with a heart rate ing certain forces on the arm such as Have a question or comment?
of 79 beats a minute or higher had playing tennis or lifting weights We appreciate every letter sent to Second
about a 50 percent increased risk of Whether you’re playing tennis, Opinion but cannot publish an answer to each
developing heart failure compared with d­ oing yardwork, or doing something question or respond to requests for consultation
men who had lower resting heart rates. that involves a lot of hand, wrist and on individual medical conditions. Editorial
The same didn’t hold true for the near- arm movements — such as food prep- comments can be directed to:
ly 3,000 women who were also part of aration or carpentry — you can mini-
the study. The apparent link between mize your risk of tennis elbow by Managing Editor, Mayo Clinic Health Letter,
resting heart rate and increased risk of avoiding the risk factors listed above. 200 First St. SW, Rochester, MN 55905, or
heart failure occurred only in men. To avoid problems, consider: send email to [email protected]
■ Switching tasks periodically — or
Generally speaking, a lower heart taking frequent breaks — so that you For information about Mayo Clinic services,
rate is better overall, since a well- don’t end up overworking a specific you may telephone any of our three facilities:
trained heart muscle is more efficient, group of muscles and tendons. Rochester, Minn., 507-284-2511;
pumps more blood per contraction and ■ Trying to avoid gripping a tool hard- Jacksonville, Fla., 904-953-2000;
therefore doesn’t have to pump as er than is necessary and being gentle Scottsdale, Ariz., 480-301-8000 or visit
o­ ften. Lifestyle changes, such as losing with twisting or up-and-down motions www.MayoClinic.org
excess weight and getting more physi- of the wrist.
cal activity, are reasonable approaches Check out Mayo Clinic’s consumer health
to help lower your heart rate. ❒ website, at www.MayoClinic.com

Q I developed tennis elbow from
doing yardwork. It’s better now,
but I’m wondering how to avoid this
in the future.

A Tennis elbow (lateral elbow ten-
dinopathy) is an irritation of ten-
dons as they attach to the outer part of
the elbow. It’s common among tennis

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8 www.HealthLetter.MayoClinic.com December  2013