TY - JOUR T1 - Paracetamol: not as safe as we thought? A systematic literature review of observational studies JF - Annals of the Rheumatic Diseases JO - Ann Rheum Dis DO - 10.1136/annrheumdis-2014-206914 SP - annrheumdis-2014-206914 AU - Emmert Roberts AU - Vanessa Delgado Nunes AU - Sara Buckner AU - Susan Latchem AU - Margaret Constanti AU - Paul Miller AU - Michael Doherty AU - Weiya Zhang AU - Fraser Birrell AU - Mark Porcheret AU - Krysia Dziedzic AU - Ian Bernstein AU - Elspeth Wise AU - Philip G Conaghan Y1 - 2015/02/10 UR - http://ard.bmj.com/content/early/2015/02/09/annrheumdis-2014-206914.abstract N2 - Objectives We conducted a systematic literature review to assess the adverse event (AE) profile of paracetamol. Methods We searched Medline and Embase from database inception to 1 May 2013. We screened for observational studies in English, which reported mortality, cardiovascular, gastrointestinal (GI) or renal AEs in the general adult population at standard analgesic doses of paracetamol. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation. Pooled or adjusted summary statistics were presented for each outcome. Results Of 1888 studies retrieved, 8 met inclusion criteria, and all were cohort studies. Comparing paracetamol use versus no use, of two studies reporting mortality one showed a dose–response and reported an increased relative rate of mortality from 0.95 (0.92 to 0.98) to 1.63 (1.58 to 1.68). Of four studies reporting cardiovascular AEs, all showed a dose–response with one reporting an increased risk ratio of all cardiovascular AEs from 1.19 (0.81 to 1.75) to 1.68 (1.10 to 2.57). One study reporting GI AEs reported a dose–response with increased relative rate of GI AEs or bleeds from 1.11 (1.04 to 1.18) to 1.49 (1.34 to 1.66). Of four studies reporting renal AEs, three reported a dose–response with one reporting an increasing OR of ≥30% decrease in estimated glomerular filtration rate from 1.40 (0.79 to 2.48) to 2.19 (1.4 to 3.43). Discussion Given the observational nature of the data, channelling bias may have had an important impact. However, the dose–response seen for most endpoints suggests a considerable degree of paracetamol toxicity especially at the upper end of standard analgesic doses. ER -