Trust the VA, of all agencies, to come up with the proposition that eating Tylenol is perfectly okay if you have a liver disease. The recipe for success lies no further away than the closest VAMC next door to a University with a medical school. Voila! Richmond VAMC’s finest hepatologist steps into the breech and answers the burning question. But first, the parade of doctors who weighed in on this:
In a November 2006 letter, Dr. Khudatyan, a private physician, noted that Tylenol codeine and ibuprofen are known to be hepatotoxic medically and that the Veteran has a history of using these medications on a concurrent basis for several years. The physician opined that these medications caused a deterioration of the Veteran’s liver function.
In August 2008, Dr. Dickstein provided a qualified medical evaluation (QME) supplemental report for the Veteran’s workers compensation claim, which mostly relates to the likely source of his hepatitis C infection. Of note, however, Dr. Dickstein indicated that liver dysfunction can cause gallstones.
In January 2011, the Veteran submitted a private medical opinion from Dr. Bash, a neuro-radiologist. Dr. Bash cited reports of liver injury and death being associated with acetaminophen medications. He opined that logical medical principles state that if the normal liver is damaged by acetaminophen, then it is very likely that even therapeutic Tylenol treatments to an infected liver will also cause irreversible accelerated liver damage.
In May 2012, Dr. Heuman, Chief of Hepatology at the Richmond VAMC, provided a VHA opinion. Dr. Heuman provided the following opinions:
1) To a reasonable degree of medical certainty, the Veteran’s chronic liver disease was caused by chronic hepatitis C viral infection. Additional contributors to liver injury may have included hepatic steatosis related to alcohol use and/or nonalcoholic fatty liver disease; from the available records the review is unable to support or exclude these possibilities.
2) His liver disease between 1997 and 2004 was not disabling but may have progressed gradually; slowly progressive liver fibrosis is typical of hepatitis C. He was offered antiviral treatment to eradicate hepatitis C and arrest the progression of his liver disease, but apparently declined on multiple occasions.
3) There is no credible evidence in the medical literature to indicate that chronic use of acetaminophen, ibuprofen, indomethacin or codeine is associated with chronic liver injury leading to cirrhosis or its complications. The assertion by Dr. Khudatyan and Dr. Bash that this occurred in the present case is pure speculation and without scientific support.
4) Acetaminophen can cause acute or subacute liver injury when taken in excessive doses (greater than 2.5 g daily), but has not been credibly associated with chronic liver injury leading to cirrhosis. The liver toxicity of acetaminophen is characterized by acute elevations of the transaminases (AST and ALT) that return to normal with days to weeks of stopping the acetaminophen. The transaminase elevations in this case were low grade and chronic, typical of liver injury caused by chronic hepatitis C. The doses given to this patient were within the safe range, even for patients with liver disease.”
5) Cholelithiasis may be associated with chronic liver disease, particularly cirrhosis.
6) In my judgment the treatment prescribed by the VA for control of pain in this man with chronic hepatitis C infection was within the standard of care for a reasonable health care provider.
7) To a reasonable degree of medical certainty, the treatment prescribed by the VA did not contribute to the patient’s chronic progressive liver injury.
It appears those little flyers with impossibly small print that come with Tylenol are full of hooey. Any evidence of hepatotoxicity is absent. No flies on VA. So ignore that stuff and when you feel pain, munch a bunch of Tylenol with the assurance of Dr. Heuman that it will absolutely not have deleterious effects on your liver health.
How, exactly, can these fellows look you in the face and repeat these lies. Ah, how right you are. They don’t . Dr. Heuman was several thousand miles away from our Johnny Reno in Nevada. Considering the prior BVA decision I discussed before this one, I find it odd that two BVA judges can have such differing opinions on the veracity of the evidence presented without doing a little due diligence on their own.
Dr. Bash, who advertises his nexus letters as bulletproof, may have to revise his signage. I would be appalled to think $6000.00 wouldn’t buy anything better than that nexus. Granted, VA is in full battle rattle when they take on 1151s and CUE but anyone with shit for brains knows of the evils of HCV and acetaminophen. Here they simply ignored medical science and buy the VA doc’s blather because somebody slipped in the word hepatologist after his name. He could have been a proctology expert last week as we all know and may be a noted neurosurgeon next week. It’s all in how you massage it. It’s too late to fight this one again at the BVA. With any luck, a CAVC single judge will eviscerate it and spill the stupidity out for all to see. A remand is what may save the bacon. This would certainly be the ticket for Dr. Bash to fill in the gaps.
A good teaching moment is in order here as well. Notice how the BVA VLJ bushwhacks the other doctors. All are unknowledgable in the art of hepatology even though they are taught these bedrock medical principles in school. To say a General practitioner lacks that Je ne sais quoi to opine on matter liver is asinine. Similarly, to denigrate Dr. Bash simply because his specialty is radiology is pointless. It might be appropriate to 86 him because he just googled a bunch of articles without citing documented studies of liver damage via Tylenol toxicity.
Initially, the Board points out that the Dr. Heuman specializes in hepatology, the specific area of medicine at issue. Although he noted that he is not an expert in hepatotoxicity, he has the esoteric knowledge and expertise of the liver required to make the necessary determinations in this case. Likewise, the October 2010 VA examiner specializes in internal medicine and therefore has some additional knowledge and training in this area beyond that of a general practitioner. Cf. Black v. Brown, 10 Vet. App. 279 (1997). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). On the other hand, Dr. Bash specializes in radiology and Dr. Khudatyan is a family care physician. While they presumably have some general medical knowledge of the issues at hand, they do not share the same level of expertise as the October 2010 VA examiner and Dr. Heuman.
This whole decision stinks and has about as much impartiality involved in it as Bernie Madoff mildly suggesting stock picks to you in 2008. Dr. Khudatyan wasn’t the model for a clear and concise nexus but his hypothesis was sound. Pray tell, why do a hepatologist with no expertise in Hepatotoxicity and a lowly VA examiner, unidentified as to medical degree, beat two doctors who were asked to opine on this subject specifically. In short, why is one favored over another when all admittedly are not true specialists in this art? VA’s logic is not only suspect, it is defective.
Before you go out and splatter $6 K for a hepatologic nexus, make sure you do a lot of the footwork yourself. The internet is rife with all the needed info. Assemble it and give it to the doctor. Let him construct it. Use documented testing that has been published. The Vet was on the right track here but let the VA’s IMO get away relatively unchallenged because he was not prepared for the lengths VA will go to defend their turf.
Wowser. The Hunter-Holmes-McGuire VAMC. She must have been a hell of a woman Vet and incredibly fond of hyphenating her name. That or she had one of those kinky menage à trois relationships afoot.