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Zdunek M, Mitra A, Mokrzycki MH. Plasma exchange for the removal of digoxin-specific antibody fragments in renal failure: timing is important for maximizing clearance. Am J Kidney Dis 2000; 36:177-83. [PMID: 10873888 DOI: 10.1053/ajkd.2000.8291] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Life-threatening digoxin toxicity may be effectively treated with digoxin-specific antibody fragments (Fab). However, in end-stage renal disease, the digoxin-Fab complexes persist in the circulation and dissociate, potentially resulting in rebounding free digoxin levels and the recurrence of symptomatic toxicity. To prevent this rebound phenomenon, plasma exchange (PE) has been implemented for the removal of the digoxin-Fab complexes in renal failure. However, there is only one case report describing its use in this setting. To better determine the optimal timing of PE after Fab administration, we performed two PE treatments (each preceded by Fab) in a patient with acute renal failure and acute digoxin poisoning. The admission serum digoxin level was 21 ng/mL. The timing of the PE treatments relative to Fab dosing was as follows: the first PE was performed 26 hours post-Fab, and the second PE was performed 2.5 hours post-Fab. The plasma ultrafiltrate digoxin concentration was 2.5-fold greater when PE was performed 2.5 hours versus 26 hours after Fab administration (19.9 versus 8.1 ng/mL). The combined total amount of digoxin removed in the ultrafiltrate plasma was minimal (0.13 mg), less than 1% of the total amount of ingested drug. We conclude that the optimal timing of PE is within the first 3 hours after Fab administration. Although PE is efficacious for removing digoxin-Fab complexes, thus preventing rebound digoxin toxicity, it is not efficacious for improving total digoxin clearance because of the large apparent volume of distribution of digoxin (5 to 8 L/kg).
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Affiliation(s)
- M Zdunek
- Department of Medicine, Division of Nephrology, Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1999; 37:731-51. [PMID: 10584586 DOI: 10.1081/clt-100102451] [Citation(s) in RCA: 249] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the Boards of the two societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. Although many studies in animals and volunteers have demonstrated that multiple-dose activated charcoal increases drug elimination significantly, this therapy has not yet been shown in a controlled study in poisoned patients to reduce morbidity and mortality. Further studies are required to establish its role and the optimal dosage regimen of charcoal to be administered. Based on experimental and clinical studies, multiple-dose activated charcoal should be considered only if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. With all of these drugs there are data to confirm enhanced elimination, though no controlled studies have demonstrated clinical benefit. Although volunteer studies have demonstrated that multiple-dose activated charcoal increases the elimination of amitriptyline, dextropropoxyphene, digitoxin, digoxin, disopyramide, nadolol, phenylbutazone, phenytoin, piroxicam, and sotalol, there are insufficient clinical data to support or exclude the use of this therapy. The use of multiple-dose charcoal in salicylate poisoning is controversial. One animal study and 2 of 4 volunteer studies did not demonstrate increased salicylate clearance with multiple-dose charcoal therapy. Data in poisoned patients are insufficient presently to recommend the use of multiple-dose charcoal therapy for salicylate poisoning. Multiple-dose activated charcoal did not increase the elimination of astemizole, chlorpropamide, doxepin, imipramine, meprobamate, methotrexate, phenytoin, sodium valproate, tobramycin, and vancomycin in experimental and/or clinical studies. Unless a patient has an intact or protected airway, the administration of multiple-dose activated charcoal is contraindicated. It should not be used in the presence of an intestinal obstruction. The need for concurrent administration of cathartics remains unproven and is not recommended. In particular, cathartics should not be administered to young children because of the propensity of laxatives to cause fluid and electrolyte imbalance. In conclusion, based on experimental and clinical studies, multiple-dose activated charcoal should be considered only if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline.
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Abstract
Digoxin continues to be an important cause of drug toxicity. On the basis of a healthy volunteer study, activated charcoal has been proposed as a treatment for digoxin chronic intoxication. In order to evaluate the effect of activated charcoal on digoxin elimination in intoxicated patients during routine practice, we reviewed all Serum Digoxin Level Requests for adult in-patients from 1991 to 1993, with digoxin levels > 2.5 ng/ml. Of a total of 39 cases, 23 had been treated with activated charcoal while 16 had not. Digoxin elimination half-life during activated charcoal therapy was 36 h (S.D. 14 h; 95% C.I. 30-42 h) while in the non-treated group it was 68 h (S.D. 19 h, 95% C.I. 57-78). Calculated total body clearance of digoxin was 55 ml/min (S.D. 17 ml/min; 95% C.I. 45-64 ml/min) for the non-treated group versus 98 ml/min (S.D. 34 ml/min; 95% C.I. 83-113 ml/min) for the group receiving charcoal, representing an 78% increase in digoxin elimination.
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Affiliation(s)
- C Ibañez
- Clinical Pharmacology Service, Hospital La Paz, Universidad Autónoma de Madrid, Spain
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Rawashdeh NM, al-Hadidi HF, Irshaid YM, Battah AK. Gastrointestinal dialysis of digoxin using cholestyramine. PHARMACOLOGY & TOXICOLOGY 1993; 72:245-8. [PMID: 8372041 DOI: 10.1111/j.1600-0773.1993.tb01644.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The pharmacokinetic parameters of digoxin given intravenously (0.075 mg/kg) alone and following treatment with oral cholestyramine (8 gm in 50 ml water) were studied in rabbits. Pretreatment with cholestyramine produced a significant decrease in the serum concentration of digoxin and significantly enhances its systemic clearance as indicated by a statistically significant decrease in the area under the concentration-time curve (AUC), half time of elimination (t 1/2), and mean residence time (MRT). These findings indicate that the idea of gastrointestinal dialysis, known with activated charcoal, could be extended to ion-exchange resins that could be a potentially useful adjunctive measure in the management of drug overdose especially with commonly used drugs with a low therapeutic index like digoxin.
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Affiliation(s)
- N M Rawashdeh
- Department of Pharmacology, Faculty of Medicine, University of Science & Technology, Irbid, Jordan
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al-Meshal MA, el-Sayed YM, al-Angary AA, al-Dardiri MM. Effect of oral activated charcoal on propranolol pharmacokinetics following intravenous administration to rabbits. J Clin Pharm Ther 1993; 18:39-44. [PMID: 8473358 DOI: 10.1111/j.1365-2710.1993.tb00564.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The pharmacokinetics of propranolol following intravenous administration (1 mg/kg), with and without treatment with oral activated charcoal, was investigated in rabbits. In charcoal-treated rabbits a significant reduction in propranolol serum concentrations was observed compared to control animals. Charcoal treatment significantly reduced the half-life of elimination (16.6%) and the mean residence time (19%) of propranolol. A 17% increase in the systemic clearance and a 14% decrease in AUC were also noted. Charcoal administration did not significantly alter the volume of distribution (Vc' V(area) and Vss) or the apparent distribution half-life. A two-compartment model adequately described propranolol in control and treated rabbits. The results indicate that administration of oral activated charcoal enhances the systemic elimination of propranolol. This is presumably mediated by interruption of the enterohepatic circulation of propranolol by activated charcoal.
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Affiliation(s)
- M A al-Meshal
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Affiliation(s)
- J A Vale
- National Poisons Information Service, Birmingham Centre, Dudley Road Hospital, UK
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Abstract
Significant digitalis toxicity, although uncommon, is a medical emergency. Recognition of the problem and good supportive care (eg, administration of activated charcoal and binding resins, correction of potassium levels, restoration of heart rhythm) are the cornerstones of treatment. If indicated, immunotherapy with digoxin immune Fab (Digibind) is a valuable and effective tool.
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Affiliation(s)
- T J Krisanda
- Department of Emergency Medicine, York Hospital, PA 17405
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Bayer MJ. Recognition and management of digitalis intoxication: implications for emergency medicine. Am J Emerg Med 1991; 9:29-32; discussion 33-4. [PMID: 1997019 DOI: 10.1016/0735-6757(91)90165-g] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Digitalis intoxication is among the most common serious adverse drug reactions in clinical medicine. While the recent development of a radioimmunoassay to accurately measure serum concentrations of digoxin has been of assistance, digitalis intoxication remains a difficult diagnosis to make with certainty. The difficulty in diagnosing digitalis intoxication arises from the nonspecificity of its associated signs and symptoms. The most common symptoms include fatigue, weakness, nausea, and anorexia. These symptoms can occur with many illnesses other than digitalis intoxication. Similarly, the electrocardiographic disturbances caused by cardiac glycosides may be nondiagnostic. The arrhythmias commonly associated with digitalis toxicity are often nonspecific and can be a reflection of the patient's underlying heart disease. The measurement of serum digoxin levels is useful, but studies have demonstrated overlap of the levels between groups with and without toxicity. Due to the modulation of the cardiac effects of digitalis glycosides by such clinical variables as underlying myocardial or renal disease, electrolyte and acid-base imbalances, and other factors, the correlation of toxicity with particular serum digoxin concentrations may vary. Because of the inherent difficulties in confirming the diagnosis of digitalis intoxication in some cases, digoxin-specific Fab antibodies may play a role as a diagnostic tool. Certainly, digoxin-specific Fab antibodies play a significant part in the treatment of digitalis intoxication. Fab antibodies have been successfully used to reverse the effects of digoxin, digitoxin, and oleander poisoning. These antibodies are useful in the treatment of acute and chronic digitalis intoxication in all age groups, including geriatric and pediatric populations.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M J Bayer
- Department of Medicine, UCLA School of Medicine
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McLuckie A, Forbes AM, Ilett KF. Role of repeated doses of oral activated charcoal in the treatment of acute intoxications. Anaesth Intensive Care 1990; 18:375-84. [PMID: 2221332 DOI: 10.1177/0310057x9001800315] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
While single dose activated charcoal is effective in preventing drug absorption, repeated doses not only prevent absorption but also can increase systemic drug clearance. The mechanism for the latter effect may involve interruption of enterohepatic recycling and/or promotion of drug exsorption from the systemic circulation into the gut lumen. A comprehensive review of reported studies in volunteer subjects and overdose patients showed that repeated dose activated charcoal markedly decreased the half-life and/or increased the clearance of a wide range of drugs. Side-effects of the treatment were infrequent, but included aspiration pneumonia, diarrhoea and constipation. The addition of laxatives to repeated dose charcoal treatment did not offer any significant increase in drug clearance and is not recommended. It is suggested that the optimal regimen for the use of repeat dose activated charcoal in acute drug intoxications is an initial dose of 75-100 g, followed by 50 g every 4 hours until the risks of systemic drug toxicity are reduced to an acceptable level.
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Affiliation(s)
- A McLuckie
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, Western Australia
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el-Sayed YM, Hasan MM. Enhancement of morphine clearance following intravenous administration by oral activated charcoal in rabbits. J Pharm Pharmacol 1990; 42:538-41. [PMID: 1981579 DOI: 10.1111/j.2042-7158.1990.tb07054.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A single dose of activated charcoal (10 g) significantly reduced the half-life of elimination (1.02 +/- 0.10 and 0.70 +/- 0.04 h for the control and treated groups, respectively) and mean residence time (1.01 +/- 0.12 and 0.76 +/- 0.05 h for the control and treated groups, respectively) of morphine in rabbits. A 40% increase in the systemic clearance (85.73 +/- 7.72 and 122.64 +/- 16.32 mL min-1 kg-1 for the control and treated groups, respectively) and a 30% decrease in AUC (204.38 +/- 22.20 and 140.03 +/- 19.32 micrograms h L-1 in the control and treated groups, respectively) were also noted. Charcoal administration did not significantly alter the volume of distribution (Varea and Vss) or the apparent distribution half-life. A two-compartment model adequately described morphine kinetics in control and treated rabbits; charcoal administration produced a significant increase in the tissue compartment rate constant (K21). This finding indicates that activated charcoal not only enhances the systemic elimination of morphine, but also accelerates the rate of transfer of morphine from the tissue compartment to the central compartment.
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Affiliation(s)
- Y M el-Sayed
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid
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Hasan MM, Hassan MA, Rawashdeh NM. Effect of oral activated charcoal on the pharmacokinetics of quinidine and quinine administered intravenously to rabbits. PHARMACOLOGY & TOXICOLOGY 1990; 67:73-6. [PMID: 2395819 DOI: 10.1111/j.1600-0773.1990.tb00785.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The pharmacokinetics of quinidine and quinine following intravenous administration (10 mg/kg) with and without concurrent treatment with oral activated charcoal was studied in the rabbit. Marked differences were observed in the pharmacokinetic parameters. Compared to quinidine, quinine was characterized by larger volume of distribution (Vd), systemic clearance (Cl) and elimination rate constant (Kel), and smaller half-life of elimination (t1/2), mean residence time (MRT) and area under the curve (AUC). Activated charcoal administered orally (15 g) significantly decreased the serum concentrations of quinidine but not quinine. Furthermore, charcoal treatment significantly enhanced the systemic elimination of quinidine as indicated by the significant increase in Cl and decrease in t1/2, MRT and AUC. By contrast, activated charcoal had no significant effect on the pharmacokinetic parameters of quinine. Differences between quinidine and quinine in respect to the effect of activated charcoal on the systemic elimination of these drugs seem at least, in part, dependent on dispositional factors. The high Cl and Vd of quinine in the rabbit are probably factors that mask the effect of charcoal on the elimination of this drug.
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Affiliation(s)
- M M Hasan
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid
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Hasan MM, el-Sayed YM, Abdelaziz AA. The effect of oral activated charcoal on the systemic clearance of gentamicin in rabbits with acute renal failure. J Pharm Pharmacol 1990; 42:85-8. [PMID: 1972407 DOI: 10.1111/j.2042-7158.1990.tb05359.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The effect of oral administration of activated charcoal on total body clearance of gentamicin administered intravenously (2 mg kg-1) has been studied in normal rabbits and rabbits with induced renal failure. Gastric intubation of a single dose (10 g) of activated charcoal to normal rabbits produced a significant reduction in gentamicin serum concentrations compared to control. Significant differences between treated and control groups, compatible with enhancement of gentamicin elimination, were observed in the calculated pharmacokinetic parameters (Kel, t 1/2, CL and AUC). To examine whether renal failure could augment the effect of activated charcoal in enhancing the systemic clearance of gentamicin, uranyl nitrate was used (0.75 mg kg-1, i.v.) to induce acute renal failure in rabbits. The derived pharmacokinetic parameters of gentamicin during the control phase in these animals were consistent with severe renal failure. The administration of activated charcoal, 2.5 h following gentamicin injection, produced a steeper decline in gentamicin concentration-time profiles and significant changes in Kel, t 1/2 and CL. The Kel and CL values increased to about 200%, while the t 1/2 value decreased to about 50%. The apparent changes in the pharmacokinetic parameters induced by charcoal administration were more marked in rabbits with renal failure than in normal rabbits; however, induction of renal failure did not augment the charcoal-induced clearance of gentamicin quantitatively.
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Affiliation(s)
- M M Hasan
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid
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Huang JD. Stereoselective gastrointestinal clearance of disopyramide in rabbits treated with activated charcoal. J Pharm Sci 1988; 77:959-62. [PMID: 3225758 DOI: 10.1002/jps.2600771113] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The ability of activated charcoal to enhance the drug elimination of two enantiomers, R- and S-disopyramide, was compared in rabbits. Orally administered activated charcoal significantly decreased the area under the serum concentration curve of R-disopyramide, whereas the same treatment had no effect on that of S-disopyramide. The difference could be explained by the difference in the hepatic extraction ratio of two enantiomers in rabbits. S-Disopyramide is a drug of high hepatic extraction ratio in rabbits and R-disopyramide is of intermediate hepatic extraction ratio. Equations were derived to illustrate the influence of the hepatic extraction ratio on the apparent gastrointestinal clearance. A higher hepatic extraction ratio decreases the apparent gastrointestinal clearance of a drug. This phenomenon may explain some unsuccessful experiments of gastrointestinal dialysis. When considering the use of activated charcoal to enhance systemic drug elimination, the hepatic extraction ratio of the drug should be included.
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Affiliation(s)
- J D Huang
- Department of Pharmacology, National Cheng Kung University, Medical College, Tainan, Taiwan, Republic of China
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Neuvonen PJ, Olkkola KT. Oral activated charcoal in the treatment of intoxications. Role of single and repeated doses. MEDICAL TOXICOLOGY AND ADVERSE DRUG EXPERIENCE 1988; 3:33-58. [PMID: 3285126 DOI: 10.1007/bf03259930] [Citation(s) in RCA: 125] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Activated charcoal has an ability to adsorb a wide variety of substances. This property can be applied to prevent the gastrointestinal absorption of various drugs and toxins and to increase their elimination, even after systemic absorption. Single doses of oral activated charcoal effectively prevent the gastrointestinal absorption of most drugs and toxins present in the stomach at the time of charcoal administration. Known exceptions are alcohols, cyanide, and metals such as iron and lithium. In general, activated charcoal is more effective than gastric emptying. However, if the amount of drug or poison ingested is very large or if its affinity to charcoal is poor, the adsorption capacity of activated charcoal can be saturated. In such cases properly performed gastric emptying is likely to be more effective than charcoal alone. Repeated dosing with oral activated charcoal enhances the elimination of many toxicologically significant agents, e.g. aspirin, carbamazepine, dapsone, dextropropoxyphene, cardiac glycosides, meprobamate, phenobarbitone, phenytoin and theophylline. It also accelerates the elimination of many industrial and environmental intoxicants. In acute intoxications 50 to 100g activated charcoal should be administered to adult patients (to children, about 1 g/kg) as soon as possible. The exceptions are patients poisoned with caustic alkalis or acids which will immediately cause local tissue damages. To avoid delays in charcoal administration, activated charcoal should be a part of first-aid kits both at home and at work. The 'blind' administration of charcoal neither prevents later gastric emptying nor does it cause serious adverse effects provided that pulmonary aspiration in obtunded patients is prevented. In severe acute poisonings oral activated charcoal should be administered repeatedly, e.g. 20 to 50g at intervals of 4 to 6 hours, until recovery or until plasma drug concentrations have fallen to non-toxic levels. In addition to increasing the elimination of many drugs and toxins even after their systemic absorption, repeated doses of charcoal also reduce the risk of desorbing from the charcoal-toxin complex as the complex passes through the gastrointestinal tract. Charcoal will not increase the elimination of all substances taken. However, as the drug history in acute intoxications is often unreliable, repeated doses of oral activated charcoal in severe intoxications seem to be justified unless the toxicological laboratory has identified the causative agent as not being prone to adsorption by charcoal. The role of repeated doses of oral activated charcoal in chronic intoxication has not been clearly defined.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- P J Neuvonen
- Department of Clinical Pharmacology, University of Helsinki
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Abstract
The pharmacokinetic response of theophylline following the oral administration of activated charcoal was investigated in rabbits. Rabbits were continuously infused with a theophylline solution at a rate of 2.12 mg/h. At the fourth hour of theophylline infusion, 20 g of activated charcoal was administered by intubation to the rabbit (n = 12). The concentration of theophylline in serum gradually decreased after the charcoal treatment. The magnitude of the change in theophylline concentration induced by charcoal varied among animals. By comparing the steady-state theophylline concentration in the control and treated animals, the total body clearance was found to increase from 94.4 +/- 7.5 to 210 +/- 27 mL/h/kg (mean +/- SE). The rate of change of theophylline concentration in serum following charcoal treatment was fitted with a simulation curve by assuming a stepwise increase in clearance immediately following the charcoal treatment. The results indicated that activated charcoal exerted its maximum effect in increasing theophylline clearance immediately after its administration.
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Affiliation(s)
- J D Huang
- Department of Pharmacology, National Cheng Kung University, Medical College, Tainan, Taiwan, Republic of China
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Huang JD, Tzou MC. The effect of activated charcoal on the volume of distribution of drugs. J Pharm Sci 1986; 75:923-4. [PMID: 3783467 DOI: 10.1002/jps.2600750924] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Tenenbein M. Pediatric toxicology: current controversies and recent advances. CURRENT PROBLEMS IN PEDIATRICS 1986; 16:185-233. [PMID: 3519098 DOI: 10.1016/0045-9380(86)90012-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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