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Indumathi MC, Swetha K, Abhilasha KV, Siddappa S, Kumar SM, Prasad GK, Chen CH, Marathe GK. Selenium Ameliorates Acetaminophen-Induced Oxidative Stress via MAPK and Nrf2 Pathways in Mice. Biol Trace Elem Res 2024; 202:2598-2615. [PMID: 37702962 DOI: 10.1007/s12011-023-03845-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
Overdose of acetaminophen (paracetamol), a widely used non-prescriptive analgesic and antipyretic medication, is one of the main causes of drug-induced acute liver failure around the world. Oxidative stress contributes to this hepatotoxicity. Antioxidants are known to protect the liver from oxidative stress. Selenium, a potent antioxidant, is a commonly used micronutrient. Here, we evaluated the protective effect of selenium on acetaminophen-induced hepatotoxicity. Treating Wistar albino mice with sodium selenite (1 mg/kg) before or after inducing hepatotoxicity with acetaminophen (150 mg/kg) significantly reduced the levels of liver injury biomarkers such as serum glutamate oxaloacetate transaminase and serum glutamate pyruvate transaminase. In addition, selenium-treated mice showed decreased levels of oxidative stress markers such as protein carbonyls and myeloperoxidase. Acetaminophen treatment stimulated all three mitogen-activated protein kinases (MAPKs) and Keap1 and decreased the expression of nuclear factor erythroid 2-related factor 2 (Nrf2) and heme oxygenase-1 in liver and in isolated mouse peritoneal macrophages, which was reversed by selenium treatment. Our findings suggest that the reactive oxygen species-mediated Nrf2 and MAPK pathways are critical players in acetaminophen-induced hepatotoxicity. These key findings offer an alternative therapeutic target for addressing acetaminophen-induced hepatotoxicity.
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Affiliation(s)
| | - Kamatam Swetha
- Department of Studies in Biochemistry, 8J8C+98P, University of Mysore, Manasagangotri, Mysore, 570006, Karnataka, India
| | | | - Shiva Siddappa
- Division of Biochemistry, School of Life Sciences, 8MV2+MPG, Sri Shivarathreeshwara Nagara, JSS Academy of Higher Education and Research, Bannimantap A Layout, Bannimantap, Mysuru, Karnataka, 570015, India
| | - Shivamadhaiah Manjula Kumar
- Department of Studies in Biochemistry, 8J8C+98P, University of Mysore, Manasagangotri, Mysore, 570006, Karnataka, India
| | - Govinda Keerthi Prasad
- Department of Studies in Biochemistry, 8J8C+98P, University of Mysore, Manasagangotri, Mysore, 570006, Karnataka, India
| | - Chu-Huang Chen
- Vascular and Medicinal Research, The Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Gopal Kedihithlu Marathe
- Department of Studies in Biochemistry, 8J8C+98P, University of Mysore, Manasagangotri, Mysore, 570006, Karnataka, India.
- Department of Studies in Molecular Biology, 8J8C+JFP, University of Mysore, Manasagangotri, Mysore, 570006, Karnataka, India.
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Chomchai S, Mekavuthikul P, Phuditshinnapatra J, Chomchai C. Sensitivity of dose-estimations for acute acetaminophen overdose in predicting hepatotoxicity risk using the Rumack-Matthew Nomogram. Pharmacol Res Perspect 2022; 10:e00920. [PMID: 35106928 PMCID: PMC8929339 DOI: 10.1002/prp2.920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/08/2022] Open
Abstract
Timely assessment of acetaminophen concentration in overdose situations is not always available in resource-poor settings. The 150 mg/kg dose-estimate for acetaminophen is widely considered as criterion for acetaminophen overdose. Its sensitivity and specificity when compared to the 150 mg/L treatment line on the Rumack-Matthew Nomogram (150-treatment line) has rarely been evaluated. This is a retrospective chart review of acute acetaminophen overdose patients. We evaluated the sensitivity and specificity of the 150, 200 mg/kg and 8- and 10-g dose-estimates by plotting the serum acetaminophen levels and using 150-treatment line on the Nomogram as the treatment cut-off. A comparison of medical care costs was performed. We enrolled 784 cases for analysis. Median (IQR) age was 23 (20-28) years (81.9% female). There were 545 cases (69.5%) where the estimated ingested acetaminophen dose were ≥150 mg/kg and 406 cases (51.8%) with concentrations ≥150-treatment line. Hepatotoxicity and acute liver injury (ALI) occurred in 7.3% and 23.9%, respectively. The sensitivity and specificity of 150 mg/kg dose-estimate for the 150-treatment line were 92.6% (95% CI 89.6, 94.8) and 55.3% (95% CI 50.3, 60.2). Among patients with dose-estimate below150 mg/kg, none developed hepatotoxicity and 17 (7.1%) develop ALI. The administration of activated charcoal significantly decreased the risk of being above the 150-treatment line by half. In resource-poor setings, the use of 150 mg/kg dose-estimate as a stand-alone criteria for initiation of N-acetylcysteine therapy is satisfactory, especially when combined with decontamination with activated charcoal and follow up of aminotransferase at 24 h.
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Affiliation(s)
- Summon Chomchai
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pattaraporn Mekavuthikul
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jariya Phuditshinnapatra
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chulathida Chomchai
- Division of Science, Mahidol University International College, Nakhon Pathom, Thailand.,Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Dayasiri K, Rao S. Fifteen-minute update: International normalised ratio as the treatment end point in children with acute paracetamol poisoning. Arch Dis Child Educ Pract Ed 2021; 108:181-183. [PMID: 34880073 DOI: 10.1136/archdischild-2020-320190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/15/2021] [Indexed: 11/04/2022]
Abstract
Paracetamol is one of the most frequent reasons for poisonings across the UK with an estimated 90,000 patients and 150 deaths annually. International normalised ratio (INR) may be elevated due to hepatocellular damage and is frequently used to monitor progress on N-acetyl cysteine. N-acetyl cysteine is associated with reduced activity of vitamin K dependent clotting factors leading to a benign elevation of INR. In asymptomatic children with normal aspartate transaminase/alanine transaminase, isolated borderline elevation of INR following paracetamol overdose should be reviewed for possible N-acetyl cysteine induced elevation of INR. Due to these factors, in those with borderline persistent elevation of INR, N-acetyl cysteine can be safety stopped if INR is falling on two or more consecutive tests and is <3.0.
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Affiliation(s)
- Kavinda Dayasiri
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Sahana Rao
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK .,Paediatrics, University of Oxford, Oxford, Oxfordshire, UK
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Pourkarim F, Rahimpour E, Khoubnasabjafari M, Jouyban-Gharamaleki V, Gharakhani A, Jouyban A. Validation of a colorimetric method for determination of paracetamol in exhaled breath condensate. CHEMICAL PAPERS 2021. [DOI: 10.1007/s11696-021-01520-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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The Role of Resveratrol in Liver Disease: A Comprehensive Review from In Vitro to Clinical Trials. Nutrients 2021; 13:nu13030933. [PMID: 33805795 PMCID: PMC7999728 DOI: 10.3390/nu13030933] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022] Open
Abstract
Many studies have shown that resveratrol has a lot of therapeutic effects on liver disorders. Its administration can significantly increase the survival rate after liver transplantation, reduce fat deposition and ischemia-induced necrosis and apoptosis in Wistar rats. Resveratrol can provide Liver protection against chemical, cholestatic, and alcohol-mediated damage. It can improve glucose metabolism and lipid profile, reduce liver fibrosis, and steatosis. Additionally, it is capable of altering the fatty acid composition of the liver cells. Resveratrol may be a potential treatment option for the management of non-alcoholic fatty liver disease (NAFLD) due to its anti-inflammatory, antioxidant, and calorie-restricting effects. There are also studies that have evaluated the effect of resveratrol on lipid and liver enzyme profiles among patients with metabolic syndrome (MetS) and related disorders. Based on the extent of liver disease worldwide and the need to find new treatment possibilities, this review critically examines current in vitro and in vivo preclinical studies and human clinical studies related to liver protection.
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Wong A, Cheung B, Nejad C, Gantier M, Graudins A. Hepatotoxicity after paracetamol overdose in a patient with cystic fibrosis despite early acetylcysteine and utility of microRNA to predict hepatotoxicity. Clin Toxicol (Phila) 2018; 56:904-906. [PMID: 29564929 DOI: 10.1080/15563650.2018.1454596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
CASE DETAILS A 19-year-old girl presented to the emergency department following overdose of 10 g of paracetamol on a background history of cystic fibrosis. Paracetamol concentration was below the nomogram line, but was treated with acetylcysteine seven hours post-overdose given her symptomatology. Nineteen hours following her overdose she developed hepatotoxicity, despite early initiation of acetylcysteine. She was discharged well six days post-ingestion. On presentation, delta miRNA-122-miR483 was 20 times that of control patients, however, alanine aminotransferase was normal. DISCUSSION Patients with cystic fibrosis are more likely to have glutathione deficiency, and greater susceptibility to liver injury. Delta miRNA may be a better detector of early liver injury than hepatic aminotransferases. Empiric treatment with acetylcysteine and serial biochemical reassessment in this setting should be considered.
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Affiliation(s)
- Anselm Wong
- a Monash Toxicology Unit and Monash Emergency Medicine Service , Monash Health , Clayton , Australia.,b Department of Medicine , Clinical Sciences at Monash Health, Monash University , Clayton , Australia
| | - Benjamin Cheung
- a Monash Toxicology Unit and Monash Emergency Medicine Service , Monash Health , Clayton , Australia
| | - Charlotte Nejad
- c Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University , Clayton , Victoria , Australia.,d Department of Molecular and Translational Science, Monash University , Clayton , Victoria , Australia
| | - Michael Gantier
- c Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University , Clayton , Victoria , Australia.,d Department of Molecular and Translational Science, Monash University , Clayton , Victoria , Australia
| | - Andis Graudins
- a Monash Toxicology Unit and Monash Emergency Medicine Service , Monash Health , Clayton , Australia.,b Department of Medicine , Clinical Sciences at Monash Health, Monash University , Clayton , Australia
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Sacre L, Ali S, Villa A, Jouffroy R, Raphalen JH, Garnier R, Baud F. Toxicodynetics in nordiazepam and oxazepam overdoses. ANNALES PHARMACEUTIQUES FRANÇAISES 2017; 75:163-171. [DOI: 10.1016/j.pharma.2017.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 01/20/2017] [Indexed: 12/14/2022]
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Gonzalez HC, Jafri SM, Gordon SC. Management of Acute Hepatotoxicity Including Medical Agents and Liver Support Systems. Clin Liver Dis 2017; 21:163-180. [PMID: 27842770 DOI: 10.1016/j.cld.2016.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Drug-induced liver injury (DILI) can be predictable or idiosyncratic and has an estimated incidence of approximately 20 cases per 100,000 persons per year. DILI is a common cause of acute liver failure in the United States. No accurate tests for diagnosing DILI exist, and its diagnosis is based on exclusion of other conditions. Managing DILI includes discontinuing the suspected causative agent and in selected cases administering an antidote. Liver support systems are used for long-term support or as a bridge to transplantation and are effective for improving encephalopathy, hyperbilirubinemia, and other liver-related conditions, but whether they improve survival remains uncertain.
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Affiliation(s)
- Humberto C Gonzalez
- Department of Transplant Surgery/Center of Advanced Liver Disease, Methodist University Hospital, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 340, Memphis, TN 38104, USA
| | - Syed-Mohammed Jafri
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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10
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Abstract
Accidental or intentional overdose with acetaminophen is a relatively common occurrence. Few patients ingesting an overdose of acetaminophen will develop a fulminant clinical course resulting in death. Some are at risk for developing acetaminophen-induced hepatotoxicity unless properly treated with the prophylactic antidote N-acetylcysteine within the first 24 hours after ingestion. Intensive supportive care will allow an excellent prognosis for those patients developing hepatotoxicity or other, more rare, sequelae of acetaminophen poisoning.
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Affiliation(s)
- Alan H. Hall
- Rocky Mountain Poison and Drug Center, Denver General Hospital, Denver, CO 80204-4507
| | - Barry H. Rumack
- Rocky Mountain Poison and Drug Center, Denver General Hospital, Denver, CO 80204-4507
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Toxicodynetics: A new discipline in clinical toxicology. ANNALES PHARMACEUTIQUES FRANÇAISES 2016; 74:173-89. [PMID: 27107462 DOI: 10.1016/j.pharma.2016.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Regarding the different disciplines that encompass the pharmacology and the toxicology, none is specifically dedicated to the description and analysis of the time-course of relevant toxic effects both in experimental and clinical studies. The lack of a discipline devoted to this major field in toxicology results in misconception and even in errors by clinicians. MATERIAL AND METHODS Review of the basic different disciplines that encompass pharmacology toxicology and comparing with the description of the time-course of effects in conditions in which toxicological analysis was not performed or with limited analytical evidence. RESULTS Review of the literature clearly shows how misleading is the current extrapolation of toxicokinetic data to the description of the time-course of toxic effects. CONCLUSION A new discipline entitled toxicodynetics should be developed aiming at a more systematic description of the time-course of effects in acute human and experimental poisonings. Toxicodynetics might help emergency physicians in risk assessment when facing a poisoning and contribute to a better assessment of quality control of data collected by poison control centres. Toxicodynetics would also allow a quantitative approach to the clinical effects resulting from drug-drug interaction.
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Wong A, Graudins A. Simplification of the standard three-bag intravenous acetylcysteine regimen for paracetamol poisoning results in a lower incidence of adverse drug reactions. Clin Toxicol (Phila) 2015; 54:115-9. [DOI: 10.3109/15563650.2015.1115055] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Anselm Wong
- Emergency Physician and Clinical Toxicologist, Monash Health Toxicology Service, Monash Health, Victoria, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Austin Toxicology Service, Austin Hospital, Victoria, Australia
- Victorian Poisons Information Centre, Austin Hospital, Victoria, Australia
| | - Andis Graudins
- Emergency Physician and Clinical Toxicologist, Monash Health Toxicology Service, Monash Health, Victoria, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Victorian Poisons Information Centre, Austin Hospital, Victoria, Australia
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13
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Wong A, Sivilotti MLA, Dargan PI, Wood DM, Greene SL. External validation of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity from paracetamol overdose. Clin Toxicol (Phila) 2015; 53:807-14. [DOI: 10.3109/15563650.2015.1066507] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Mishima-Iwai M, Takahashi K, Yokode M, Kimura Y, Sawai Y, Ueda Y, Chiba T. Late-onset acetaminophen-induced allergic hepatitis with progression to chronicity. Hepatol Res 2015; 45:814-7. [PMID: 25088083 DOI: 10.1111/hepr.12399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/14/2014] [Accepted: 07/28/2014] [Indexed: 12/28/2022]
Abstract
Acetaminophen (paracetamol), a widely used antipyretic/analgesic, is a well-known agent causing acute hepatic injury. Whereas most cases are caused by its intrinsic hepatotoxicity, idiosyncratic hepatitis by the allergic mechanism is extremely rare. We herein report a case of late-onset acetaminophen-induced allergic hepatitis with progression to chronicity. This unique case extends the spectrum of acetaminophen-induced liver injury. Clinicians should be aware of this unusual clinical manifestation. The mechanism underlying the immunological reaction to acetaminophen remains to be elucidated.
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Affiliation(s)
- Masako Mishima-Iwai
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ken Takahashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masataka Yokode
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshito Kimura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yugo Sawai
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshihide Ueda
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsutomu Chiba
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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O'Donnell JT, Marks DH, Danese P, O'Donnell JJ. Drug-induced liver disease: primer for the primary care physician. Dis Mon 2014; 60:55-104. [PMID: 24507900 DOI: 10.1016/j.disamonth.2013.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Benson BE, Farooqi MF, Klein-Schwartz W, Litovitz T, Webb AN, Borys DJ, Lung D, Rutherfoord Rose S, Aleguas A, Sollee DR, Seifert SA. Diphenhydramine dose–response: a novel approach to determine triage thresholds. Clin Toxicol (Phila) 2010; 48:820-31. [DOI: 10.3109/15563650.2010.514269] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Acutely poisoned children remain a common problem facing pediatricians working in acute care medicine in the United States and worldwide. The management of such children continues to be challenging, and their care has evolved throughout the years. The concept of gastric decontamination in acute poisoning has significantly changed over the past 10 years, and many of the previously used techniques have been abandoned or fallen out of favor for lack of evidence to their benefit or unacceptable serious risks and side effects. Supportive care continues to be the cornerstone in managing most poisoned children. Only a few patients benefit from antidotes or specific interventions.
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Affiliation(s)
- Usama A Hanhan
- Division of Pediatrics, Department of Critical Care Medicine, University Community Hospital, 3100 East Flecher Ave., Tampa, FL 33613, USA.
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Daly FFS, Fountain JS, Murray L, Graudins A, Buckley NA. Guidelines for the management of paracetamol poisoning in Australia and New Zealand--explanation and elaboration. A consensus statement from clinical toxicologists consulting to the Australasian poisons information centres. Med J Aust 2008; 188:296-301. [PMID: 18312195 DOI: 10.5694/j.1326-5377.2008.tb01625.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 11/29/2007] [Indexed: 01/13/2023]
Abstract
Paracetamol is involved in a large proportion of accidental paediatric exposures and deliberate self-poisoning cases, although subsequent hepatic failure and death are both uncommon outcomes. The optimal management of most patients with paracetamol overdose is usually straightforward. However, several differing nomograms and varying recommendations regarding potential risk factors for hepatic injury introduce complexity. In order to reconcile management advice with current Australasian clinical toxicology practice, revised guidelines have been developed by a panel of clinical toxicologists consulting to the poisons information centres in Australia and New Zealand using a workshop and consultative process. This article summarises the rationale for the recommendations made in these new guidelines.
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Affiliation(s)
- Frank F S Daly
- Emergency Medicine, Royal Perth Hospital, and University of Western Australia, Perth, WA, Australia.
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Hersh EV, Pinto A, Moore PA. Adverse drug interactions involving common prescription and over-the-counter analgesic agents. Clin Ther 2008; 29 Suppl:2477-97. [PMID: 18164916 DOI: 10.1016/j.clinthera.2007.12.003] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND Eight analgesic preparations with approved indications for acute pain were among the top 200 drugs prescribed in the United States in 2006. In addition, an estimated 36 million Americans use over-the-counter (OTC) analgesics daily. Given this volume of use, it is not surprising that a number of drug interactions involving analgesic drugs have been reported. OBJECTIVES This article examines the pharmacologic factors that enhance the clinical relevance of potential drug interactions and reviews the literature on drug interactions involving the most commonly used analgesic preparations in the United States. METHODS A PubMed search was conducted for English-language articles published between January 1967 and July 2007. Among the search terms were drug interactions, acetaminophen, aspirin, ibuprofen, naproxen, celecoxib, NSAIDs, hydrocodone, oxycodone, codeine, tramadol, OTC analgesics, alcohol, ethanol, antihypertensive drugs, methotrexate, warfarin, SSRIs, paroxetine, fluoxetine, sertraline, citalopram, serotonin syndrome, MAOIs, and overdose. Controlled clinical trials, case-control studies, and case reports were included in the review. RESULTS A number of case reports and well-controlled clinical trials were identified that provided evidence of the relatively well known drug-drug interactions between prescription/OTC NSAIDs and alcohol, antihypertensive drugs, high-dose methotrexate, and lithium, as well as between frequently prescribed narcotics and other central nervous system depressants. In contrast, the ability of recent alcohol ingestion to exacerbate the hepatotoxic potential of therapeutic doses of acetaminophen is not supported by either case reports or clinical research. Use of ibuprofen according to OTC guidelines in patients taking cardioprotective doses of aspirin does not appear to interfere with aspirin's antiplatelet activity, whereas chronic prescription use of ibuprofen and other NSAIDs may interfere. Low-dose aspirin intake appears to abolish the gastroprotective effects of cyclooxygenase-2-selective inhibitors, including celecoxib. There is evidence of other less well known and potentially clinically significant drug-drug interactions, including the ability of selective serotonin reuptake inhibitors to inhibit the analgesic activity of tramadol and codeine through inhibition of their metabolic activation, to induce serotonin syndrome when used chronically in the presence of high doses of tramadol through synergistic serotonergic action, and to increase the potential for gastrointestinal bleeding associated with NSAID therapy through additive or supra-additive antiplatelet activity. CONCLUSIONS Considering the widespread use of analgesic agents, the overall incidence of serious drug-drug interactions involving these agents has been relatively low. The most serious interactions usually involved other interacting drugs with low therapeutic indices or chronic and/or high-dose use of an analgesic and the interacting drug.
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Affiliation(s)
- Elliot V Hersh
- Department of Oral Surgery and Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania 19104-6030, USA.
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Miller MA, Navarro M, Bird SB, Donovan JL. Antiemetic use in acetaminophen poisoning: how does the route of N-acetylcysteine administration affect utilization? J Med Toxicol 2008; 3:152-6. [PMID: 18072168 DOI: 10.1007/bf03160931] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION We sought to compare antiemetic use after acetaminophen poisoning in patients treated with oral or intravenous (IV) N-acetylcysteine (NAC). METHODS Our retrospective chart review identified 20 orally treated patients and 17 IV-treated patients. For both groups, we calculated the total number of antiemetic doses given, their associated cost, and also determined parameters that correlated with antiemetic use. RESULTS IV-treated patients received fewer total antiemetic doses than those receiving oral NAC (1.1 0.2 vs. 2.8 0.7; P 0.04). Antiemetic cost correlated with doses received for both groups; however, because the regression lines differed (P 0.02), antiemetic therapy cost was less in IV-treated patients. In addition, serum acetaminophen concentration correlated with total antiemetic doses in oral NAC patients (P 0.002) but not with IV treatment patients (P 0.78). CONCLUSIONS Intravenous NAC reduced antiemetic utilization, and it costs less than oral therapy. Furthermore, antiemetic use appeared to be determined by a combination of acetaminophen concentration and NAC administration route.
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Jang GR, Harris RZ. Drug interactions involving ethanol and alcoholic beverages. Expert Opin Drug Metab Toxicol 2008; 3:719-31. [PMID: 17916057 DOI: 10.1517/17425255.3.5.719] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ethanol is likely among the most widely and extensively used drugs in the world. It has also been demonstrated to alter the expression or activity of some drug-metabolizing enzymes. Thus, marked ethanol-provoked drug interactions could be of notable clinical importance. To date, relatively few clinically important interactions have been reported, involving cocaine, disulfiram and tacrolimus. Limited or modest interactions with ethanol have also been reported for drugs such as abacavir, cisapride, 'ecstasy' (3,4-methylenedioxymetamfetamine), gamma-hydroxybutyrate, methylyphenidate, metronidazole and verapamil. Most of these interactions do not seem to involve CYP2E1, the enzyme initially characterized and cloned based on its ability to metabolize and be induced by ethanol. Important work has elucidated the relationship between CYP2E1-mediated formation of the hepatotoxic metabolite of acetaminophen and alcohol consumption. Lastly, drug interactions involving other components of alcoholic beverages such as flavonoid and other polyphenolic components of red wine have been reported.
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Affiliation(s)
- Graham R Jang
- Amgen, Inc., Department of Pharmacokinetics and Drug Metabolism, One Amgen Center Dr, Thousand Oaks, CA 91320, USA.
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Crouch BI, Caravati EM, Dandoy C. Effect of dilution with beverages on the smell and taste of oral acetylcysteine. Am J Health Syst Pharm 2007; 64:1965-8. [PMID: 17823110 DOI: 10.2146/ajhp060568] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The effect of dilution with beverages on the smell and taste of oral acetylcysteine was studied. METHODS A 5% solution of acetylcysteine was prepared from a 20% solution using water, Fresca, Coca-Cola, cranberry juice, or chocolate milk. Adult pharmacy students blinded to the diluent used a visual analogue scale (VAS) to rate the smell and taste for each 5% solution. For the taste evaluation, approximately 10 mL of each 5% solution was placed in a cup with a lid and straw. The difference in VAS scores for taste and smell was measured using the Kruskal-Wallis rank sum test. Comparisons were performed using the Mann-Whitney U test and the Bonferroni adjustment, with the level of significance set at <0.005. RESULTS A total of 42 adult students participated in the study. Fresca was rated as the least offensive diluent with respect to smell by 22 students (52%) and taste by 33 students (79%). The chocolate milk-acetylcysteine solution was rated as the most offensive smelling by 22 students (52%) and most the offensive tasting by 11 students (26%). Cranberry juice was rated the most offensive tasting by 12 students (29%). The VAS score for Fresca was significantly lower than for all other beverages with respect to both smell and taste (p < 0.005). CONCLUSION Acetylcysteine 20% oral solution diluted with Fresca to a 5% solution was reported to have the least offensive odor and taste and should be considered as an option when attempting to improve the palatability of oral acetylcysteine to adults.
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Abstract
Acetaminophen is a commonly used antipyretic and analgesic agent. It is safe when taken at therapeutic doses; however, overdose can lead to serious and even fatal hepatotoxicity. The initial metabolic and biochemical events leading to toxicity have been well described, but the precise mechanism of cell injury and death is unknown. Prompt recognition of overdose, aggressive management, and administration of N-acetylcysteine can minimize hepatotoxicity and prevent liver failure and death. Liver transplantation can be lifesaving for those who develop acute liver failure.
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Affiliation(s)
- Anne M Larson
- Division of Gastroenterology, Hepatology Section, University of Washington, 1959 NE Pacific Street, Box 356174, Seattle, WA 98195-6174, USA.
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Opiate Addicted Patients: The Misconceptions of Chronic Acetaminophen Ingestion. ADDICTIVE DISORDERS & THEIR TREATMENT 2006. [DOI: 10.1097/01.adt.0000210705.64951.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Most toxicologic exposures resolve within 24 hours, yet catastrophic outcomes may occur if patients are directly discharged from the emergency department (ED). These cases are, perhaps, the ideal candidates for observation unit (OU) management. This article reviews the criteria for admission and discharge as well as clinical management strategies in the OU for the most common toxicologic exposures. Special attention is given to the multidisciplinary interactions among the ED physician, the medical toxicologist, the physiatrist, and the specialty laboratory.
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Affiliation(s)
- T Lemke
- Department of Emergency Medicine, Brown University School of Medicine, Providence, Rhode Island, USA
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Drug-Induced Hepatotoxicity. J Pharm Pract 1999. [DOI: 10.1177/089719009901200604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Fiedler MA, Biddle C. Review of chemical, medication, and anesthesia toxicity in the OR. AORN J 1998; 67:398, 401-6, 409-11. [PMID: 9505120 DOI: 10.1016/s0001-2092(06)62887-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A host of toxic substances exist in the OR. The toxicity of prep solutions, cleaning chemicals, common medications, and trace anesthetic gases varies greatly. Nurses use, direct others in the use of, or administer potential toxins while breathing air that may be contaminated to some degree with anesthetic vapors. Often, the OR nurse is the neighborhood resource when questions about the toxicity of common chemicals and drugs arise. A general knowledge of the toxicity of these substances improves the nurse's ability to assess the risk from trace anesthetic gases, prevent injury to patients, provide first aid when potentially dangerous exposure occurs, and direct others in the safe use of OR chemicals.
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Affiliation(s)
- M A Fiedler
- School of Health Related Professions, University of Alabama at Birmingham, USA
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Affiliation(s)
- L Sung
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, K1H 8L1
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Stork CM, Rees S, Howland MA, Kaplan L, Goldfrank L, Hoffman RS. Pharmacokinetics of extended relief vs regular release Tylenol in simulated human overdose. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1996; 34:157-62. [PMID: 8618248 DOI: 10.3109/15563659609013764] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of this trial was to compare the pharmacokinetics of the two available acetaminophen dosage forms in simulated human overdose. METHODS Ten healthy volunteers received acetaminophen, 75 mg/kg orally, either as the regular release or extended relief formulation in a random, crossover fashion. Blood samples were analyzed using a TDx assay and a best fit correlation of data points was determined by PCNONLIN. RESULTS The area under the curves for extended relief acetaminophen and regular release acetaminophen were 426 mg h/L and 432 mg h/L, respectively (p = 0.768). The mean half times for extended relief acetaminophen and regular release acetaminophen were 4.02 h and 2.56 h, respectively (p < 0.001). The mean maximum serum acetaminophen concentrations were 62.6 mg/L (414.4 mmol/L:) and 94.3 mg/L (624.3 mmol/L) for extended relief acetaminophen and regular release acetaminophen, respectively (p < 0.001) and the mean time to maximum serum acetaminophen concentrations were 0.87 h and 0.75 h for extended relief acetaminophen and regular release acetaminophen, respectively (p = 0.508). CONCLUSIONS Although the formulations appear to have equal bioavailability, their half-lives and peak concentrations were significantly different. Further study is required to determine whether these differences affect the assessment and management of poisoned patients.
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Affiliation(s)
- C M Stork
- New York City Poison Control Center, Bellevue Hospital Center New York, USA
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Eddleston JM, Sharer NM. Antioxidant Therapy in Critical Illness. YEARBOOK OF INTENSIVE CARE AND EMERGENCY MEDICINE 1996. [DOI: 10.1007/978-3-642-80053-5_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Singer AJ, Carracio TR, Mofenson HC. The temporal profile of increased transaminase levels in patients with acetaminophen-induced liver dysfunction. Ann Emerg Med 1995; 26:49-53. [PMID: 7793720 DOI: 10.1016/s0196-0644(95)70237-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE It is often taught that acetaminophen-induced liver dysfunction occurs only after a latent period of 24 to 48 hours. This study was designed to evaluate the temporal profile of transaminase levels in patients with acetaminophen-induced hepatotoxicity. DESIGN Prospective data collection using standard poison control center data sheets. PARTICIPANTS Hospitalized patients with acetaminophen exposure who were reported to the Long Island Poison Control Center between January 1993 and June 1994. Patients who presented within 24 hours of ingestion and in whom increased aspartate aminotransferase (AST) levels developed during hospitalization were included in the data analysis. Patients who presented more than 24 hours after ingestion, who had ingested another potentially hepatotoxic agent, or who had ingested acetaminophen over a period of more than 2 hours were excluded. RESULTS Of 1,825 patients with reported acetaminophen exposure, 779 had potentially toxic ingestions and were examined in an emergency department. Of 291 patients with toxic acetaminophen levels who were admitted, 36 (12%) had increased levels of AST at some point during hospitalization. All received oral N-acetylcysteine within 2.5 hours of presentation. In 11 of 19 patients who met all inclusion criteria (58%), AST levels were noted to be increased in the 24 hours after ingestion. The median peak AST level was 422 IU/L (range, 74 to 8,538 IU/L). AST levels peaked within 48 hours in 4 patients (21%) and within 72 hours in 18 patients (95%). Six of eight patients with peak AST levels greater than 1,000 IU/L had increased transaminase levels during the 24 hours after acetaminophen ingestion. CONCLUSION Acetaminophen poisoning may cause the serum transaminase level to increase during the 24 hours after ingestion.
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Affiliation(s)
- A J Singer
- Department of Emergency Medicine, University Medical Center, State University of New York, Stony Brook, USA
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36
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Jaimovich DG. Transport management of the patient with acute poisoning. Pediatr Clin North Am 1993; 40:407-30. [PMID: 8451089 DOI: 10.1016/s0031-3955(16)38518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Poisoning in children is a common clinical problem encountered by pediatricians, general practitioners, and emergency room physicians. Poisoning in children less than 5 years of age is usually accidental, whereas, in young adults, any disparity between expected history and clinical findings should suggest poisoning. It is imperative that the treating physician expeditiously recognize, begin treating, and plan to transfer, when indicated, by specialized pediatric transport team the critically ill poisoned child to a tertiary care facility.
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Affiliation(s)
- D G Jaimovich
- Department of Pediatrics, Christ Hospital and Medical Center, Rush Medical College, Oak Lawn, Illinois
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Brotodihardjo AE, Batey RG, Farrell GC, Byth K. Hepatotoxicity from paracetamol self-poisoning in western Sydney: a continuing challenge. Med J Aust 1992; 157:382-5. [PMID: 1447987 DOI: 10.5694/j.1326-5377.1992.tb137246.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the annual incidence of admissions for paracetamol overdosage in the years 1985 to 1990, morbidity and mortality rates, predictors of poor prognosis and the most appropriate use of N-acetylcysteine (NAC). DESIGN A retrospective review of case records of all patients with a discharge diagnosis of paracetamol overdosage. SETTING A 900-bed tertiary referral teaching hospital in western Sydney with a busy accident and emergency department. PATIENTS 306 patient records were reviewed and details of the overdose and admission were recorded. INTERVENTIONS NAC infusion in patients with possible paracetamol hepatotoxicity. MAIN OUTCOME MEASURES Blood paracetamol levels; elevated alanine aminotransferase levels; prolonged prothrombin time; severe liver injury; and NAC side effects. RESULTS Annual admission rate was constant at circa 55 per annum. Female to male ratio was 2:1. Predictors of liver injury included paracetamol dose over 10 g, presentation more than 10 hours after the overdose and chronic ingestion of more than 80 g alcohol per day. There were no deaths. Fifty-five patients (18%) had toxic paracetamol levels, 51% received treatment with NAC, including 40% of those with non-toxic levels, and 11% of those treated with NAC experienced side effects. CONCLUSION Paracetamol overdosage continues to be a significant cause of hospital admissions in western Sydney. Severe hepatic damage occurs infrequently and the prognosis for liver injury, when it occurs, is good. Treatment with NAC should be reserved for patients with definite indications for the drug.
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Myers WC, Otto TA, Harris E, Diaco D, Moreno A. Acetaminophen overdose as a suicidal gesture: a survey of adolescents' knowledge of its potential for toxicity. J Am Acad Child Adolesc Psychiatry 1992; 31:686-90. [PMID: 1644732 DOI: 10.1097/00004583-199207000-00016] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acetaminophen is a popular nonprescription analgesic that is often taken in overdose by adolescents during suicidal gestures. The authors hypothesized that most adolescents are naive about the toxic and lethal potential of acetaminophen in overdose. A one-page, 12-item questionnaire was administered to 169 high school students to evaluate their perceptions and knowledge in this area. Whereas only 22% of the sample underestimated the dose of acetaminophen necessary to cause harm, 40.5% underestimated the potential lethality of acetaminophen in overdose. Moreover, 17% of the sample did not believe one could ingest enough acetaminophen to cause death. The lack of knowledge about acetaminophen's potential dangerousness, its widespread availability, and an absence of early symptoms of hepatotoxicity make this medication highly dangerous to those adolescents who take it in overdose during parasuicidal behavior.
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Affiliation(s)
- W C Myers
- Department of Psychiatry, University of Florida, College of Medicine, Gainesville 32610-0234
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Smilkstein MJ, Bronstein AC, Linden C, Augenstein WL, Kulig KW, Rumack BH. Acetaminophen overdose: a 48-hour intravenous N-acetylcysteine treatment protocol. Ann Emerg Med 1991; 20:1058-63. [PMID: 1928874 DOI: 10.1016/s0196-0644(05)81352-6] [Citation(s) in RCA: 216] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To determine the safety and efficacy of a 48-hour IV N-acetylcysteine (IV NAC) treatment protocol for acute acetaminophen overdose. DESIGN Nonrandomized trial open to all eligible patients. SETTING Multicenter; hospitals included moderate- and high-volume private, university, and municipal hospitals in urban and suburban settings. TYPE OF PARTICIPANTS Two hundred twenty-three patients were entered. Of these, 179 met inclusion criteria: acute acetaminophen overdose, plasma acetaminophen concentration above the treatment nomogram line, treatment with IV NAC according to the protocol, and sufficient data to determine outcome. INTERVENTIONS IV NAC treatment consisted of a loading dose of 140 mg/kg followed by 12 doses of 70 mg/kg every four hours. MEASUREMENTS AND MAIN RESULTS Patients were grouped for analysis according to risk group based on the initial plasma acetaminophen concentration. Hepatotoxicity (aspartate aminotransferase or alanine aminotransferase of more than 1,000 IU/L) developed in 10% (five of 50) of patients at "probable risk" when IV NAC was started within ten hours of acetaminophen ingestion and in 27.1% (23 of 85) when therapy was begun after ten to 24 hours. Among "high-risk" patients first treated 16 to 24 hours after overdose, hepatotoxicity occurred in 57.9% (11 of 19). There were two deaths (two of 179, 1.1%). Adverse reactions resulting from NAC occurred in 32 of 223 cases (14.3%), consisting in 29 of 32 patients (91% of reactions) of transient, patchy, skin erythema or mild urticaria during the loading dose that did not require discontinuation of therapy. CONCLUSION This 48-hour IV NAC protocol is safe and effective antidotal therapy for acetaminophen overdose. Based on available data, it is equal to 72-hour oral and 20-hour IV treatment protocols when started early and superior to the 20-hour IV regimen when treatment is delayed. Further study will be required to determine its relative efficacy in the high-risk patient treated very late.
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Affiliation(s)
- M J Smilkstein
- Section of Trauma and Emergency Medicine, University of Colorado Health Sciences Center, Denver
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Rose SR, Gorman RL, Oderda GM, Klein-Schwartz W, Watson WA. Simulated acetaminophen overdose: pharmacokinetics and effectiveness of activated charcoal. Ann Emerg Med 1991; 20:1064-8. [PMID: 1928875 DOI: 10.1016/s0196-0644(05)81353-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To determine the absorption rate of a supratherapeutic dose of acetaminophen elixir and compare the effect of activated charcoal (AC) given at different time intervals on preventing acetaminophen absorption. DESIGN Randomized, nonblinded, crossover controlled study. SETTING A certified regional poison control center. PARTICIPANTS Ten healthy, adult male volunteers from 21 to 39 years old. INTERVENTIONS Each subject received 5 g acetaminophen (elixir) on four occasions: a control phase plus 30 g of AC administered 15, 30, or 120 minutes after acetaminophen. Serum acetaminophen levels were obtained during the control phase only, and 24-hour urine collections were obtained during all four phases. MEASUREMENTS AND MAIN RESULTS The highest serum acetaminophen levels were measured 1.4 +/- 0.52 hours after ingestion, and absorption was 97% complete by a mean of 2.05 hours. The administration of AC at 15, 30, and 120 minutes after acetaminophen reduced urinary recovery of acetaminophen and metabolites by 48%, 44%, and 33%, respectively. CONCLUSION AC significantly reduces urinary recovery but not absorption of acetaminophen when administered two hours after acetaminophen elixir.
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Affiliation(s)
- S R Rose
- Carolinas Poison Center, Carolinas Medical Center, Charlotte, North Carolina 28232-2861
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Abstract
A 20-month-old girl ingested a maximum of 25 mL of pure methylene iodide. Within two hours, the patient exhibited lethargy and incoordination and vomited. An abdominal radiograph demonstrated the radiopaque material in the gut. In vivo conversion to carbon monoxide was documented with a peak carboxyhemoglobin level of 14.2% reached at 11 hours after ingestion. Two days after ingestion, evidence of hepatotoxicity was apparent, and fulminant hepatic failure quickly ensued. Despite aggressive supportive care and transfer to a liver transplant center, the patient died nine days after ingestion. Methylene iodide ingestion has not been previously reported in human beings. This case verifies that this substance is a potent hepatotoxin, is metabolized to carbon monoxide in vivo, is radiopaque, and may cause bone marrow suppression.
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Affiliation(s)
- P J Weimerskirch
- Department of Emergency Medicine, Eastern Virginia Graduate School of Medicine, Norfolk
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Smilkstein MJ, Knapp GL, Kulig KW, Rumack BH. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med 1988; 319:1557-62. [PMID: 3059186 DOI: 10.1056/nejm198812153192401] [Citation(s) in RCA: 718] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
During the investigational use of oral N-acetylcysteine as an antidote for poisoning with acetaminophen, 11,195 cases of suspected acetaminophen overdose were reported. We describe the outcomes of 2540 patients with acetaminophen ingestions treated with a loading dose of 140 mg of oral N-acetylcysteine per kilogram of body weight, followed four hours later by 70 mg per kilogram given every four hours for an additional 17 doses. Patients were categorized for analysis on the basis of initial plasma acetaminophen concentrations and the interval between ingestion and treatment. Hepatotoxicity developed in 6.1 percent of patients at probable risk when N-acetylcysteine was started within 10 hours of acetaminophen ingestion and in 26.4 percent of such patients when therapy was begun 10 to 24 hours after ingestion. Among patients at high risk who were treated 16 to 24 hours after an acetaminophen overdose, hepatotoxicity developed in 41 percent--a rate lower than that among historical controls. When given within eight hours of acetaminophen ingestion, N-acetylcysteine was protective regardless of the initial plasma acetaminophen concentration. There was no difference in outcome whether N-acetylcysteine was started zero to four or four to eight hours after ingestion, but efficacy decreased with further delay. There were 11 deaths among the 2540 patients (0.43 percent); in the nine fatal cases in which aminotransferase was measured before treatment, values were elevated before N-acetylcysteine was started. No deaths were clearly caused by acetaminophen among patients in whom N-acetylcysteine therapy was begun within 16 hours. We conclude that N-acetylcysteine treatment should be started within eight hours of an acetaminophen overdose, but that treatment is still indicated at least as late as 24 hours after ingestion. On the basis of available data, the 72-hour regimen of oral N-acetylcysteine is as effective as the 20-hour intravenous regimen described previously, and it may be superior when treatment is delayed.
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Affiliation(s)
- M J Smilkstein
- Rocky Mountain Poison and Drug Center, Denver, CO 80204-4507
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