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Ali J, Thompson M, Mackenzie C. Assessing the frequency and types of errors involved in the use of a modified intravenous N-acetylcysteine protocol for acetaminophen overdose. CAN J EMERG MED 2024; 26:174-178. [PMID: 38340270 DOI: 10.1007/s43678-023-00641-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/27/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Acetaminophen overdose is a leading cause of acute liver failure in developing countries. N-acetylcysteine (NAC) is a highly effective antidote for acetaminophen hepatotoxicity, typically initiated in the emergency department. Due to a known high rate of errors with the standard three-bag IV NAC protocol, in 2019, the Ontario Poison Center changed to a modified 3% IV NAC one-bag protocol. This study was undertaken to determine the frequency and types of errors associated with the use of this protocol. METHODS Data were gathered via chart review of Ontario Poison Centre electronic medical record cases identified as receiving IV NAC for acetaminophen overdose between August 1 and September 30, 2022. 218 total charts were identified, and 188 were deemed eligible based on inclusion and exclusion criteria. RESULTS Errors were identified in 25% of charts, consisting of dosing errors in 11.7%, stopping errors in 9.0%, initiation errors in 3.7%, and interruptions in therapy in 3.2%. Dosing errors were the most common type of error (44.4%), with overdoses occurring three times more than underdoses. Errors were identified at 39% of geographic locations in the charts reviewed, with similar frequency in Ontario, Manitoba, and Nunavut. Clinical outcomes were similar in charts with and without errors. INTERPRETATION The rate of errors identified with this 3% IV NAC one-bag protocol is lower than reported for the standard three-bag protocol, but remains high due to dosing errors. Previously reported issues with prolonged interruptions in therapy with the standard three-bag protocol were low with the current 3% one-bag protocol. Although severe outcomes are rare, IV NAC overdose can be fatal. Identifying local factors in emergency departments that can contribute to administration errors (i.e., dose calculation, pump programming issues) can enhance the safety of this important antidote.
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Affiliation(s)
- J Ali
- Department of Medicine, Western University, London, ON, Canada
| | - M Thompson
- Ontario Poison Centre, Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, ON, Canada
- Division of Emergency Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Connie Mackenzie
- Ontario Poison Centre, Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, ON, Canada.
- Divisions of Clinical Pharmacology and Toxicology/Respirology, Western University, London, ON, Canada.
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Bateman DN, Dart RC, Dear JW, Prescott LF, Rumack BH. Fifty years of paracetamol (acetaminophen) poisoning: the development of risk assessment and treatment 1973-2023 with particular focus on contributions published from Edinburgh and Denver. Clin Toxicol (Phila) 2023; 61:1020-1031. [PMID: 38197864 DOI: 10.1080/15563650.2023.2293452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Fifty years ago, basic scientific studies and the availability of assay methods made the assessment of risk in paracetamol (acetaminophen) poisoning possible. The use of the antidote acetylcysteine linked to new methods of risk assessment transformed the treatment of this poisoning. This review will describe the way in which risk assessment and treatments have developed over the last 50 years and highlight the remaining areas of uncertainty. METHODS A search of PubMed and its subsidiary databases revealed 1,166 references published in the period 1963-2023 using the combined terms "paracetamol", "poisoning", and "acetylcysteine". Focused searches then identified 170 papers dealing with risk assessment of paracetamol poisoning, 141 with adverse reactions to acetylcysteine and 114 describing different acetylcysteine regimens. To manage the extensive literature, we focused mainly on contributions made by the authors during their time in Edinburgh and Denver. DOSE AND CONCENTRATION RESPONSE The key relationship between paracetamol dose and toxicity risk was established in 1971 and led to the development of the Rumack-Matthew nomogram from data collected in Edinburgh. MECHANISMS OF TOXICITY A series of papers on the mechanisms of toxicity were published in 1973, and these showed that paracetamol hepatotoxicity was caused by the formation of a toxic intermediate epoxide metabolite normally detoxified by glutathione but which, in excess, was bound covalently to hepatic enzymes and proteins. An understanding of the relationship between the rate of paracetamol metabolism, paracetamol concentration, and toxic hazard in humans soon followed. ANTIDOTE DEVELOPMENT AND EFFICACY IN PATIENTS These discoveries were followed by the testing of a range of sulfhydryl-donors in animals and "at risk" patients. Acetylcysteine was developed as the lead intravenous antidote in the United Kingdom. The license holder in the United States refused to make an intravenous formulation. Thus, oral acetylcysteine became the antidote trialed in the United States National Multicenter Study. Intravenous acetylcysteine regimens used initially in the United Kingdom and subsequently in the United States used loading doses of 150 mg/kg over 15 minutes or one hour, 50 mg/kg over four hours, and 100 mg/kg over 16 hours. These regimens were associated with adverse drug reactions (nausea, vomiting and anaphylactoid reactions) and hence, treatment interruption. Newer dosing regimens now give loading doses more slowly. One, the Scottish and Newcastle Anti-emetic Pretreatment protocol, using an acetylcysteine regimen of 100 mg/kg over two hours followed by 200 mg/kg over 10 hours, has been widely adopted in the United Kingdom. A cohort comparison study suggests this regimen has comparable efficacy to standard regimens and offers opportunities for selective higher acetylcysteine dosing. RISK ASSESSMENT AT PRESENTATION No dose-ranging studies with acetylcysteine were done, and no placebo-controlled studies were performed. Thus, there is uncertainty regarding the optimal dose of acetylcysteine, particularly in patients ingesting very large overdoses of paracetamol. The choice of intervention concentration on the Rumack-Matthew nomogram has important consequences for the proportion of patients treated. The United States National Multicenter Study used a "treatment" line starting at 150 mg/L (992 µmol/L) at 4 hours post overdose, extending to 24 hours with a half-life of 4 hours, now standard there, and subsequently adopted in Australia and New Zealand. In the United Kingdom, the treatment line was initially 200 mg/L (1,323 µmol/L) at 4 hours (the Rumack-Matthew "risk" line). In 2012, the United Kingdom Medicines and Healthcare products Regulatory Agency lowered the treatment line to 100 mg/L (662 µmol/L) at 4 hours for all patients, increasing the number of patients admitted and treated at a high cost. Risk assessment is a key issue for ongoing study, particularly following the development of potential new antidotes that may act in those at greatest risk. The development of biomarkers to assess risk is ongoing but has yet to reach clinical trials. CONCLUSION Even after 50 years, there are still areas of uncertainty. These include appropriate acetylcysteine doses in patients who ingest different paracetamol doses or multiple (staggered) ingestions, early identification of at-risk patients, and optimal treatment of late presenters.
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Affiliation(s)
- D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Medical Toxicology, University of CO School of Medicine, Aurora, CO, USA
| | - James W Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Laurie F Prescott
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Barry H Rumack
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Wu K, Qin J, Liu M, Yan X, Guo C. Bioinformatics approach and experimental validation reveal the hepatoprotective effect of pachyman against acetaminophen-associated liver injury. Aging (Albany NY) 2023; 15:8800-8811. [PMID: 37679038 PMCID: PMC10522380 DOI: 10.18632/aging.205000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023]
Abstract
Pachyman, known as Poria cocos polysaccharides, refers to the bioactive compounds isolated from Poria cocos. Pachyman is thought to exert cytoprotective action. However, the detailed mechanisms of pachyman action for hepatoprotection remain unknown. In this study, we aimed to assess the therapeutic actions, molecular mechanisms, and key target proteins of pachyman in the treatment of liver injury through network pharmacology and molecular docking assays. Furthermore, these bioinformatic findings were validated by an acetaminophen (APAP)-induced liver injury in vivo. Primarily using bioinformatic analysis, we screened and characterized 12 genes that act as potential therapeutic targets of pachyman against APAP-induced liver injury, in which all core targets were obtained. By using enrichment analysis, these core target genes of pachyman were characterized to reveal the pharmacological functions and molecular mechanisms of anti-liver injury induced by APAP. A molecular docking simulation was further performed to certain anti-liver injury target proteins of pachyman, including cytochrome P450 3A4 enzyme (CYP3A4) and inducible nitric oxide synthase (NOS2). In animal experiments, pachyman exerted potent hepatoprotective activities in prenatal APAP-exposed offspring livers, characterized by activated hepatocellular CYP3A4 and NOS2 expressions. These current findings have thus indicated that pachyman exerts hepatoprotective effects and may be the promising nutraceuticals for the treatment of APAP-induced liver injury.
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Affiliation(s)
- Ka Wu
- Department of Pharmacy, The Second People’s Hospital of Nanning City, The Third Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jingru Qin
- Department of Clinical Pharmacy, Guigang City People’s Hospital, The Eighth Affiliated Hospital of Guangxi Medical University, Guigang, Guangxi, China
| | - Meizhen Liu
- Department of Clinical Pharmacy, Guigang City People’s Hospital, The Eighth Affiliated Hospital of Guangxi Medical University, Guigang, Guangxi, China
| | - Xin Yan
- Department of Endocrinology, The Second People’s Hospital of Nanning City, The Third Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chao Guo
- Department of Clinical Pharmacy, Guigang City People’s Hospital, The Eighth Affiliated Hospital of Guangxi Medical University, Guigang, Guangxi, China
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Dong K, Zhang M, Liu Y, Gao X, Wu X, Shi D, Guo C, Wang J. Pterostilbene-Loaded Soluplus/Poloxamer 188 Mixed Micelles for Protection against Acetaminophen-Induced Acute Liver Injury. Mol Pharm 2023; 20:1189-1201. [PMID: 36647568 DOI: 10.1021/acs.molpharmaceut.2c00881] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Excessive acetaminophen (APAP) induces excess reactive oxygen species (ROS), leading to liver damage. Pterostilbene (PTE) has excellent antioxidant and anti-inflammatory activities, but poor solubility limits its biological activity. In this study, we prepared PTE-loaded Soluplus/poloxamer 188 mixed micelles (PTE-MMs), and the protective mechanism against APAP-induced liver injury was investigated. In vitro results showed that PTE-MMs protected H2O2-induced HepG2 cell proliferation inhibition, ROS accumulation, and mitochondrial membrane potential destruction. Immunofluorescence results indicated that PTE-MMs significantly inhibited H2O2-induced DNA damage and cGAS-STING pathway activation. For in vivo protection studies, PTE-MMs (25 and 50 mg/kg) were administered orally for 5 days, followed by APAP (300 mg/kg). The results showed that APAP significantly induced injury in liver histopathology as well as an increase in serum aspartate aminotransferase and alanine aminotransferase levels. Moreover, the above characteristics of APAP-induced acute liver injury were inhibited by PTE-MMs. In addition, APAP-induced changes in the activities of antioxidant enzymes such as SOD and GSH in liver tissue were also inhibited by PTE-MMs. Immunohistochemical results showed that PTE-MMs inhibited APAP-induced DNA damage and cGAS-STING pathway activation in liver tissues. For in vivo therapeutic effect study, mice were first given APAP (300 mg/kg), followed by oral administration of PTE-MMs (50 mg/kg) for 3 days. The results showed that PTE-MMs exhibited promising therapeutic effects on APAP-induced acute liver injury. In conclusion, our study shows that the Soluplus/poloxamer 188 MM system has the potential to enhance the biological activity of PTE in the protection and therapeutic of liver injury.
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Affiliation(s)
- Kehong Dong
- Department of Pharmacy, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao266042, China
| | - Mei Zhang
- Department of Pharmacy, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao266042, China.,Department of Pharmacy, The First Affiliated Hospital of Suzhou University, Suzhou215000, China
| | - Ying Liu
- Department of Pharmacy, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao266042, China
| | - Xintao Gao
- Department of Pharmacy, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao266042, China
| | - Xiaochen Wu
- Department of Pharmacy, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao266042, China
| | - Dayong Shi
- State Key Laboratory of Microbial Technology, Shandong University, Qingdao, 266273Shandong, China
| | - Chuanlong Guo
- Department of Pharmacy, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao266042, China.,State Key Laboratory of Microbial Technology, Shandong University, Qingdao, 266273Shandong, China
| | - Jing Wang
- Department of Biology Science and Technology, Baotou Teacher's College, Baotou014030, China
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Chidiac AS, Buckley NA, Noghrehchi F, Cairns R. Paracetamol (acetaminophen) overdose and hepatotoxicity: mechanism, treatment, prevention measures, and estimates of burden of disease. Expert Opin Drug Metab Toxicol 2023; 19:297-317. [PMID: 37436926 DOI: 10.1080/17425255.2023.2223959] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Paracetamol is one of the most used medicines worldwide and is the most common important poisoning in high-income countries. In overdose, paracetamol causes dose-dependent hepatotoxicity. Acetylcysteine is an effective antidote, however despite its use hepatotoxicity and many deaths still occur. AREAS COVERED This review summarizes paracetamol overdose and toxicity (including mechanisms, risk factors, risk assessment, and treatment). In addition, we summarize the epidemiology of paracetamol overdose worldwide. A literature search on PubMed for poisoning epidemiology and mortality from 1 January 2017 to 26 October 2022 was performed to estimate rates of paracetamol overdose, liver injury, and deaths worldwide. EXPERT OPINION Paracetamol is widely available and yet is substantially more toxic than other analgesics available without prescription. Where data were available, we estimate that paracetamol is involved in 6% of poisonings, 56% of severe acute liver injury and acute liver failure, and 7% of drug-induced liver injury. These estimates are limited by lack of available data from many countries, particularly in Asia, South America, and Africa. Harm reduction from paracetamol is possible through better identification of high-risk overdoses, and better treatment regimens. Large overdoses and those involving modified-release paracetamol are high-risk and can be targeted through legislative change.
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Affiliation(s)
- Annabelle S Chidiac
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, Australia
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
- Faculty of Medicine and Health, School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Firouzeh Noghrehchi
- Faculty of Medicine and Health, School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Rose Cairns
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, Australia
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
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Stanton MT. Part
II
: Interactive case: Toxicology and poison control. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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7
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Janković SM. Acetaminophen toxicity and overdose: current understanding and future directions for NAC dosing regimens. Expert Opin Drug Metab Toxicol 2022; 18:745-753. [PMID: 36420805 DOI: 10.1080/17425255.2022.2151893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although N-acetyl-cysteine (NAC) has long been used for the treatment of acetaminophen poisoning/overdose, the optimal NAC dosing regimen for varying patterns or severity of the poisoning/overdose is still unknown. AREAS COVERED Relevant literature was searched for in the MEDLINE (from 1964 until August 31st, 2022), SCOPUS (from 2004 until August 31st, 2022) and GOOGLE SCHOLAR (from 2004 until August 31st, 2022) databases, without restriction in terms of publication date. The inclusion criteria were: original clinical studies reporting results, and studies investigating efficacy and safety of NAC dosing regimens in case(s) of overdose or poisoning with acetaminophen. EXPERT OPINION For a more effective treatment of acetaminophen poisoning in the future, it will be crucial to advance the technology of measuring acetaminophen, its metabolites and NAC in the serum, preferably with the point-of-care technique, so that in real time it can be continuously assessed whether it is necessary to administer NAC, and further to increase the dose of NAC and extend the duration of its administration, or not.
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Eivazkhani F, Ebrahimi B, Yousefi B, Fatehi R, Fathi R, Akbarinejad V. Effects of N-Acetyl-L-Cystein Antioxidant on Ex Vivo Culture of Vitrified Premature Mouse Ovarian Tissue. Biopreserv Biobank 2022; 20:331-339. [PMID: 35507947 DOI: 10.1089/bio.2021.0147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Optimization of practical ways to obtain mature follicles from cryopreserved ovarian tissues, especially in patients suffering from ovarian dysfunction, is very important. In vitro ovarian tissue culture allows faster screening of follicle development and reduces follicle isolation damage. During ovarian tissue culture, controlling oxidative stress is critical to support better follicular development and less damage. Immature Naval Medical Research Institute (NMRI) mouse ovaries (8-days-old) were randomly distributed into four cultured groups; non-vitrified, vitrified, non-vitrified N-acetyl-L-cysteine (NAC)+, and vitrified NAC+. Ovaries of vitrified groups along with non-vitrified ovaries were cultured on agar gel in the presence or absence of NAC for 5 days. Afterward, morphological evaluations, mRNA expressions of Gdf9, Bmp6, Lif, Amh, Bax, and Bcl2 genes, malondialdehyde, and total antioxidant capacities were compared between four groups at the first and last day of culture. Good preservation of tissue integrity and an increase of follicular development were observed in all groups. In addition, the expression of Gdf9, Lif, Bax, and Bcl2 genes were increased and Amh was decreased in groups cultured in the presence of NAC compared to groups cultured without NAC. Although total antioxidant capacity was not significantly different between the experimental groups, the lipid peroxidation and apoptotic index were significantly reduced in the presence of NAC. Thus, it appears that NAC antioxidant acts as a contributory factor for the ex vivo culture of ovarian tissue and reduces oxidative stress, apoptotic index, and improves follicular development, especially in non-vitrified groups.
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Affiliation(s)
- Farideh Eivazkhani
- Department of Embryology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran.,Abnormal Uterine Bleeding Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Bita Ebrahimi
- Department of Embryology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Behpour Yousefi
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Roya Fatehi
- Department of Embryology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Rouhollah Fathi
- Department of Embryology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Vahid Akbarinejad
- Department of Theriogenology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
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Baum RA, Su MK, Weant KA. The Cents of the Dosage Cap in Patients Greater than 100 Kilograms Receiving N-Acetylcysteine for Acetaminophen Toxicity. J Med Toxicol 2022; 18:67-68. [PMID: 35006548 PMCID: PMC8758848 DOI: 10.1007/s13181-021-00872-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Regan A. Baum
- Department of Pharmacy Services, University of Kentucky HealthCare, 800 Rose Street, H112, Lexington, KY 40536-2093 USA
| | - Mark K. Su
- New York City Poison Control Center, The Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, 455 1st Avenue, Room 123, New York, NY 10016 USA
| | - Kyle A. Weant
- Department of Clinical Pharmacy and Outcome Sciences, University of South Carolina College of Pharmacy, 715 Sumter Street – CLS316A, Columbia, SC 29208 USA
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Abstract
Acetaminophen is a common medication taken in deliberate self-poisoning and unintentional overdose. It is the commonest cause of severe acute liver injury in Western countries. The optimal management of most acetaminophen poisonings is usually straightforward. Patients who present early should be offered activated charcoal and those at risk of acute liver injury should receive acetylcysteine. This approach ensures survival in most. The acetaminophen nomogram is used to assess the need for treatment in acute immediate-release overdoses with a known time of ingestion. However, scenarios that require different management pathways include modified-release, large/massive, and repeated supratherapeutic ingestions.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Barker Street, Randwick, New South Wales 2031, Australia.
| | - Nicholas A Buckley
- Pharmacology and Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2050, Australia
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Burnham K, Yang T, Smith H, Knight S. A review of alternative intravenous acetylcysteine regimens for acetaminophen overdose. Expert Rev Clin Pharmacol 2021; 14:1267-1278. [PMID: 34187297 DOI: 10.1080/17512433.2021.1946392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Acetylcysteine is the standard treatment for preventing hepatotoxicity caused by acetaminophen overdose. Several novel approaches to the management of acetaminophen overdose have been suggested to improve patient safety by reducing adverse drug reactions and dosing errors. This article reviews these alternative treatment regimens and intends to offer a detailed assessment of the available options to assist providers in managing cases of acetaminophen overdose. AREAS COVERED This review article covers observational and experimental studies that assessed the efficacy and safety of alternative intravenous acetylcysteine regimens for acetaminophen overdose. A literature search was conducted using PubMed, ProQuest, and Scopus to identify the studies, which included results through April 2021. The assessment of alternative regimens consists of a discussion on the limitations and benefits, barriers to implementation, and important considerations for each regimen. EXPERT OPINION Several alternative regimens have been studied and implemented in various institutions. Many of these dosing regimens have supporting safety data but most lack robust data. A reduction in infusion-related side effects is an important outcome, but established efficacy, local poison center familiarity with the regimen, institutional resources, and patient-specific factors should be equally considered when deciding on implementing and using an alternative dosing strategy.
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Affiliation(s)
- Kevin Burnham
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Tianrui Yang
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Haleigh Smith
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Steven Knight
- Methodist Mansfield Medical Center, Mansfield, TX, USA
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Baumgartner K, Filip A, Liss D, Devgun J, Schwarz E, Mullins M. N-acetylcysteine for acetaminophen toxicity: The one-bag regimen. Br J Clin Pharmacol 2020; 87:2399-2400. [PMID: 33190332 DOI: 10.1111/bcp.14631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/23/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Kevin Baumgartner
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ari Filip
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St Louis, Missouri, USA
| | - David Liss
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jason Devgun
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Evan Schwarz
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael Mullins
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St Louis, Missouri, USA
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Mullins ME, Yu M, O’Grady L, Khan S, Schwarz ES. Adverse reactions in patients treated with the one-bag method of N-acetylcysteine for acetaminophen ingestion. TOXICOLOGY COMMUNICATIONS 2020. [DOI: 10.1080/24734306.2020.1770498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Michael E. Mullins
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mary Yu
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Lauren O’Grady
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Shariq Khan
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Evan S. Schwarz
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
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Awad NI, Geib AJ, Roy A, Cocchio C, Bridgeman PJ. Protocol deviations in intravenous acetylcysteine therapy for acetaminophen toxicity. Am J Emerg Med 2020; 38:830-833. [DOI: 10.1016/j.ajem.2019.158405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022] Open
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Wong A, Heard K, Graudins A, Dart R, Sivilotti MLA. Adducts Post Acetaminophen Overdose Treated with a 12-Hour vs 20-Hour Acetylcysteine Infusion. J Med Toxicol 2020; 16:188-194. [PMID: 31939054 DOI: 10.1007/s13181-020-00757-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/28/2019] [Accepted: 01/04/2020] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Acetaminophen protein adducts in the circulation are a specific biomarker of acetaminophen oxidation, and may be a more sensitive measure of impending hepatic injury following overdose than alanine transaminase (ALT). We performed an exploratory analytical substudy of adducts during a clinical trial (NACSTOP) of abbreviated (12-hour) versus control (20-hour) acetylcysteine to identify any signal of diminished antidotal effectiveness with shortened therapy. METHODS We measured adducts at 0, 12, and 20 hours from a convenience sample of subjects enrolled in the cluster-controlled NACSTOP trial evaluating a 12-hour ("abbreviated"; 200 mg/kg over 4 hours, 50 mg/kg over 8 hours) vs 20-hour acetylcysteine regimen ("control"; 200 mg/kg over 4 hours, 100 mg/kg over 16 hours). Adducts were assayed using high-performance liquid chromatography/mass spectrometry. RESULTS Median ALT 20 hours after the initiation of acetylcysteine was 12 U/L (IQR 8,14) in the abbreviated 12-hour regimen group (N = 8), compared with the control group 16 U/L (IQR 11,21; N = 21) (p = 0.46). Adduct concentrations were similarly low in both groups: abbreviated [(0.005 μmol/L, IQR (0,0.14)] and control [(0.005 μmol/L, IQR (0,0.05)] (p = 0.61). CONCLUSIONS There were minimal to no acetaminophen protein adducts detected. These findings further support discontinuing acetylcysteine when acetaminophen concentrations are low and liver function tests normal after 12 hours of treatment.
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Affiliation(s)
- Anselm Wong
- School of Clinical Sciences, Department of Medicine, Monash University, Melbourne, Victoria, Australia. .,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia. .,Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Victoria, 3084, Australia.
| | - Kennon Heard
- Rocky Mountain Poison and Drug Center, Denver Health and Hospitals, Denver, CO, USA.,Section of Medical Pharmacology and Toxicology, Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Andis Graudins
- School of Clinical Sciences, Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Toxicology Service, Monash Health, School of Clinical Sciences, Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Marco L A Sivilotti
- Departments of Emergency Medicine, and of Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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16
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Rampon G, Wartman H, Osmon S, Scalzo A. Use of fomepizole as an adjunct in the treatment of acetaminophen overdose: a case series. TOXICOLOGY COMMUNICATIONS 2019. [DOI: 10.1080/24734306.2019.1705596] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Garrett Rampon
- Saint Louis University School of Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
- Department of Internal Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
| | - Haley Wartman
- Saint Louis University School of Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
| | - Stephen Osmon
- Saint Louis University School of Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
- Department of Internal Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
- Division of Pulmonary & Critical Care, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
| | - Anthony Scalzo
- Saint Louis University School of Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
- Department of Internal Medicine, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
- Division of Toxicology, SSM Health Saint Louis University Hospital, SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, MO, USA
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Mullins ME, Yarema MC, Sivilotti MLA, Thompson M, Algren DA, Beuhler MC, Holstege CP. Comment on “Acetylcysteine in paracetamol poisoning: a perspective of 45 years of use” by D. N. Bateman and J. W. Dear, Toxicol. Res., 2019, 8, 489. Toxicol Res (Camb) 2019. [DOI: 10.1039/c9tx00158a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
We point out an acetylcysteine protocol that a previous article (D. N. Bateman and J. W. Dear, Toxicol. Res., 2019, 8, 489–498) overlooked. The standard concentration protocol uses a uniform concentration of 30 mg mL−1 for all patients to reduce errors in preparation and administration. Usually a single 1 L bag is sufficient for most patients. Various centers in the US and Canada use this approach.
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Affiliation(s)
- Michael E. Mullins
- Section of Medical Toxicology, Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Mark C. Yarema
- Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Margaret Thompson
- Ontario Poison Centre, Division of Clinical Pharmacology and Toxicology, Hospital for Sick Kids, Toronto, Ontario, Canada
| | - D. Adam Algren
- Department of Emergency Medicine, Children's Mercy Medical Center, Kansas City, Missouri, USA
| | - Michael C. Beuhler
- North Carolina Poison Center, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Christopher P. Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Chartottesville, Virginia, USA
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Mullins ME, Yarema MC, Sivilotti MLA, Thompson M, Beuhler MC, Algren DA, Holstege CP. Comment on “Transition to two-bag intravenous acetylcysteine for acetaminophen overdose”. Clin Toxicol (Phila) 2019; 58:433-435. [DOI: 10.1080/15563650.2019.1649418] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Michael E. Mullins
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mark C. Yarema
- Alberta Health Services Poison and Drug Information Service, Calgary, Canada
| | | | - Margaret Thompson
- Division of Clinical Pharmacology and Toxicology, Ontario Poison Centre, Hospital for Sick Children, Toronto, Canada
| | - Michael C. Beuhler
- North Carolina Poison Control, Atrium Health-Carolinas Medical Center, Charlotte, NC, USA
| | - D. Adam Algren
- Department of Emergency Medicine, Children’s Mercy Medical Center, Kansas City, MO, USA
| | - Christopher P. Holstege
- Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine, Chartottesville, VA, USA
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Pettie JM, Caparrotta TM, Hunter RW, Morrison EE, Wood DM, Dargan PI, Thanacoody RH, Thomas SH, Elamin ME, Francis B, Webb DJ, Sandilands EA, Eddleston M, Dear JW. Safety and Efficacy of the SNAP 12-hour Acetylcysteine Regimen for the Treatment of Paracetamol Overdose. EClinicalMedicine 2019; 11:11-17. [PMID: 31317129 PMCID: PMC6610779 DOI: 10.1016/j.eclinm.2019.04.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/22/2019] [Accepted: 04/10/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acetylcysteine (NAC) is effective at preventing liver injury after paracetamol overdose. The Scottish and Newcastle Anti-emetic Pre-treatment for Paracetamol Poisoning (SNAP) Study demonstrated that a 12 h NAC regimen was associated with fewer adverse drug reactions compared with the standard 21 h regimen. Here, we describe the clinical effectiveness of the SNAP NAC regimen. METHODS The SNAP regimen, consisting of intravenous NAC 100 mg/kg over 2 h then 200 mg/kg over 10 h, was introduced to treat all paracetamol overdose patients at the Royal Infirmary of Edinburgh, the Royal Victoria Infirmary, Newcastle and St Thomas' Hospital, London. Patient data were prospectively and systematically collected before and after the change in treatment (total patients N = 3340, 21 h N = 1488, SNAP N = 1852). Health record linkage was used to determine patient outcome after hospital discharge. FINDINGS There was no difference in liver injury or liver synthetic dysfunction between regimens. Hepatotoxicity (peak ALT > 1000 U/L) occurred in 64 (4.3%) and 67 (3.6%) patients, respectively, in the 21 h and SNAP groups (absolute difference - 0.7%, 95% CI - 2.1 to 0.6). Multivariable logistic regression did not identify treatment regimen as an outcome-associated factor. No patients were readmitted to hospital with, or died from, liver failure within 30 days of discharge. Anti-histamine treatment (for NAC anaphylactoid drug reactions) was prescribed for 163 (11.0%) patients with the 21 h regimen and 37 (2.0%) patients with the SNAP regimen (absolute difference 9.0% (95% CI 7.3 to 10.7)). INTERPRETATION In clinical use the SNAP regimen has similar efficacy as standard therapy for preventing liver injury and produces fewer adverse reactions.
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Key Words
- ALT, Alanine transaminase activity
- Acute liver failure
- Clinical practice
- Drug-induced liver injury
- INR, International normalised ratio
- MHRA, Medicines and Healthcare Products Regulatory Agency's
- NAC
- NAC, Acetylcysteine
- NAPQI, N‑acetyl‑p‑benzoquinone imine
- Paracetamol
- RIE, Royal Infirmary of Edinburgh
- RVI, The Royal Victoria Infirmary, Newcastle
- SNAP, Scottish and Newcastle Anti-emetic Pre-treatment for Paracetamol Poisoning
- STH, St Thomas' Hospital, London
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Affiliation(s)
| | - Thomas M. Caparrotta
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, UK
| | - Robert W. Hunter
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, UK
| | - Emma E. Morrison
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, UK
| | - David M. Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I. Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ruben H. Thanacoody
- Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle NE2 4HH, UK
| | - Simon H.L. Thomas
- Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle NE2 4HH, UK
| | - Muhammad E.M.O. Elamin
- Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle NE2 4HH, UK
| | - Ben Francis
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, UK
| | - David J. Webb
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Michael Eddleston
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, UK
| | - James W. Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, UK
- Corresponding author at: Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK.
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Hendrickson RG. What is the most appropriate dose of N-acetylcysteine after massive acetaminophen overdose? Clin Toxicol (Phila) 2019; 57:686-691. [DOI: 10.1080/15563650.2019.1579914] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Robert G. Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
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Hoyte C, Dart RC. Transition to two-bag intravenous acetylcysteine for acetaminophen overdose: a poison center's experience. Clin Toxicol (Phila) 2019; 57:217-218. [PMID: 30689437 DOI: 10.1080/15563650.2018.1510127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Christopher Hoyte
- a Rocky Mountain Poison and Drug Center , Denver Health and Hospital Authority , Denver , CO , USA.,b Department of Emergency Medicine , University of Colorado School of Medicine , Aurora , CO , USA
| | - Richard C Dart
- a Rocky Mountain Poison and Drug Center , Denver Health and Hospital Authority , Denver , CO , USA
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22
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Schmidt LE, Rasmussen DN, Petersen TS, Macias-Perez IM, Pavliv L, Kaelin B, Dart RC, Dalhoff K. Fewer adverse effects associated with a modified two-bag intravenous acetylcysteine protocol compared to traditional three-bag regimen in paracetamol overdose. Clin Toxicol (Phila) 2018; 56:1128-1134. [DOI: 10.1080/15563650.2018.1475672] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Lars E. Schmidt
- Rigshospitalet and Glostrup University Hospital, Copenhagen, Denmark
| | | | - Tonny S. Petersen
- Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | | | - Leo Pavliv
- Cumberland Pharmaceuticals Inc., Nashville, Tennessee
| | - Byron Kaelin
- Cumberland Pharmaceuticals Inc., Nashville, Tennessee
| | | | - Kim Dalhoff
- Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
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23
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O'Grady L, Mullins ME, Schwarz ES. A comment on ‘An assessment of the variation in the concentrations of acetylcysteine in infusions for the treatment of paracetamol overdose’. Br J Clin Pharmacol 2017; 83:2833-2834. [DOI: 10.1111/bcp.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/21/2017] [Accepted: 07/09/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Lauren O'Grady
- Division of Emergency MedicineWashington University School of Medicine Saint Louis MO USA
| | - Michael E. Mullins
- Division of Emergency MedicineWashington University School of Medicine Saint Louis MO USA
| | - Evan S. Schwarz
- Division of Emergency MedicineWashington University School of Medicine Saint Louis MO USA
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24
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Baker KA, Austin EB, Wang GS. Antidotes: Familiar Friends and New Approaches for the Treatment of Select Pediatric Toxicological Exposures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Schwarz ES, Mullins ME, Liss D. When two is not better than one. Br J Clin Pharmacol 2017; 83:2310-2311. [PMID: 28543530 DOI: 10.1111/bcp.13320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Evan S Schwarz
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Michael E Mullins
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - David Liss
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
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N-Acetylcysteine (NAC)-Induced Hyponatremia Caused by an Electronic Medical Record (EMR) Order Error. J Med Toxicol 2016; 11:355-8. [PMID: 25631537 DOI: 10.1007/s13181-015-0461-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Intravenous N-acetylcysteine (NAC) causes few adverse drug events, with mild anaphylactoid reactions being the most common. Hyponatremia as a complication of hypoosmolar NAC solution has been reported. We describe how a locally constructed electronic medical record (EMR) order set for IV NAC resulted in a seizure from hyponatremia due to excess free water administration. CASE REPORT A 13-month-old female with no past medical history presented to a hospital after ingesting an unknown number of acetaminophen 500 mg tablets. The 4-h acetaminophen concentration was 343 mcg/mL, and she was started on IV NAC. 8.2 h into her 21-h IV NAC protocol, she developed a tonic-clonic seizure. Repeat serum sodium was 124 mEq/L, a decrease from 142 mEq/L at the time of admission. She was treated with hypertonic saline, lorazepam, and levetiracetam and had no further seizures. A brain MRI and EEG were both normal. After the seizure was stabilized, the providers noticed that the patient had receive a total of 900 mL of D5W (112.5 mL/kg) in the first 9 h of hospitalization. This was caused by a poorly constructed, restrictive, EMR order set that did not allow customization of the IV NAC preparation. DISCUSSION Because the 21-h IV NAC administration involves preparation of 3 different doses infused over 3 different time intervals, an order set was developed to reduce ordering errors. However, error in its construction caused the pharmacist to prepare a solution containing too much free water, decreasing patient's intravascular sodium and resulting in a seizure. CONCLUSION The purposes of our case report were to highlight the dangers of overreliance on EMR order sets and to recognize hyponatremic seizures as an adverse reaction of an inappropriately prepared IV NAC.
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Chiew AL, Isbister GK, Duffull SB, Buckley NA. Evidence for the changing regimens of acetylcysteine. Br J Clin Pharmacol 2016; 81:471-81. [PMID: 26387650 PMCID: PMC4767192 DOI: 10.1111/bcp.12789] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 01/01/2023] Open
Abstract
Paracetamol overdose prior to the introduction of acetylcysteine was associated with significant morbidity. Acetylcysteine is now the mainstay of treatment for paracetamol poisoning and has effectively reduced rates of hepatotoxicity and death. The current three-bag intravenous regimen with an initial high loading dose was empirically derived four decades ago and has not changed since. This regimen is associated with a high rate of adverse effects due mainly to the high initial peak acetylcysteine concentration. Furthermore, there are concerns that the acetylcysteine concentration is not adequate for 'massive' overdoses and that the dose and duration may need to be altered. Various novel regimens have been proposed, looking to address these issues. Many of these modified regimens aim to decrease the rate of adverse reactions by slowing the loading dose and thereby decrease the peak concentration. We used a published population pharmacokinetic model of acetylcysteine to simulate these modified regimens. We determined mean peak and 20 h acetylcysteine concentrations and area under the under the plasma concentration-time curve to compare these regimens. Those regimens that resulted in a lower peak acetylcysteine concentration have been shown in studies to have a lower rate of adverse events. However, these studies were too small to show whether they are as effective as the traditional regimen. Further research is still needed to determine the optimum dose and duration of acetylcysteine that results in the fewest side-effects and treatment failures. Indeed, a more patient-tailored approach might be required, whereby the dose and duration are altered depending on the paracetamol dose ingested or paracetamol concentrations.
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Affiliation(s)
- Angela L Chiew
- Clinical and Experimental Toxicology Unit, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
| | - Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | | | - Nicholas A Buckley
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
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Pauley KA, Sandritter TL, Lowry JA, Algren DA. Evaluation of an Alternative Intravenous N-Acetylcysteine Regimen in Pediatric Patients. J Pediatr Pharmacol Ther 2015; 20:178-85. [PMID: 26170769 DOI: 10.5863/1551-6776-20.3.178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Conventionally, intravenous N-acetylcysteine (IV-NAC) administration is a 3-bag regimen administered over the course of 21 hours, which increases the risk of reconstitution and administration errors. To minimize errors, an alternative IV-NAC regimen consists of a loading dose (150 mg/kg) followed by a maintenance infusion (15 mg/kg/hr) until termination criteria are met. The aim was to determine the clinical outcomes of an alternative IV-NAC regimen in pediatric patients. METHODS A retrospective review of pharmacy dispensing records and diagnostic codes at a pediatric hospital identified patients who received alternative IV-NAC dosing from March 1, 2008, to September 10, 2012, for acetaminophen overdoses. Exclusion criteria included chronic liver disease, initiation of oral or other IV-NAC regimens, and initiation of standard IV-NAC infusion prior to facility transfer. Clinical and laboratory data were abstracted from the electronic medical record. Descriptive statistics were utilized. Clinical outcomes and adverse drug reaction incidences were compared between the alternative and Food and Drug Administration (FDA)-approved IV-NAC regimens. RESULTS Fifty-nine patients (mean age 13.4 ± 4.3 years; range: 2 months-18 years) with acetaminophen overdoses were identified. Upon IV-NAC discontinuation, 45 patients had normal alanine transaminase (ALT) concentrations, while 14 patients' ALT concentrations remained elevated (median 140 units/L) but were trending downward. Two patients (3.4%) developed hepatotoxicity (aspartate transaminase/ALT > 1000 units/L). No patients developed hepatic failure, were listed for a liver transplant, were intubated, underwent hemodialysis, or died. Two patients (3.4%) developed anaphylactoid reactions. No known medication or administration errors occurred. Clinical outcome incidences of the studied endpoints with the alternative IV-NAC regimen are at the lower end of published incidence ranges compared to the FDA IV-NAC regimen for acetaminophen overdoses. CONCLUSIONS This alternative IV-NAC regimen appears to be effective and well tolerated among pediatric patients when compared to the FDA-approved regimen. It may also result in fewer reconstitution and administration errors, leading to improved patient safety.
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Affiliation(s)
- Kathryn A Pauley
- Department of Pharmacy, Children's Mercy Hospital, Kansas City, Missouri
| | - Tracy L Sandritter
- Division of Clinical Pharmacology and Therapeutic Innovations, Children's Mercy Hospital, Kansas City, Missouri
| | - Jennifer A Lowry
- Division of Clinical Pharmacology and Therapeutic Innovations, Children's Mercy Hospital, Kansas City, Missouri
| | - D Adam Algren
- Division of Clinical Pharmacology and Therapeutic Innovations, Children's Mercy Hospital, Kansas City, Missouri
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Chyka PA. Acetylcysteine and Acetaminophen Overdose: The Many Shades of Gray. J Pediatr Pharmacol Ther 2015; 20:160-2. [DOI: 10.5863/1551-6776-20.3.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Peter A. Chyka
- Department of Clinical Pharmacy, College of Pharmacy, the University of Tennessee Health Science Center, Knoxville, Tennessee
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McGovern AJ, Vitkovitsky IV, Jones DL, Mullins ME. Can AST/ALT ratio indicate recovery after acute paracetamol poisoning? Clin Toxicol (Phila) 2015; 53:164-7. [PMID: 25652258 DOI: 10.3109/15563650.2015.1006399] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Paracetamol (acetaminophen or APAP) is the most common pharmaceutical exposure in the US. Elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels indicate hepatic toxicity. AST and ALT levels rise in similar proportions but later decline at different rates, with AST falling more rapidly than ALT. OBJECTIVE To determine whether the AST/ALT ratio can indicate that a patient has passed the time of peak AST concentration. METHODS We retrospectively identified cases of patients hospitalized for acute APAP poisoning by querying the pharmacy database of all patients treated with acetylcysteine (NAC) from January 1, 2001 to March 19, 2013. We included all patients with severe APAP poisoning, defined as AST or ALT greater than 1000 IU/L. Patients who were given NAC for other indications, those without APAP poisoning, and those receiving liver transplantation were excluded. We then recorded paired AST and ALT concentrations from each patient's hospital course. We classified each pair as clearly post-peak or not, and calculated the AST/ALT ratio for each pair of values. We compared different thresholds of AST/ALT ratio in increments of 0.1 to find the optimal value that reliably indicated resolving transaminases. RESULTS We identified 1820 patients who received NAC during the study period. Of these, 333 received NAC for suspected poisoning by APAP. After excluding patients without severe APAP poisoning, other diagnoses explaining transaminase elevations, and patients who underwent liver transplantation, we had 37 evaluable patients with 343 evaluable pairs of AST and ALT concentrations. An AST/ALT ratio less than or equal to 0.4 was 99% sensitive for identifying patients with resolving transaminases. CONCLUSION An AST/ALT ratio less than or equal to 0.4 following severe hepatoxicity from paracetamol poisoning appears to be highly predictive of recovery in patients treated with NAC. This has potential to be an indicator of safe discontinuation of NAC treatment.
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Affiliation(s)
- Allison J McGovern
- Division of Emergency Medicine, Washington University School of Medicine , Saint Louis, MO , USA
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31
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Chomchai S, Chomchai C. Predicting acute acetaminophen hepatotoxicity with acetaminophen-aminotransferase multiplication product and the Psi parameter. Clin Toxicol (Phila) 2014; 52:506-11. [DOI: 10.3109/15563650.2014.917180] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McIntyre S, Greene S, McD Taylor D. Response to Introduction of an N-acetylcysteine weight-based dosing chart reduces prescription errors in the treatment of paracetamol poisoning: Reply. Emerg Med Australas 2013; 25:286-7. [PMID: 23759056 DOI: 10.1111/1742-6723.12084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sivilotti MLA, Juurlink DN, Garland JS, Lenga I, Poley R, Hanly LN, Thompson M. Antidote removal during haemodialysis for massive acetaminophen overdose. Clin Toxicol (Phila) 2013; 51:855-63. [PMID: 24134534 DOI: 10.3109/15563650.2013.844824] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Haemodialysis is sometimes used for patients with massive acetaminophen overdose when signs of "mitochondrial paralysis" (lactic acidosis, altered mental status, hypothermia and hyperglycaemia) are present. The role of haemodialysis is debated, in part because the evidence base is weak and the endogenous clearance of acetaminophen is high. There is also concern because the antidote acetylcysteine is also dialyzable. We prospectively measured serum acetylcysteine concentrations during haemodialysis in three such cases. CASE DETAILS Three adults each presented comatose and acidemic 10 to ~18 h after ingesting > 1000mg/kg of acetaminophen. Two were hypothermic and hyperglycaemic. Serum lactate concentrations ranged from 7 mM to 12.5 mM. All three were intubated, and initial acetaminophen concentrations were as high as 5980 μM (900 μg/mL). An intravenous loading dose of 150 mg/kg acetylcysteine was initiated between 10.8 and ~18 h post ingestion, and additional doses were empirically administered during haemodialysis to compensate for possible antidote removal. A single run of 3-4 h of haemodialysis removed 10-20 g of acetaminophen (48-80% of remaining body burden), reduced serum acetaminophen concentrations by 56-84% (total clearance 3.4-7.8 mL/kg/min), accelerated native acetaminophen clearance (mean elimination half-life 580 min pre-dialysis, 120 min during and 340 min post-dialysis) and corrected acidemia. Extraction ratios of acetylcysteine across the dialysis circuit ranged from 73% to 87% (dialysance 3.0 to 5.3 mL/kg/min). All three patients recovered fully, and none developed coagulopathy or other signs of liver failure. DISCUSSION When massive acetaminophen ingestion is accompanied by coma and lactic acidosis, emergency haemodialysis can result in rapid biochemical improvement. As expected, haemodialysis more than doubles the clearance of both acetaminophen and acetylcysteine. Because acetylcysteine dosing is largely empirical, we recommend doubling the dose during haemodialysis, with an additional half-load when dialysis exceeds 6 h.
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Affiliation(s)
- M L A Sivilotti
- Department of Emergency Medicine, Queen's University , Kingston, ON , Canada
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Schwarz ES, Mullins ME. Introduction of an N-acetylcysteine weight-based dosing chart reduces prescription errors in the treatment of paracetamol poisoning: Reply. Emerg Med Australas 2013; 25:285-6. [DOI: 10.1111/1742-6723.12078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Evan S Schwarz
- Division of Emergency Medicine; Washington University School of Medicine; Saint Louis; Missouri; USA
| | - Michael E Mullins
- Division of Emergency Medicine; Washington University School of Medicine; Saint Louis; Missouri; USA
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Abstract
Acetaminophen poisoning remains one of the more common drugs taken in overdose with potentially fatal consequences. Early recognition and prompt treatment with N-acetylcysteine can prevent hepatic injury. With acute overdose, the Rumack-Matthew nomogram is a useful tool to assess risk and guide management. Equally common to acute overdose is the repeated use of excessive amounts of acetaminophen. Simultaneous ingestion of several different acetaminophen-containing products may result in excessive dosage. These patients also benefit from N-acetylcysteine. Standard courses of N-acetylcysteine may need to be extended in patients with persistently elevated plasma concentrations of acetaminophen or with signs of hepatic injury.
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Affiliation(s)
- Michael J Hodgman
- Department of Emergency Medicine, Upstate New York Poison Center, SUNY Upstate Medical University, Suite 202, 250 Harrison Street, Syracuse, NY 13202, USA.
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Abstract
Paracetamol (acetaminophen) overdose remains the leading cause of death or transplantation due to acute liver failure in many parts of the world. Acetylcysteine has long been recognized as an effective antidote, via oral or intravenous administration, minimizing the risk and severity of acute liver injury if administered sufficiently early after a paracetamol overdose. Despite this, its mechanisms of action remain obscure, and there is uncertainty regarding the optimal dose and duration of treatment. The intravenous infusion protocol was originally developed as a three-step loading regimen; it causes very high early peak plasma concentrations of acetylcysteine whereas the later maintenance infusion is associated with much lower concentrations. This pharmacokinetic profile is associated with two particular concerns: a high rate of occurrence of adverse effects that occur after the initial loading infusion, and the possibility that the maintenance phase of treatment might deliver too low a dose of acetylcysteine for optimum protection against liver injury. Recently described novel administration regimens offer different rates of intravenous acetylcysteine administration in both the loading and maintenance phases. These alternative regimens appear to be well tolerated in small patient groups, but too few clinical data are available to evaluate their comparative efficacy in preventing paracetamol-induced liver injury.
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Affiliation(s)
- W Stephen Waring
- Acute Medical Unit, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8HE, UK
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Mullins ME, Vitkovitsky IV. Hemolysis and Hemolytic Uremic Syndrome following Five-fold N-Acetylcysteine Overdose. Clin Toxicol (Phila) 2011; 49:755-9. [DOI: 10.3109/15563650.2011.609821] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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