Effect of activated charcoal in 70% sorbitol in healthy individuals

Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose

INTRODUCTION

The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations.

OBJECTIVES

The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal?  Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal.

METHODS

A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations.  One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study.

RESULTS

From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals.

CONCLUSIONS

This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death.  Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.

Effect of single dose administration activated charcoal containing sorbitol on serum sodium concentration and hydration status in dogs

OBJECTIVE

To assess the administration of a commercially available activated charcoal suspension with sorbitol (ACS) on serum sodium concentrations and hydration status in healthy dogs.

DESIGN

Prospective study.

SETTING

Private referral hospital.

ANIMALS

Nine healthy adult dogs.

INTERVENTIONS

Dogs were administered 1 mg/kg maropitant (Cerenia; Pfizer Animal Health, New York, NY) intravenously 1 hour prior to charcoal administration. Dogs were administered a single dose of 2 g/kg ACS.

MEASUREMENTS AND MAIN RESULTS

Blood samples and body weights were obtained prior to charcoal administration and 2, 4, 6, 8, 10, and 12 hours post ACS administration. Venous sodium, potassium, chloride, blood urea nitrogen, creatinine, lactate, packed cell volume, and total plasma protein were measured at each time interval. All dogs returned 2-4 weeks after ACS administration for a 12 hour period of water restriction and to serve as their own control group. The same measurements were repeated during water restriction period as following ACS administration. The increase in serum sodium concentration was significantly higher following ACS administration when compared to control period (P = 0.0002). All dogs administered ACS experienced a significant degree of weight loss (P = 0.0371) when compared to the control period. Following administration of ACS, the hematocrit of the dogs administered ACS was found to be significantly increased (P = 0.0001), when compared to the control period.

CONCLUSION

Patients that are administered a single dose of ACS are at risk of developing dehydration and secondary hypernatremia as observed in the dogs during the study period. Patients receiving ACS should have electrolytes monitored and would benefit from fluid therapy as previously recommended.

Position Paper: Cathartics

The administration of a cathartic alone has no role in the management of the poisoned patient and is not recommended as a method of gut decontamination. Experimental data are conflicting regarding the use of cathartics in combination with activated charcoal. No clinical studies have been published to investigate the ability of a cathartic, with or without activated charcoal, to reduce the bioavailability of drugs or to improve the outcome of poisoned patients. Based on available data, the routine use of a cathartic in combination with activated charcoal is not endorsed. If a cathartic is used, it should be limited to a single dose in order to minimize adverse effects of the cathartic. A review of the literature since the preparation of the 1997 Cathartics Position Statement revealed no new evidence that would require a revision of the conclusions of the Statement.

Position statement: cathartics. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists

In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the Boards of the two societies and being endorsed by other societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. The administration of a cathartic alone has no role in the management of the poisoned patient and is not recommended as a method of gut decontamination. Experimental data are conflicting regarding the use of cathartics in combination with activated charcoal. No clinical studies have been published to investigate the ability of a cathartic, with or without activated charcoal, to reduce the bioavailability of drugs or to improve the outcome of poisoned patients. Based on available data, the routine use of a cathartic in combination with activated charcoal is not endorsed. If a cathartic is used, it should be limited to a single dose in order to minimize adverse effects.

Theophylline toxicity

Theophylline toxicity continues to be a commonly encountered clinical problem. Patients may present with a vast array of toxic manifestations, including life-threatening cardiovascular and neurologic toxicity. Despite the considerable attention this topic has received in the literature, there remain some important controversies regarding the identification of high risk patients and how best to manage them. This review attempts to summarize the current state of knowledge regarding theophylline toxicity with special emphasis on toxic manifestations and the role of elimination enhancing modalities.

[Oral administration of activated charcoal-sorbitol suspension as first aid in prevention of poison resorption?]

Due to its paramount adsorption capacity, activated charcoal is supposed to be the remedy of choice for binding a variety of drugs in the gastrointestinal tract. Hence it is surprising--at least according to the advice of German textbooks--that activated charcoal is only recommended for administration after time-consuming treatments like induced emesis and gastric lavage. Particularly with infants at home, a ready-for-use suspension of activated charcoal would allow the early management of acute poisoning. In such cases, inactivation of the poison by adsorption could be particularly helpful, since the period after ingestion is usually short. The charcoal-sorbitol-suspension (30 g activated charcoal in 150 ml of 70% sorbitol) is a creamy preparation which is easy to drink, because density and viscosity prevent sedimentation. The prescription-free drugs can be dispensed by each pharmacist. The present study was undertaken to investigate the influence of sorbitol on the adsorption capacity of activated charcoal. To this end, adsorption isotherms were established in vitro and compared with results in volunteers to whom NAPAP, diphenhydramine or codeine was administered separately. These drugs are gaining increasing importance in medicinal toxicology since they are constituents of various analgesics and cold remedies. To determine absorption, the cumulative urinary excretion was estimated of the parent drugs and their main metabolites.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypernatremia due to repeated doses of charcoal-sorbitol

Hypernatremic dehydration due to unreplaced stool water losses often complicates the use of the osmotic cathartic lactulose in the treatment of hepatic encephalopathy. Sorbitol, another osmotic cathartic commonly used in the treatment of drug intoxications, has been reported in the pediatric literature to induce severe hypernatremia, but there is only a rare case report in an adult. We report a dramatic case of severe hypernatremia secondary to repetitive administration of activated charcoal-sorbitol suspension for the treatment of phenobarbital intoxication in an adult. Based on our experience with this case, several recommendations are provided regarding management of drug intoxications with charcoal-sorbitol suspension, including meticulous attention to fluid-electrolyte balance, type of replacement fluid, and dosing of the suspension.

Acute sulfasalazine overdose

Sulfasalazine (salicylazosulfapyridine, Azulfidine) has been widely used over the last half century for inflammatory bowel diseases, but overdose has not been reported. A 23 year-old male ingested 25 g of sulfasalazine in a suicide attempt. He underwent prompt treatment and survived with no ill-effects.

The effect of activated charcoal on phenytoin pharmacokinetics

STUDY OBJECTIVES

To examine the effect of administration of oral activated charcoal with or without sorbitol on the elimination of phenytoin.

SETTING

Emergency department of a rural teaching institution.

TYPE OF PARTICIPANTS

Eight normal volunteers.

INTERVENTIONS

Subjects received 15 mg/kg phenytoin as an IV infusion. During the first phase of the study, oral activated charcoal was administered to a total dose of 140 g over a ten-hour period. During the second phase of the study, phenytoin alone was administered.

MEASUREMENTS AND MAIN RESULTS

Administration of activated charcoal resulted in a significant decrease in the area under the curve 0-inf (p = .008) and in total body clearance (P = .008). No difference in the effect on phenytoin pharmacokinetic parameters was noted when the charcoal was administered with or without sorbitol, but fewer gastrointestinal adverse effects were noted without sorbitol treatment.

CONCLUSION

Oral activated charcoal was shown to affect phenytoin pharmacokinetic parameters. Further pharmacokinetic/pharmacodynamic studies are warranted to determine if activated charcoal results in a faster recovery from phenytoin toxicity.

Excipients in valproic acid syrup may cause diarrhea: a case report

A 5-year-old child receiving valproic acid syrup for seizure control developed diarrhea probably from the excipient ingredients. Each 5 mL of valproic acid syrup contains sucrose 3 g, glycerin 0.75 g, and sorbitol 0.75 g, providing daily amounts of 36, 9, and 9 g of sucrose, glycerin, and sorbitol, respectively. The diarrhea resolved when the child was switched to another valproic acid product. Clinicians should be aware of potential problems that may occur from excipient ingredients in pharmaceutical products when evaluating adverse effects of medications.

Contribution of sorbitol combined with activated charcoal in prevention of salicylate absorption

The use of cathartics and activated charcoal in treating toxic ingestions has become a standard treatment modality. Sorbitol has been shown to be the most rapidly acting cathartic, but its therapeutic significance has been debated. Using a previously described aspirin overdose model, ten healthy volunteers participated in a crossover design study that investigated the effect of activated charcoal alone versus that of activated charcoal and sorbitol in preventing salicylate absorption. In phase 1 of the study, subjects consumed 2.5 g aspirin followed by 25 g activated charcoal one hour later. Urine was collected for 48 hours and analyzed for quantitative salicylate metabolites. Phase 2 was identical except that 1.5 g/kg sorbitol was consumed with the activated charcoal. The mean amount of aspirin absorbed without the use of sorbitol was 1.26 +/- 0.15 g, whereas the mean absorption was 0.912 +/- 0.18 g with the addition of sorbitol. This is a 28% decrease in absorption of salicylates attributable to the use of sorbitol. The difference is significant at P less than .05 by the paired Student's t test. This study demonstrates that the addition of sorbitol significantly decreases drug absorption in a simulated drug overdose model. Effects on absorption in actual overdose situations and on patient outcome should be the subjects of further study.

Toxicodynamic approach to management of the poisoned patient

We recommend a toxicodynamic approach to the management of the poisoned patient. We define the period between ingestion and onset of toxic manifestations (clinical or laboratory) as the preclinical phase, during which the management of the patient necessarily depends solely on the history of ingestion and the predicted toxicity. In the toxic phase during which the patient shows clinical or laboratory evidence of toxicity, the history, clinical status (signs, symptoms, drug levels, laboratory parameters), and toxicodynamics should guide the therapy. In the resolution phase, when the patient shows clinical improvement and declining drug levels, treatment should be based on clinical status. Gastrointestinal decontamination is critical in the first two phases and may be of value during the resolution phase until the body drug burden declines to safe levels. We recommend an aggressive approach to gastrointestinal decontamination, especially in the preclinical phase. With a history of a potentially toxic ingestion of an absorbable drug, an observation period until passage of a charcoal-laden stool should be achieved before discharge of the patient.

Effects of activated charcoal and sorbitol on sodium pentobarbital absorption in the rat

Three activated charcoals were tested for their ability to reduce the oral absorption of sodium pentobarbital (SP) in rats. Fasted adult, male rats were given 40 mg/kg of C-14 labelled SP by gavage (2 ml). Five minutes after drug administration, the animals were given 40 mg of either Darco (G-60), United States Pharmacopeia (USP) or SuperChar (SC) activated charcoals. The charcoals were administered as a slurry in either 1 ml of water, or 1 ml of 70 percent (w/v) sorbitol solution. Water (control) and sorbitol given alone were tested separately. Various pharmacokinetic parameters were calculated from the plasma concentration of SP determined at various time intervals after drug administration. When given in water, only SC significantly (p less than .01) reduced the peak plasma concentration and oral bioavailability of SP. Sorbitol given alone produced diarrhea but did not affect drug absorption. However, sorbitol selectively enhanced the effectiveness of G-60 and USP charcoals and, as a result, all charcoals significantly reduced SP absorption when given along with the cathartic. The results suggest that when given in water, charcoal antidotal effectiveness is proportional to absorptive surface area, and that sorbitol may enhance the antidotal effectiveness of some charcoals but not others.

Dosage recommendations for activated charcoal-sorbitol treatment

Activated charcoal-sorbitol mixture is used for the treatment of acute poisoning. Based on our experience with healthy adults, overdosed patients and published reports, we have devised a protocol for use of this mixture in different concentrations of sorbitol. The dose is based on the size of the patient, type of poison, and the clinical status. In seriously ill adult patients, we recommend the use of 1 g/kg of activated charcoal in 4.3 ml/kg body weight of 70% sorbitol every 4 hours until the first stool containing charcoal appears. In children and ambulatory adults, the same dose of activated charcoal may be administered in 4.3 ml/kg body weight of 35% sorbitol. Patients requiring multiple doses may be administered activated charcoal as aqueous and sorbitol suspensions alternately every 2-6 hours after the first charcoal stool has appeared. The patients on multiple dose regimen, especially children, should be closely monitored for any fluid or electrolyte imbalance or depletion of essential vitamins.

Gastrointestinal transit times of cathartics combined with charcoal

Oral activated charcoal usually is administered in toxic ingestions along with a cathartic. A study was done in volunteers to determine the rapidity of gastrointestinal transit when activated charcoal was administered with various cathartics. A control of activated charcoal was compared to the gastrointestinal transit times of activated charcoal plus the cathartics magnesium citrate, magnesium sulfate, or sorbitol. Activated charcoal alone produced a mean transit time of 23.5 hours; magnesium citrate catharsis occurred in 4.2 hours, magnesium sulfate catharsis occurred in 9.3 hours, and sorbitol catharsis occurred in 0.9 hours. Sorbitol clearly was the most rapidly acting cathartic.