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Austin E, Wolfe CE, Murphy NG. N-acetylcysteine for acetaminophen poisoning: translating poison center protocols to the bedside. CAN J EMERG MED 2024; 26:141-142. [PMID: 38358643 DOI: 10.1007/s43678-024-00660-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Emily Austin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Ontario Poison Centre, Toronto, ON, Canada.
| | - Caitlin E Wolfe
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
- Atlantic Canada Poison Centre, Halifax, NS, Canada
| | - Nancy G Murphy
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
- Atlantic Canada Poison Centre, Halifax, NS, Canada
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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: 1] [Impact Index Per Article: 1.0] [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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Prescott LF. Paracetamol (acetaminophen) poisoning: The early years. Br J Clin Pharmacol 2024; 90:127-134. [PMID: 37683599 DOI: 10.1111/bcp.15903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 09/10/2023] Open
Abstract
Paracetamol (acetaminophen) was marketed in the 1950s as a nonprescription analgesic/antipyretic without any preclinical toxicity studies. It became used increasingly for self-poisoning, particularly in the UK and was belatedly found to cause acute liver damage, which could be fatal. Management of poisoned patients was difficult as maximum abnormalities of liver function were delayed for 3 days or more after an overdose. There was no treatment and the mechanism of hepatotoxicity was not known. The paracetamol half-life was prolonged with liver damage occurring when it exceeded 4 h and the Rumack-Matthew nomogram was an important advance that allowed stratification of patients into separate zones of risk. It is used to guide prognosis and treatment and its predictive value could be increased by combining it with the paracetamol half-life. The problems of a sheep farmer in Australia in the early 1970s led to the discovery of the mechanism of paracetamol hepatotoxicity, and the first effective treatment of overdosage with intravenous (IV) cysteamine. This had unpleasant side effects and administration was difficult. N-acetylcysteine soon became the treatment of choice for paracetamol overdose and given early it was very effective when administered either IV or orally. N-acetylcysteine could cause anaphylactoid reactions, particularly early during IV administration when the concentrations were highest. Simpler and shorter regimes with slower initial rates of infusion have now been introduced with a reduced incidence of these adverse effects. In addition, there has been a move to use larger doses of N-acetylcysteine given over longer periods for patients who are more severely poisoned and those with risk factors. There has been much interest recently in the search for novel biomarkers such as microRNAs, procalcitonin and cyclophilin that promise to have greater specificity and sensitivity than transaminases. Paracetamol-protein adducts predict hepatotoxicity and are specific biomarkers of toxic paracetamol metabolite exposure. Another approach would be measurement of the plasma levels of cysteine and inorganic sulfate. It is 50 years since the first effective treatment for paracetamol poisoning and, apart from liver transplantation, there is still no effective treatment for patients who present late.
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Affiliation(s)
- Laurie F Prescott
- Emeritus Professor of Clinical Pharmacology, University of Edinburgh, Edinburgh, UK
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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: 1] [Impact Index Per Article: 1.0] [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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O'Callaghan C, Graudins A, Wong A. A two-bag acetylcysteine regimen is associated with shorter delays and interruptions in the treatment of paracetamol overdose. Clin Toxicol (Phila) 2021; 60:319-323. [PMID: 34402711 DOI: 10.1080/15563650.2021.1966027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The three-bag intravenous (IV) acetylcysteine regimen for paracetamol overdose is associated with frequent and long delays during treatment. This has not been previously studied in regard to the two-bag regimen. AIMS Our primary aim was to compare the cumulative duration of delays during IV acetylcysteine infusion between the three-bag and two-bag regimens. Secondary aims were to compare the frequency of delays and to identify causes for delay. METHODS This was a retrospective cohort study of patients receiving IV acetylcysteine for the treatment of paracetamol overdose, conducted at three Australian emergency departments. A cohort of patients treated with the three-bag regimen from October 2009 to October 2013 was compared to patients treated with the two-bag regimen from February 2014 to May 2020. Start times of each infusion were sourced from medical records and delays were calculated by comparing actual infusion time against prescribed time. Evidence of adverse drug reactions - gastrointestinal reactions and cutaneous and systemic non-allergic anaphylactoid reactions (NAARs) - were also recorded. RESULTS The three-bag cohort included 271 cases and the two-bag cohort included 598 cases. Delays were significantly shorter in the two-bag cohort, compared to the three-bag cohort: median delay 35 min (IQR: 15, 70) vs 65 min (IQR: 40, 105), p < 0.01. Delays longer than 1 h were less frequent in the two-bag cohort: 31% vs 51%, p < 0.01. NAARs were associated with significantly longer delays in both cohorts and were more frequent in the three-bag cohort. CONCLUSIONS The two-bag regimen was associated with significantly fewer and shorter delays. NAARs, which were more frequent in the three-bag cohort, were associated with significantly longer delays.
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Affiliation(s)
- Charlotte O'Callaghan
- Department of Medicine, School of Clinical Sciences at Monash Health. Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Andis Graudins
- Department of Medicine, School of Clinical Sciences at Monash Health. Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.,Monash Toxicology and Emergency Department, Monash Health, Victoria, Australia
| | - Anselm Wong
- Department of Medicine, School of Clinical Sciences at Monash Health. Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.,Monash Toxicology and Emergency Department, Monash Health, Victoria, Australia.,Austin Toxicology Unit and Emergency Department, Austin Health, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, University of Melbourne, Victoria, 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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Wong A. Comment on Truncated IV acetylcysteine treatment duration has potential to safely preserve resources during the COVID-19 pandemic. Clin Toxicol (Phila) 2020; 59:77-78. [PMID: 32870053 DOI: 10.1080/15563650.2020.1809667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Anselm Wong
- Austin Toxicology Unit and Emergency Department, Victorian Poisons Information Centre, Austin Health, Emergency Physician and Clinical Toxicologist, NHMRC Research Fellow, Heidelberg, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
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8
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Isbister GK, Chiew A. The changing face of paracetamol toxicity and new regimens for an old antidote acetylcysteine. Br J Clin Pharmacol 2020; 87:715-716. [PMID: 32748454 DOI: 10.1111/bcp.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Waratah, New South Wales, Australia
| | - Angela Chiew
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
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Ibrahim H, Perl A, Smith D, Lewis T, Kon Z, Goldenberg R, Yarta K, Staniloae C, Williams M. Therapeutic blockade of inflammation in severe COVID-19 infection with intravenous N-acetylcysteine. Clin Immunol 2020; 219:108544. [PMID: 32707089 PMCID: PMC7374140 DOI: 10.1016/j.clim.2020.108544] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023]
Abstract
Glucose 6-phosphate dehydrogenase (G6PD) deficiency facilitates human coronavirus infection due to glutathione depletion. G6PD deficiency may especially predispose to hemolysis upon coronavirus disease-2019 (COVID-19) infection when employing pro-oxidant therapy. However, glutathione depletion is reversible by N-acetylcysteine (NAC) administration. We describe a severe case of COVID-19 infection in a G6PD-deficient patient treated with hydroxychloroquine who benefited from intravenous (IV) NAC beyond reversal of hemolysis. NAC blocked hemolysis and elevation of liver enzymes, C-reactive protein (CRP), and ferritin and allowed removal from respirator and veno-venous extracorporeal membrane oxygenator and full recovery of the G6PD-deficient patient. NAC was also administered to 9 additional respirator-dependent COVID-19-infected patients without G6PD deficiency. NAC elicited clinical improvement and markedly reduced CRP in all patients and ferritin in 9/10 patients. NAC mechanism of action may involve the blockade of viral infection and the ensuing cytokine storm that warrant follow-up confirmatory studies in the setting of controlled clinical trials.
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Affiliation(s)
- Homam Ibrahim
- New York University Grossman School of Medicine, NY, New York, United States of America.
| | - Andras Perl
- Upstate Medical University Hospital, Syracuse, New York, United States of America.
| | - Deane Smith
- New York University Grossman School of Medicine, NY, New York, United States of America
| | - Tyler Lewis
- New York University Grossman School of Medicine, NY, New York, United States of America
| | - Zachary Kon
- New York University Grossman School of Medicine, NY, New York, United States of America
| | - Ronald Goldenberg
- New York University Grossman School of Medicine, NY, New York, United States of America
| | - Kinan Yarta
- New York University Grossman School of Medicine, NY, New York, United States of America
| | - Cezar Staniloae
- New York University Grossman School of Medicine, NY, New York, United States of America
| | - Mathew Williams
- New York University Grossman School of Medicine, NY, New York, United States of America
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Goodnough R, Canseco K. Truncated IV acetylcysteine treatment duration has potential to safely preserve resources during the COVID-19 pandemic. Clin Toxicol (Phila) 2020; 59:69. [PMID: 32345063 DOI: 10.1080/15563650.2020.1758327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Robert Goodnough
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Karla Canseco
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
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Wong A, Isbister G, McNulty R, Isoardi K, Harris K, Chiew A, Greene S, Gunja N, Buckley N, Page C, Graudins A. Efficacy of a two bag acetylcysteine regimen to treat paracetamol overdose (2NAC study). EClinicalMedicine 2020; 20:100288. [PMID: 32211597 PMCID: PMC7082646 DOI: 10.1016/j.eclinm.2020.100288] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/06/2020] [Accepted: 02/07/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Previous studies of paracetamol overdose treatment show that a 2-bag, 20-h intravenous (IV) acetylcysteine regimen decreased the incidence of non-allergic anaphylactic reactions compared to the 3-bag, 21 h IV regimen, but have not examined efficacy of the 20-h 2 bag regimen. METHODS This was a multi-centre observational study of paracetamol overdose presentations treated with a 2-bag IV acetylcysteine regimen (200 mg/kg over 4 h, 100 mg/kg over 16 h) compared to a 3-bag regimen, performed from 2009 to 2019. Patients were referred from the emergency department to the inpatient toxicology units for continued management. For the primary non-inferiority analysis: subjects had single, acute ingestions, a serum paracetamol-concentration performed 4 to 8-h post-ingestion. The primary outcome was development of acute liver injury (ALI), defined as peak ALT>150 U/L; and > double admission baseline ALT (for presentations within 24 h post-overdose). Secondary outcomes included adverse reactions to acetylcysteine (cutaneous and systemic). FINDING Out of 6419 paracetamol overdoses, 2763 received acetylcysteine. For the primary analysis, 1003 received the 2-bag and 783 the 3-bag acetylcysteine regimen. When presentation bloods were performed 4 to 8-h post-overdose, 21 (3.1%) developed ALI with the 2-bag regimen vs 16 (2.9%) with the 3-bag regimen (Difference: 0.2%, 95%CI:-1.6 to 2.2). The incidence of hepatotoxicity was: 1.2% (n = 8) with the two-bag regimen and 1.6% (n = 9) with the three-bag regimen (Difference -0.4%, 95%CI -1.75, 0.91). When presentation bloods were performed 8 to 24-h post-overdose, 70 (21%) developed ALI with the 2-bag regimen vs 46 (23%) with the 3-bag regimen (Difference: -2%, 95%CI -9.12 to 5.36). There were significantly less cutaneous and systemic non-allergic anaphylactic reactions recorded after treatment with the two-bag than the three-bag regimen (1.3% [n = 17] and 7.1% [n = 65], Difference: -5.8%, 95%CI -7.6 to -4.0, p < 0.0001), respectively. INTERPRETATION A two-bag intravenous acetylcysteine regimen was found to be non-inferior to the three-bag regimen with regards to efficacy in preventing acute liver injury for early presentations of paracetamol overdose. No important differences were seen for any other presentations. The two-bag regimen also decreased the incidence of both non-allergic anaphylactic reactions and gastrointestinal adverse events from acetylcysteine treatment. FUNDING AW is funded by a National Health and Medical Research Council (NHMRC) Early Career Fellowship ID 1159907. GI is funded by a NHMRC Senior Research Fellowship ID 1061041. The NHMRC had no role in the design, writing of this manuscript. The corresponding author (AW) had full access to all the data in the study and final responsibility for the decision to submit the manuscript for publication.
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Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Unit, Victoria, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Geoff Isbister
- Clinical Toxicology Research Group, University of Newcastle, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, NSW, Australia
| | - Richard McNulty
- Department of Emergency Medicine, Blacktown Mount Druitt hospitals, Sydney, Australia
- Western Sydney Toxicology Service, Western Sydney LHD, Sydney, Australia
| | - Katherine Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Keith Harris
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Angela Chiew
- Clinical Toxicology Unit, Princes of Wales Hospital, Randwick, NSW, Australia
- Pharmacology, Faculty of Medicine and Health, University of Sydney, Australia
| | - Shaun Greene
- Victorian Poisons Information Centre and Austin Toxicology Unit, Victoria, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, Victoria, Australia
- Department of Forensic Medicine, Monash University, Victoria, Australia
- Guy's and St Thomas’ NHS Foundation Trust, United Kingdom
| | - Naren Gunja
- Western Sydney Toxicology Service, Western Sydney LHD, Sydney, Australia
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
- Emergency Medicine, Westmead Clinical School, University of Sydney, Australia
| | - Nicholas Buckley
- Department of Pharmacology, Faculty of Medicine and Health, University of Sydney, Australia
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Colin Page
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andis Graudins
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
- Monash Toxicology Unit, Dandenong Hospital, Monash Health, Victoria, Australia
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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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Daoud A, Dalhoff KP, Christensen MB, Bøgevig S, Petersen TS. Two-bag intravenous N-acetylcysteine, antihistamine pretreatment and high plasma paracetamol levels are associated with a lower incidence of anaphylactoid reactions to N-acetylcysteine. Clin Toxicol (Phila) 2019; 58:698-704. [PMID: 31601129 DOI: 10.1080/15563650.2019.1675886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Context: N-acetylcysteine (NAC) is used worldwide to prevent liver injury after paracetamol overdoses. Anaphylactoid reactions to NAC occur frequently and often lead to treatment interruptions or discontinuations. In Denmark in 2013, the NAC treatment regimen was simplified from a three-bag to a two-bag NAC regimen. Factors of importance for the development of anaphylactoid reaction to this new regimen are poorly explored. Previous studies have suggested a protective effect of high plasma levels of paracetamol on the development of anaphylactoid reactions. Likewise, exposure to antihistamines prior to NAC treatment may protect against these reactions.Methods: This is a retrospective cohort study of patients treated with NAC and with at least one plasma paracetamol sample performed in the Capital Region of Denmark from 2010 to 2017. The primary outcome was the incidence of anaphylactoid reactions to NAC requiring intravenous treatment with antihistamines and/or glucocorticoids. Logistic regression analyses were carried out to identify the risk of developing an anaphylactoid reaction to NAC affected by influencing factors.Results: Of 4315 admissions included in the study, 259 (6.0%) developed an anaphylactoid reaction to NAC. The two-bag regimen (adjusted OR 0.44 [95%CI: 0.32-0.60]), increasing age (adjusted OR 0.84 [95%CI: 0.78-0.90] per 10-year increase) or children <10 years (adjusted OR 0.14 [95%CI: 0.04-0.36]) and antihistamine co-ingestion in overdose (adjusted OR 0.17 [95%CI: 0.02-0.64]) were associated with significantly fewer anaphylactoid reactions. High plasma paracetamol concentrations protected against development of anaphylactoid reactions during the two-bag regimen (adjusted OR 0.59 [95%CI: 0.47-0.71] and three-bag regimen 0.82 [95%CI: 0.72-0.94] per doubling of paracetamol concentration). The effect differed between the two regimens (p = .004 for interaction).Conclusion: In this retrospective cohort, a high peak plasma paracetamol concentration, age, antihistamine co-ingestion and use of the two-bag NAC regimen were associated with fewer anaphylactoid reactions to NAC.
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Affiliation(s)
- Alaa Daoud
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark
| | - Kim Peder Dalhoff
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark.,Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikkel Bring Christensen
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark.,Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Bøgevig
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark.,Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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14
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Graudins A, Wong A. Paracetamol overdose: limiting the potential for harm. Med J Aust 2019; 211:211-212. [DOI: 10.5694/mja2.50306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Andis Graudins
- Monash Health Melbourne VIC
- Monash University Melbourne VIC
| | - Anselm Wong
- Monash University Melbourne VIC
- Victorian Poisons Information CentreAustin Hospital Melbourne VIC
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15
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Bateman DN, Dear JW. Acetylcysteine in paracetamol poisoning: a perspective of 45 years of use. Toxicol Res (Camb) 2019; 8:489-498. [PMID: 31341611 PMCID: PMC6610312 DOI: 10.1039/c9tx00002j] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/26/2019] [Indexed: 12/28/2022] Open
Abstract
Paracetamol poisoning was first reported in 1966. The development of antidotes followed within 10 years, and by 1980 acetylcysteine (NAC) was acknowledged as the optimal therapy available. This article examines the history of the development of NAC and recent developments in its use. We offer suggestions for improvements in the way NAC may be administered and outline new developments that should have major impacts on the way we manage paracetamol poisoning in the near future.
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Affiliation(s)
- D Nicholas Bateman
- Pharmacology , Toxicology and Therapeutics , University of Edinburgh , Edinburgh , UK .
| | - James W Dear
- Pharmacology , Toxicology and Therapeutics , University of Edinburgh , Edinburgh , UK .
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16
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Wong A, Graudins A, Heard K, Dalhoff K, Sivilotti ML. Improving the management of the paracetamol poisoned patient. EClinicalMedicine 2019; 12:10. [PMID: 31388658 PMCID: PMC6677687 DOI: 10.1016/j.eclinm.2019.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/18/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre, Emergency Department and Austin Toxicology Unit, Austin Health, Heidelberg, Victoria 3084, Australia
- School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
- Centre for Integrated Critical Care, University of Melbourne, Victoria, Australia
- Corresponding author.
| | - Andis Graudins
- Monash Toxicology Service and Monash Emergency Research Collaborative, Dandenong Hospital, Victoria, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Kennon Heard
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Kim Dalhoff
- Department of Clinical Medicine, Bispebjerg-Frederiksberg Hospital -, Bispebjerg, Denmark
| | - Marco L.A. Sivilotti
- Departments of Emergency and of Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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17
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Chiew AL, Buckley NA. SNAP - A Large Step in the Move towards Personalised Dosing of Acetylcysteine. EClinicalMedicine 2019; 11:3-4. [PMID: 31317127 PMCID: PMC6611096 DOI: 10.1016/j.eclinm.2019.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Angela L. Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
| | - Nicholas A. Buckley
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
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18
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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: 39] [Impact Index Per Article: 7.8] [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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19
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ROS Reduction Does Not Decrease the Anticancer Efficacy of X-Ray in Two Breast Cancer Cell Lines. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:3782074. [PMID: 31001373 PMCID: PMC6437742 DOI: 10.1155/2019/3782074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/02/2019] [Indexed: 12/16/2022]
Abstract
Radiotherapy is effective on a large number of cancer types and is one of the most frequently administrated treatments for cancer patients. The anticancer efficacy of X-ray radiotherapy has been frequently correlated with reactive oxygen species (ROS) elevation, which is also a limiting factor for its toxicity on normal tissues. Here, we found that although 4-10 Gy X-rays could significantly reduce cell numbers in both MDA-MB-231 and MCF-7 breast cancer cells, the ROS level changes are less in MCF-7 cells than in MDA-MB-231 cells. Moreover, although both the ROS scavenger N-acetyl-L-cysteine (NAC) and 1 T static magnetic field (SMF) could reduce X-ray-induced ROS elevation, they did not prevent X-ray-induced cell number reduction or cell death increase, which is significantly different from cisplatin. These results demonstrate that although the anticancer efficacy of cisplatin on two breast cancer cell lines is dependent on ROS, the anticancer efficacy of X-ray is not. Moreover, by testing 19 different cell lines, we found that 1 T SMF could effectively reduce ROS levels in multiple cell lines by 10-20%, which encourages further studies to investigate whether SMF could be used as a potential "physical antioxidant" in the future.
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20
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Wong A, Nejad C, Gantier M, Choy KW, Doery J, Graudins A. MicroRNA from a 12-h versus 20-h acetylcysteine infusion for paracetamol overdose. Hum Exp Toxicol 2019; 38:646-654. [PMID: 30838890 DOI: 10.1177/0960327119833740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paracetamol overdose is common and microRNA (miR)-122 expression is increased with liver injury. We aimed to measure miR-122 in the setting of an abbreviated paracetamol overdose treatment regimen. We compared miRNA expression in patients treated for paracetamol poisoning with an abbreviated 12-h intravenous acetylcysteine regimen (200 mg/kg over 4 h, 50 mg/kg over 8 h) or a 20-h regimen (200 mg/kg over 4 h, 100 mg/kg over 16 h) (NACSTOP trial). miR-122 expression is increased (decreased cycle threshold (Ct) values) with paracetamol liver injury. We assessed miR-122 expression in patients receiving the two acetylcysteine regimens and in a separate group with acute liver injury (ALI). We examined 121 blood samples in 38 patients. After 20 h of acetylcysteine, median alanine transaminase (ALT) was 12 U/L (18, 14) versus 16 U/L (11, 21) ( p = 0.17) and median miR-122 Ct was 30.1 (interquartile range (IQR): 28.9, 33.3) versus 31.4 (28.9, 33.9) ( p = 0.7) in the NACSTOP abbreviated and control groups, respectively. Median normalized miR-122 Ct after 20 h of acetylcysteine was 2.2 (IQR 1.9, 6.4), 1.1 (0.7, 2.9), 63.9 (2.5, 168), 123.2 (40.9, 207.8) in the NACSTOP-abbreviated, NACSTOP-control, ALI and hepatotoxicity groups, respectively. There was no significant difference in ALT or miRNA between NACSTOP treatment groups and no signal of increased liver injury from an abbreviated 12-h acetylcysteine regimen. These findings suggest that an abbreviated acetylcysteine regimen in low-risk patients who have overdosed on paracetamol is safe. Further study is required to validate this finding utilizing miRNA as a comparative biomarker.
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Affiliation(s)
- A Wong
- 1 Monash Toxicology Unit and Emergency Medicine Service, Monash Health, Victoria, Australia.,2 Austin Toxicology and Emergency Department, Austin Health, Victoria, Australia.,3 Department of Medicine, Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - C Nejad
- 4 Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia.,5 Department of Molecular and Translational Science, Monash University, Clayton, Victoria, Australia
| | - M Gantier
- 4 Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Monash University, Clayton, Victoria, Australia.,5 Department of Molecular and Translational Science, Monash University, Clayton, Victoria, Australia
| | - K W Choy
- 6 Monash Pathology Department, Monash Health, Victoria, Australia
| | - James Doery
- 3 Department of Medicine, Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,6 Monash Pathology Department, Monash Health, Victoria, Australia
| | - A Graudins
- 1 Monash Toxicology Unit and Emergency Medicine Service, Monash Health, Victoria, Australia.,3 Department of Medicine, Clinical Sciences at Monash Health, Monash University, Victoria, Australia
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21
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Wong A, Homer N, Dear JW, Choy KW, Doery J, Graudins A. Paracetamol metabolite concentrations following low risk overdose treated with an abbreviated 12-h versus 20-h acetylcysteine infusion. Clin Toxicol (Phila) 2018; 57:312-317. [PMID: 30453788 DOI: 10.1080/15563650.2018.1517881] [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: 10/27/2022]
Abstract
CONTEXT To compare degree of liver injury and paracetamol metabolite concentrations after treatment with standard of care (20-h) vs. abbreviated (12-h) acetylcysteine regimens used in paracetamol overdose (NACSTOP trial). METHODS Timed blood samples from a cohort of subjects enrolled in the cluster-controlled NACSTOP trial evaluating a 12-h acetylcysteine regimen (200 mg/kg over 4 h, 50 mg/kg over 8 h) were assayed for paracetamol metabolites as a pilot study, using liquid chromatography/mass spectrometry. Control group subjects received a 20-h course of acetylcysteine (200 mg/kg over 4 h, 100 mg/kg over 16 h). The intervention group received a 12-h acetylcysteine regimen (stopped after at least 12 h of treatment). Positive control groups not in the trial with acute liver injury (ALI) or hepatotoxicity were also studied. RESULTS One hundred and forty-one blood samples were collected from 40 patients receiving acetylcysteine after paracetamol overdose. Median ALT after 20 h of acetylcysteine was 12 U/L (IQR 8.14) in the abbreviated regimen group, compared to the control group 16 U/L (IQR 11.21) (p = .46). There was no significant difference in median metabolite concentrations on presentation and after 20 h of acetylcysteine between these two groups (p > .05). Presentation median sum CYP-metabolite/total metabolite percentages were 2.5 and 3.0 in the abbreviated and control NACSTOP groups, respectively. CONCLUSIONS An abbreviated 12-h acetylcysteine regimen for paracetamol overdose used in the NACSTOP trial had similar circulating metabolite concentrations compared to a 20-h regimen in selected subjects with low risk of hepatotoxicity. This suggests that further acetylcysteine may not be needed in the abbreviated group at time of cessation.
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Affiliation(s)
- Anselm Wong
- a Monash Toxicology Unit and Emergency Medicine Service , Monash Health , Victoria , Australia.,b Department of Medicine, School of Clinical Sciences , Monash University , Victoria , Australia.,c Austin Toxicology Service , Austin Health , Victoria , Australia
| | - Natalie Homer
- d Edinburgh Clinical Research Facility , Queen's Medical Research Institute , Edinburgh , UK
| | - James W Dear
- e Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Sciences , University of Edinburgh , Edinburgh , UK
| | - Kay Weng Choy
- f Monash Pathology , Monash Health , Victoria , Australia
| | - James Doery
- b Department of Medicine, School of Clinical Sciences , Monash University , Victoria , Australia.,f Monash Pathology , Monash Health , Victoria , Australia
| | - Andis Graudins
- a Monash Toxicology Unit and Emergency Medicine Service , Monash Health , Victoria , Australia.,b Department of Medicine, School of Clinical Sciences , Monash University , Victoria , Australia
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