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Sami F, Berg S, Manadan AM, Mycyk MB. Acetaminophen overdose: analysis of 2018 US nationwide emergency database. Intern Emerg Med 2024; 19:1727-1732. [PMID: 38446370 DOI: 10.1007/s11739-024-03555-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Recognized risk factors for acetaminophen overdose include alcohol, opioids, and mood disorders. The aim of this study is to assess additional risk factors for acetaminophen overdose evaluated in the emergency department (ED). METHODS A retrospective study was performed using the 2018 US Nationwide Emergency Department Sample (NEDS). All adult ED visits for acetaminophen overdose were included in the study group and those without it were taken as control. STATA, 16.1 was used to perform multivariable logistic regression analysis and adjusted odds ratios (ORadj) were reported. RESULTS We identified 27,792 ED visits for acetaminophen overdose. Relative to non-acetaminophen ED visits, this group was younger (median age 32 vs 47 years; p < 0.0001), more often female (66.1% vs 57.0%; p < 0.0001), had higher ED charges ($3,506 vs $2,714; p < 0.0001), higher proportion of alcohol-related disorders (15.8% vs 3.5%; p < 0.0001), anxiety disorders (30.2% vs 8.3%; p < 0.0001), cannabis use (8.7% vs 1.4%; p < 0.0001), hematology/oncology diagnoses (13.3% vs 10.9%; p < 0.0001), mood disorders (52.4% vs 7.9%; p < 0.0001), opioid-related disorders (4.1% vs 1.0%; p < 0.0001), and suicide attempt/ideation (12.2% vs 1.1%; p < 0.0001). Multivariable analysis showed alcohol-related disorders (ORadj 2.67), anxiety disorders (ORadj 1.24), cannabis (ORadj 1.63), females (ORadj 1.45), Income Q3 (ORadj 1.09), hematology/oncology diagnoses (ORadj 1.40), mood disorders (ORadj 10.07), opioid-related disorders (ORadj 1.20), and suicide attempt/ideation (ORadj 1.68) were associated with acetaminophen overdose. CONCLUSION In addition to previously recognized risks, our study demonstrated that cannabis use and hematologic/oncologic comorbidities were more common among acetaminophen-overdose ED visits. These new findings are concerning because of rapid legalization of cannabis and the increasing incidence of cancer worldwide. Additional investigation into these risks should be a priority for clinicians, policymakers, and researchers.
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Affiliation(s)
- Faria Sami
- Department of Internal Medicine, Cook County Health, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - Sarah Berg
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, Chicago, USA
| | | | - Mark B Mycyk
- Department of Emergency Medicine, Cook County Health, Chicago, USA
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McGill MR, Curry SC. The Evolution of Circulating Biomarkers for Use in Acetaminophen/Paracetamol-Induced Liver Injury in Humans: A Scoping Review. LIVERS 2023; 3:569-596. [PMID: 38434489 PMCID: PMC10906739 DOI: 10.3390/livers3040039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Acetaminophen (APAP) is a widely used drug, but overdose can cause severe acute liver injury. The first reports of APAP hepatotoxicity in humans were published in 1966, shortly after the development of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as the first biomarkers of liver injury as opposed to liver function. Thus, the field of liver injury biomarkers has evolved alongside the growth in APAP hepatotoxicity incidence. Numerous biomarkers have been proposed for use in the management of APAP overdose patients in the intervening years. Here, we comprehensively review the development of these markers from the 1960s to the present day and briefly discuss possible future directions.
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Affiliation(s)
- Mitchell R McGill
- Dept. of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72212, USA
- Dept. of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72212, USA
- Dept. of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72212, USA
| | - Steven C Curry
- Division of Clinical Data Analytics and Decision Support, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85006, USA
- Department of Medical Toxicology, Banner-University Medical Center Phoenix, Phoenix, AZ 85006, USA
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Shekunov J, Lewis CP, Vande Voort JL, Bostwick JM, Romanowicz M. Clinical Characteristics, Outcomes, Disposition, and Acute Care of Children and Adolescents Treated for Acetaminophen Toxicity. Psychiatr Serv 2021; 72:758-765. [PMID: 33887959 PMCID: PMC9645125 DOI: 10.1176/appi.ps.202000081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Acetaminophen is a common cause of intentional and inadvertent overdoses among children and adolescents worldwide. Little is known about characteristics and clinical outcomes of these youths. The primary goal of this naturalistic study was to describe the psychiatric characteristics, medical management, outcomes, and dispositions of children and adolescents evaluated for excessive acetaminophen exposure. METHODS The Rochester Epidemiology Project database was searched for all patients ages 0-18 treated for excessive acetaminophen exposure in Olmsted County, Minnesota, during a 7-year period (2004-2010). Demographic factors, overdose intentionality, medical and psychiatric treatment, mental health and addiction history, and disposition from the emergency department (ED) were documented. RESULTS Of 110 cases of acetaminophen overdose (89 female patients and 21 male patients), 97 (88%) were intentional and 13 (12%) were unintentional. Fifteen patients (14%) were discharged from the ED, and 69 (63%) required admission to a medical unit. Sixty-four (59%) received N-acetylcysteine. Ninety-eight (89%) were evaluated by psychiatry, and 80 (73%) were admitted for psychiatric hospitalization. Most had at least one psychiatric diagnosis, most commonly depression (55%); 22 (20%) had a prior suicide attempt. Substance use was common, notably alcohol dependence (N=16, 15%), alcohol abuse (N=18, 16%), and cannabis abuse (N=18, 16%). All survived and recovered without liver transplant. CONCLUSIONS Among pediatric patients with acetaminophen overdoses, psychiatric comorbidities and substance use were common. Most received both inpatient medical and psychiatric treatment. Interventions that restrict acetaminophen access are needed for this population, as are suicide risk reduction interventions for delivery in emergency settings.
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Affiliation(s)
- Julia Shekunov
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota (Shekunov, Vande Voort, Bostwick, Romanowicz); Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis (Lewis)
| | - Charles P Lewis
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota (Shekunov, Vande Voort, Bostwick, Romanowicz); Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis (Lewis)
| | - Jennifer L Vande Voort
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota (Shekunov, Vande Voort, Bostwick, Romanowicz); Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis (Lewis)
| | - J Michael Bostwick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota (Shekunov, Vande Voort, Bostwick, Romanowicz); Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis (Lewis)
| | - Magdalena Romanowicz
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota (Shekunov, Vande Voort, Bostwick, Romanowicz); Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis (Lewis)
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The Late-Stage Protective Effect of Mito-TEMPO against Acetaminophen-Induced Hepatotoxicity in Mouse and Three-Dimensional Cell Culture Models. Antioxidants (Basel) 2020; 9:antiox9100965. [PMID: 33050213 PMCID: PMC7601533 DOI: 10.3390/antiox9100965] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023] Open
Abstract
An overdose of acetaminophen (APAP), the most common cause of acute liver injury, induces oxidative stress that subsequently causes mitochondrial impairment and hepatic necroptosis. N-acetyl-L-cysteine (NAC), the only recognized drug against APAP hepatotoxicity, is less effective the later it is administered. This study evaluated the protective effect of mitochondria-specific Mito-TEMPO (Mito-T) on APAP-induced acute liver injury in C57BL/6J male mice, and a three dimensional (3D)-cell culture model containing the human hepatoblastoma cell line HepG2. The administration of Mito-T (20 mg/kg, i.p.) 1 h after APAP (400 mg/kg, i.p.) injection markedly attenuated the APAP-induced elevated serum transaminase activity and hepatic necrosis. However, Mito-T treatment did not affect key factors in the development of APAP liver injury including the activation of c-jun N-terminal kinases (JNK), and expression of the transcription factor C/EBP homologous protein (CHOP) in the liver. However, Mito-T significantly reduced the APAP-induced increase in the hepatic oxidative stress marker, nitrotyrosine, and DNA fragmentation. Mito-T markedly attenuated cytotoxicity induced by APAP in the HepG2 3D-cell culture model. Moreover, liver regeneration after APAP hepatotoxicity was not affected by Mito-T, demonstrated by no changes in proliferating cell nuclear antigen formation. Therefore, Mito-T was hepatoprotective at the late-stage of APAP overdose in mice.
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Tobaiqy M, MacLure K, Radwi M, Almalki AM, Alhasan AH, Tannoury M, Attieh Z. Parental Experience of Potential Adverse Drug Reactions Related to Their Oral Administration of Antipyretic Analgesic Medicines in Children in Saudi Arabia. CURRENT THERAPEUTIC RESEARCH 2020; 92:100592. [PMID: 32714474 PMCID: PMC7378853 DOI: 10.1016/j.curtheres.2020.100592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/13/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Oral antipyretic analgesic medicines are commonly used in children and have the potential for adverse drug reactions (ADRs). OBJECTIVE The aim of this study was to explore parental experiences of potential ADRs related to their oral administration of antipyretic analgesics in children in the Kingdom of Saudi Arabia. METHODS For this cross-sectional survey, a paper-based questionnaire, consent form and information sheet were handed out to 1000 parents who had administered an oral antipyretic analgesic medicine to their children during the previous 3 months. Data were entered and analyzed using SPSS version 21.0 (IBM-SPSS Inc, Armonk, NY). Simple descriptive and inferential statistics were used. Management and ethical approvals were attained. RESULTS During March to April 2017, 661 parents agreed to participate, giving a response rate of 66.1%. Of the surveyed sample, 208 parents had observed 1 or more potential ADRs (31.5%, n = 208 out of 661). Parents' (n = 208) most commonly reported potential ADRs (n = 523) were loss of appetite (23%, n = 120 out of 523), stomachache (20.3%, n = 106 out of 523), abdominal colic (13%, n = 68 out of 523), and diarrhea (10.3%, n = 54 out of 523). Parents described severity of the ADRs as slight (71.8%, n = 342 out of 476), annoying to the child (7.9%, n = 85 to of 476), significant and affecting daily tasks (3.6%, n = 17 out of 476) and significant and led to the hospital (6.7%, n = 32 out of 476). Fever was the top-ranked reason for using antipyretic analgesic medicines (41.0%, n = 271 out of 661), followed by toothache (25.0%, n = 165 out of 661) and tonsillitis/laryngitis (24.7%, n = 163 out of 661). Among parents, 34.7% (n = 165 out of 476) did not seek medical attention when a potential ADR occurred, whereas 26.3% (n = 125 out of 476) of parents took their children to hospital clinics. CONCLUSIONS Although the majority of parentally reported (but not proven) ADRs were mild, a number of significant ADRs were reported. Future research should consider whether there is a role for physicians and pharmacists in educating parents in Saudi Arabia, and perhaps more widely, about the optimal use of oral antipyretic and analgesic medicines in children. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX)© 2020 Elsevier HS Journals, Inc.
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Affiliation(s)
- Mansour Tobaiqy
- Department of Pharmacology, College of Medicine, University of Jeddah, Jeddah, P.O. Box 45311 Jeddah 21512, Makkah, Saudi Arabia
| | - Katie MacLure
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, Scotland, United Kingdom
| | - Mansoor Radwi
- Department of Hematology, College of Medicine, University of Jeddah, Jeddah, Makkah, Saudi Arabia
| | - Ashwaq M. Almalki
- Department of Ophthalmology, King Abdulaziz Medical City, Jeddah, Makkah, Saudi Arabia
| | - Ahmed H. Alhasan
- Department of Pharmacology, College of Medicine, University of Jeddah, Jeddah, P.O. Box 45311 Jeddah 21512, Makkah, Saudi Arabia
| | - Maya Tannoury
- Faculty of Health Sciences, American University of Science and Technology, Beirut, Lebanon
| | - Zouhair Attieh
- Faculty of Health Sciences, American University of Science and Technology, Beirut, Lebanon
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Wang TC, Chang FC, Lee CH, Chi HY, Huang LJ, Tseng CC. Adolescents’ misperceptions and low literacy associated with the inappropriate use of over-the-counter cold medicines. JOURNAL OF SUBSTANCE USE 2020. [DOI: 10.1080/14659891.2019.1664661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tzu-Chueh Wang
- Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Fong-Ching Chang
- Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei Taiwan
| | - Chun-Hsien Lee
- Division of Pharmacy, Tri-Service General Hospital, Taipei Taiwan
| | - Hsueh-Yun Chi
- Department of Health Developing and Marketing, Kainan University, Taoyuan, Taiwan
| | - Li-Jung Huang
- Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chie-Chien Tseng
- Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei Taiwan
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Kuwano A, Kohjima M, Suzuki H, Yamasaki A, Ohashi T, Imoto K, Kurokawa M, Morita Y, Kato M, Ogawa Y. Recombinant human soluble thrombomodulin ameliorates acetaminophen-induced liver toxicity in mice. Exp Ther Med 2019; 18:1323-1330. [PMID: 31316624 DOI: 10.3892/etm.2019.7665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/21/2019] [Indexed: 12/13/2022] Open
Abstract
Recombinant human soluble thrombomodulin alpha (rhTM) has been developed as an anticoagulant with anti-inflammatory activity. Notably, acetaminophen (APAP) -induced liver disease (AILI) is caused by direct metabolite-induced hepatotoxicity as well as hepatic hyper-coagulation. To evaluate the utility of anticoagulant for the treatment of AILI, rhTM was administered in a mouse AILI model and liver damage was analyzed. AILI was induced in 8-week-old mice by intraperitoneal injection of APAP. rhTM (20 mg/kg) or placebo was injected at the same time as APAP administration. Serum alanine aminotransferase, fibrin degradation products and high-mobility group box 1 levels were significantly decreased in the rhTM-treated group compared with the control group. Furthermore, rhTM reduced the necrotic area and fibrin deposition in liver sections. rhTM suppressed the mRNA expression of heme oxygenase-1, plasminogen activator inhibitor type-1, tissue factors, and inflammatory cytokines compared with the control group. rhTM did not change the hepatic GSH content at 2 h after APAP injection, but restored them at 4 h after the insult. rhTM ameliorated liver damage in mice with AILI, probably via the improvement in liver perfusion induced by it's anticoagulant acitivity, which can lead to the suppression of secondary liver damage.
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Affiliation(s)
- Akifumi Kuwano
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Motoyuki Kohjima
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Hideo Suzuki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Akihiro Yamasaki
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Tomoko Ohashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Koji Imoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Miho Kurokawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yusuke Morita
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Masaki Kato
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan.,Department of Molecular and Cellular Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8510, Japan.,CREST, Japan Agency for Medical Research and Development, Tokyo 100-0004, Japan
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8
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Mullen RJ, Curtis LM, O'Conor R, Serper M, McCarthy D, Bailey SC, Parker RM, Wolf MS. Visual acuity, literacy, and unintentional misuse of nonprescription medications. Am J Health Syst Pharm 2019; 75:e213-e220. [PMID: 29691264 DOI: 10.2146/ajhp170303] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Results of a study of associations between visual acuity and the risk of misuse of nonprescription acetaminophen products in a sample of community-dwelling adults are reported. METHODS In a study involving English-speaking adults at 4 primary care clinics, the potential for misuse of nonprescription acetaminophen products was measured via a functional assessment of product self-dosing and by testing patients' understanding of the risks of concomitant use (i.e., taking 2 products at the same time when contraindicated). Vision was assessed using the Rosenbaum vision chart and dichotomized as normal (visual acuity of 20/20-20/25) or low (acuity of 20/30-20/100). Bivariable and multivariable analyses were performed to determine the impact of visual acuity on medication misuse outcomes. RESULTS Among the study participants (n = 500), 39% had limited literacy, and 54% were categorized as having low vision. After controlling for age, race, and prior acetaminophen use, low vision was independently associated with an increased risk of self-dosing errors (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.25-2.21; p < 0.001) and misunderstanding of concomitant-use risks (OR, 1.41; 95% CI, 1.00-2.00; p = 0.05). Limited literacy was an independent risk factor for incorrect dosing (OR, 1.71; 95% CI, 1.25-2.35; p = 0.001) and unawareness of concomitant use instructions (OR, 4.14; 95% CI, 2.80-6.12; p < 0.001). CONCLUSION Misunderstanding of nonprescription acetaminophen product information was common among study participants and independently associated with both impaired visual acuity and low literacy skills.
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Affiliation(s)
- Rebecca J Mullen
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Laura M Curtis
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Marina Serper
- Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Stacy C Bailey
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Ruth M Parker
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Wilder ME, Richardson LD, Hoffman RS, Winkel G, Manini AF. Racial disparities in the treatment of acute overdose in the emergency department. Clin Toxicol (Phila) 2018; 56:1173-1178. [PMID: 29893609 PMCID: PMC6318059 DOI: 10.1080/15563650.2018.1478425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVES Racial and ethnic disparities in the United States continue to exist in many disciplines of medicine, extending to care in the Emergency Department (ED). We sought to examine the relationship between patient race/ethnicity and use of either antidotal therapy or gastrointestinal decontamination for individuals presenting to the ED for acute drug overdose. METHODS We completed a secondary analysis of a prospective cohort of patients with suspected acute overdose presenting to two urban tertiary care hospitals between 2009 and 2014. Race was self-identified during ED registration. Antidote administration (primary outcome) and gastrointestinal decontamination (secondary outcome) were reviewed and verified via agreement between two board certified medical toxicologists. Associations between race and outcomes were analyzed using a logistic regression model. RESULTS We reviewed 3252 ED patients with acute overdose. Overall, 542 people were treated with an antidote and 234 cases were treated with activated charcoal, either single or multiple dose. Compared to Whites, Blacks and Hispanics were significantly less likely to receive any antidote. The analysis was underpowered to detect racial disparities in the administration of activated charcoal. CONCLUSIONS Blacks and Hispanics are significantly less likely to receive any antidote when presenting to the ED for acute drug overdose. Further studies are needed to determine national prevalence of this apparent disparity in care and to fully characterize how race plays a role in management of acute overdose.
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Affiliation(s)
- Marcee E Wilder
- a Emergency Medicine Residency , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Lynne D Richardson
- b Department of Emergency Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
- c Department of Population Health Science and Policy , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Robert S Hoffman
- d Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA
| | - Gary Winkel
- e Division of Oncological Sciences , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Alex F Manini
- b Department of Emergency Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
- f Division of Medical, Toxicology , Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center , New York , NY , USA
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Eluri M, Spiller HA, Casavant MJ, Chounthirath T, Conner KA, Smith GA. Analgesic-Related Medication Errors Reported to US Poison Control Centers. PAIN MEDICINE (MALDEN, MASS.) 2018; 19:2357-2370. [PMID: 29186557 PMCID: PMC6659012 DOI: 10.1093/pm/pnx272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective This study investigates the characteristics and trends of medication errors involving analgesic medications. Design and Methods A retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012. Results From 2000 through 2012, the NPDS received 533,763 reports of analgesic-related medication errors, averaging 41,059 medication errors annually. Overall, the rate of analgesic-related medication errors reported to the NPDS increased significantly by 82.6% from 2000 to 2009, followed by a 5.7% nonsignificant decrease from 2009 to 2012. Among the analgesic categories, rates of both acetaminophen-related and opioid-related medication errors reported to the NPDS increased during 2000-2009, but the opioid error rate leveled off during 2009-2012, while the acetaminophen error rate decreased by 17.9%. Analgesic-related medication errors involved nonsteroidal anti-inflammatory drugs (37.0%), acetaminophen (35.5%), and opioids (23.2%). Children five years or younger accounted for 38.8% of analgesics-related medication errors. Most (90.2%) analgesic-related medication errors were managed on-site, rather than at a health care facility; 1.6% were admitted to a hospital, and 1.5% experienced serious medical outcomes, including 145 deaths. The most common type of medication error was inadvertently taking/given the medication twice (26.6%). Conclusion Analgesic-related medication errors are common, and although most do not result in clinical consequences, they can have serious adverse outcomes. Initiatives associated with the decrease in acetaminophen-related medication errors among young children merit additional research and potential replication as a model combining government policy and multisectoral collaboration.
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Affiliation(s)
- Madhulika Eluri
- Center for Injury Research and Policy at Nationwide Children’s Hospital, Columbus, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Henry A Spiller
- Central Ohio Poison Center, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Marcel J Casavant
- Center for Injury Research and Policy at Nationwide Children’s Hospital, Columbus, Ohio
- Central Ohio Poison Center, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | | | - Kristen A Conner
- Center for Injury Research and Policy at Nationwide Children’s Hospital, Columbus, Ohio
| | - Gary A Smith
- Center for Injury Research and Policy at Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
- Child Injury Prevention Alliance, Columbus, Ohio, USA
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11
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Ndetan H, Evans MW, Singal AK, Brunner LJ, Calhoun K, Singh KP. Light to moderate drinking and therapeutic doses of acetaminophen: An assessment of risks for renal dysfunction. Prev Med Rep 2018; 12:253-258. [PMID: 30377576 PMCID: PMC6205325 DOI: 10.1016/j.pmedr.2018.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/15/2018] [Accepted: 10/21/2018] [Indexed: 11/17/2022] Open
Abstract
This study investigated the potential effect of therapeutic doses of acetaminophen (APAP) in combination with light-moderate amounts of alcohol on kidney functions controlling for factors such as hypertension, diabetes and obesity that may predispose the kidney to APAP and/or alcohol toxicity. Secondary analysis of the 2003–2004 National Health and Nutrition Examination Survey data was performed using SAS 9.4. Odds ratios (OR) and 95% confidence intervals (CI) comparing the likelihood that individuals who ingested therapeutic doses of APAP and light-moderate amount of alcohol, compared to those who did not, would have kidney dysfunction were generated from multiple logistics regression models by further controlling for potential predisposing factors namely hypertension, diabetes and obesity. Kidney dysfunction was defined based on self-reports and laboratory examination of serum creatinine (SCr), blood urea nitrogen (BUN), glomerular filtration rate (GFR) and albumin creatinine ratio (ABCR). Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and light-moderate amount of alcohol [OR(95% CI) = 1.64(1.28–2.10) self-report, 2.18(1.81–2.63) SCr, 4.60(3.03–7.00) BUN, 3.14(2.42–4.07) GFR, and 1.71(1.36–2.14) ALBCR)] even after adjusting for hypertension, diabetes and obesity [Adjusted OR (95% CI) = 1.78 (1.22–2.58) self-report, 2.05 (1.07–3.92) GFR]. The toxic effects of APAP and alcohol on the kidney were hypothesized. The threshold doses at which these effects begin to occur are unknown. The findings of this study suggest that even therapeutic doses of APAP and light-moderate amount of alcohol could be health problematic if consumed concomitantly. Even therapeutic doses of acetaminophen may be associated with renal dysfunction. Light-moderate drinking alone may be protective of renal dysfunction. Light-moderate alcohol may enhance effect of therapeutic doses of APAP on kidney. Hypertension, obesity & diabetes may strengthen effect of APAP & alcohol on kidney.
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Affiliation(s)
- Harrison Ndetan
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, University of Texas Health Science Center, 11937 US Hwy 271, Tyler, TX 75708, United States of America
| | - Marion W Evans
- Department of Food Science, Nutrition, and Health Promotion, 105 Herzer Building, Box 9805, Mississippi State, MS 39762, United States of America
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama Birmingham, 1720 2 Ave, South, BDB 380, Birmingham, AL 35294-0012, United States of America
| | - Lane J Brunner
- Ben and Maytee Fisch College of Pharmacy, University of Texas, Tyler, 3900 University Blvd, Tyler, TX 75799, United States of America
| | - Kirk Calhoun
- University of Texas Health Science Center, 11937 US Hwy 271, Tyler, TX 75708, United States of America
| | - Karan P Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, University of Texas Health Science Center, 11937 US Hwy 271, Tyler, TX 75708, United States of America
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12
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Bell JC, Bentley JP, Downie C, Cairns R, Buckley NA, Katelaris A, Pearson SA, Nassar N. Accidental pharmacological poisonings in young children: population-based study in three settings. Clin Toxicol (Phila) 2018; 56:782-789. [DOI: 10.1080/15563650.2017.1422509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Jane C. Bell
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - Jason P. Bentley
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | | | - Rose Cairns
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | | | | | - Sallie-Anne Pearson
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
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Variability in Acetaminophen Labeling Practices: a Missed Opportunity to Enhance Patient Safety. J Med Toxicol 2016; 11:410-4. [PMID: 25697756 DOI: 10.1007/s13181-015-0464-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Confusion regarding a drug's active ingredient may lead to simultaneous use of multiple acetaminophen-containing prescriptions and increase the risk of unintentional overdose. The objective of this study was to examine prescription labeling practices for commonly prescribed acetaminophen-containing analgesics, specifically focusing on how active ingredient information and concomitant use warnings were conveyed. Patients with new acetaminophen-containing prescriptions were recruited upon discharge from an emergency department in Chicago or at an outpatient, hospital-based pharmacy in Atlanta. Label information was transcribed from prescription bottles and patients' knowledge of active ingredient was assessed by in-person interviews. Among the 245 acetaminophen-containing prescriptions, hydrocodone was the most common second active ingredient (n = 208, 84.8 %) followed by oxycodone (n = 28, 11.4 %). Acetaminophen was identified by its full name on 6.9 % (n = 17) of labels; various abbreviations were used in 93.1 % of cases. One hundred forty-seven bottles used auxiliary warning labels with the majority of labels (n = 130, 88.4 %) warning about maximum dose and 11.5 % (n = 17) about concomitant use. Most of the study participants (n = 177, 72.2 %) were not able to identify acetaminophen as an active ingredient in their prescription. There was no significant association between the use of unabbreviated labels including warning information and patients' awareness of acetaminophen as an active ingredient (36.4 vs. 27.3 %, p = 0.50). We noted high variability in labeling practices and warning information conveyed to patients receiving acetaminophen-containing prescriptions. Missed opportunities to adequately convey risk information may contribute to the burden of acetaminophen-related liver injury.
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Zhang J, Zhang L, Sun X, Yang Y, Kong L, Lu C, Lv G, Wang T, Wang H, Fu F. Acetylcholinesterase Inhibitors for Alzheimer's Disease Treatment Ameliorate Acetaminophen-Induced Liver Injury in Mice via Central Cholinergic System Regulation. J Pharmacol Exp Ther 2016; 359:374-382. [PMID: 27535978 DOI: 10.1124/jpet.116.233841] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 08/12/2016] [Indexed: 01/30/2023] Open
Abstract
Acetaminophen (APAP) is widely used as an analgesic and antipyretic agent, but it may induce acute liver injury at high doses. Alzheimer's disease patients, while treated with acetylcholinesterase inhibitor (AChEI), may take APAP when they suffer from cold or pain. It is generally recognized that inhibiting acetylcholinesterase activity may also result in liver injury. To clarify whether AChEI could deteriorate or attenuate APAP hepatotoxicity, the effects of AChEI on APAP hepatotoxicity were investigated. Male C57BL/6J mice were administrated with the muscarinic acetylcholine receptor (mAChR) blocker atropine (Atr), or classic α7 nicotine acetylcholine receptor (α7nAChR) antagonist methyllycaconitine (MLA) 1 hour before administration of AChEIs-donepezil (4 mg/kg), rivastigmine (2 mg/kg), huperzine A (0.2 mg/kg), or neostigmine (0.15 mg/kg)-followed by APAP (300 mg/kg). Eight hours later, the mice were euthanized for histopathologic examination and biochemical assay. The results demonstrated that the tested AChEIs, excluding neostigmine, could attenuate APAP-induced liver injury, accompanied by reduced reactive oxygen species formation, adenosine triphosphate and cytochrome C loss, c-Jun N-terminal kinase 2 (JNK2) phosphorylation, and cytokines. However, Atr or MLA significantly weakened the protective effect of AChEI by affecting mitochondrial function or JNK2 phosphorylation and inflammation response. These results suggest that central mAChR and α7nAChR, which are activated by accumulated acetylcholine resulting from AChEI, were responsible for the protective effect of AChEIs on APAP-induced liver injury. This indicates that Alzheimer's patients treated with AChEI could take APAP, as AChEI is unlikely to deteriorate the hepatotoxicity of APAP.
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Affiliation(s)
- Jianqiao Zhang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Leiming Zhang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Xue Sun
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Yanting Yang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Liang Kong
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Chengwen Lu
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Guangyao Lv
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Tian Wang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Hongbo Wang
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
| | - Fenghua Fu
- Key Laboratory of Molecular Pharmacology and Drug Evaluation (Ministry of Education of China), School of Pharmacy, Yantai University, Yantai, People's Republic of China
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15
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Lubrano R, Paoli S, Bonci M, Di Ruzza L, Cecchetti C, Falsaperla R, Pavone P, Matin N, Vitaliti G, Gentile I. Acetaminophen administration in pediatric age: an observational prospective cross-sectional study. Ital J Pediatr 2016; 42:20. [PMID: 26920747 PMCID: PMC4769520 DOI: 10.1186/s13052-016-0219-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/18/2016] [Indexed: 12/03/2022] Open
Abstract
Background Parents often do not consider fever as an important physiological response and mechanism of defense against infections that leads to inappropriate use of antipyretics and potentially dangerous side effects. This study is designed to evaluate the appropriateness of antipyretics dosages generally administered to children with fever, and to identify factors that may influence dosage accuracy. Results In this cross-sectional study we analyzed the clinical records of 1397 children aged >1 month and < 16 years, requiring a primary care (ambulatory) outpatient visit due to fever. We evaluated the number of children who had received >90 mg/kg/day of acetaminophen, the prescriber, the medication formula and the educational level of the caregiver who administered acetaminophen. Among those children included in our study, 74 % were administered acetaminophen for body temperature ≤ 38.4 °C. 24.12 % of children received >90 mg/kg/day of acetaminophen. Parents with university qualifications most commonly self-administered acetaminophen to their children, in a higher than standard dose. Self medication was also described in 60 % of children, whose acetaminophen was administered for temperatures < 38 °C. Acetaminophen over-dosage was also favored by the use of drug formulations as drops or syrup. Conclusions Our study shows that preventive action should be taken regarding the use of acetaminophen as antipyretic drug in children in order to reduce the fever phobia and self-prescription, especially of caregivers with higher educational levels. It is also necessary to promote a more appropriate use of acetaminophen in those parents using drops or syrup formulations.
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Affiliation(s)
- Riccardo Lubrano
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy.
| | - Sara Paoli
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy.
| | - Marco Bonci
- Paediatrics Operative Unit, Grassi Hospital, Rome, Italy.
| | - Luigi Di Ruzza
- Paediatrics Operative Unit, Policlinico Umberto I, Frosinone, Italy.
| | - Corrado Cecchetti
- Acute and Emergency Operative Unit, Bambino Gesù Paediatric Hospital, Rome, Italy.
| | - Raffaele Falsaperla
- General Paediatrics and Acute and Emergency Paediatrics Operative Unit, Vittorio Emanuele University Hospital, Catania, Italy.
| | - Piero Pavone
- General Paediatrics and Acute and Emergency Paediatrics Operative Unit, Vittorio Emanuele University Hospital, Catania, Italy.
| | - Nassim Matin
- University Medical Science of Teheran, University of Teheran, Teheran, Italy.
| | - Giovanna Vitaliti
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy. .,AOU Policlinico-OVE, University of Catania, Via Plebiscito n. 628, 95100, Catania, Italy.
| | - Isotta Gentile
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy.
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Risk Factors, Clinical Presentation, and Outcomes in Overdose With Acetaminophen Alone or With Combination Products: Results From the Acute Liver Failure Study Group. J Clin Gastroenterol 2016; 50:85-91. [PMID: 26166142 PMCID: PMC5528869 DOI: 10.1097/mcg.0000000000000378] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Acetaminophen (APAP) is the most common cause of acute liver failure (ALF) in the west. It is unknown if APAP overdose in combination with diphenhydramine or opioids confers a different clinical presentation or prognosis. Study objectives were to compare (1) baseline patient characteristics; (2) initial clinical presentation; and (3) clinical outcomes among patients with ALF due to APAP alone or in combination with diphenhydramine or opioids. METHODS We analyzed 666 cases of APAP-related liver failure using the Acute Liver Failure Study Group database from 1998 to 2012. The database contains detailed demographic, laboratory, and clinical outcome data, including hemodialysis, transplantation, and death and in-hospital complications such as arrhythmia and infection. RESULTS The final sample included 666 patients with APAP liver injury. A total 30.3% of patients were overdosed with APAP alone, 14.1% with APAP/diphenhydramine, and 56.6% with APAP/opioids. Patients taking APAP with opioids were older, had more comorbidities, and were more likely to have unintentional overdose (all P<0.0001). On presentation, 58% in the APAP/opioid group had advanced encephalopathy as compared with 43% with APAP alone (P=0.001) The APAP/diphenhydramine group presented with the highest serum aminotransferase levels, no differences in laboratory values were noted at 3 days postenrollment. No significant differences were observed in clinical outcomes among the groups. CONCLUSIONS Most patients with APAP-induced ALF were taking APAP combination products. There were significant differences in patient characteristics and clinical presentation based on the type of product ingested, however, there were no differences noted in delayed hepatotoxicity or clinical outcomes.
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Major JM, Zhou EH, Wong HL, Trinidad JP, Pham TM, Mehta H, Ding Y, Staffa JA, Iyasu S, Wang C, Willy ME. Trends in rates of acetaminophen-related adverse events in the United States. Pharmacoepidemiol Drug Saf 2015; 25:590-8. [PMID: 26530380 DOI: 10.1002/pds.3906] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 09/21/2015] [Accepted: 09/29/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE The goal of this study is to summarize trends in rates of adverse events attributable to acetaminophen use, including hepatotoxicity and mortality. METHODS A comprehensive analysis of data from three national surveillance systems estimated rates of acetaminophen-related events identified in different settings, including calls to poison centers (2008-2012), emergency department visits (2004-2012), and inpatient hospitalizations (1998-2011). Rates of acetaminophen-related events were calculated per setting, census population, and distributed drug units. RESULTS Rates of poison center calls with acetaminophen-related exposures decreased from 49.5/1000 calls in 2009 to 43.5/1000 calls in 2012. Rates of emergency department visits for unintentional acetaminophen-related adverse events decreased from 58.0/1000 emergency department visits for adverse drug events in 2009 to 50.2/1000 emergency department visits in 2012. Rates of hospital inpatient discharges with acetaminophen-related poisoning decreased from 119.8/100 000 hospitalizations in 2009 to 108.6/100 000 hospitalizations in 2011. After 2009, population rates of acetaminophen-related events per 1 million census population decreased for poison center calls and hospitalizations, while emergency department visit rates remained stable. However, when accounting for drug sales, the rate of acetaminophen-related events (per 1 million distributed drug units) increased after 2009. Prior to 2009, the rates of acetaminophen-related hospitalizations had been slowly increasing (p-trend = 0.001). CONCLUSIONS Acetaminophen-related adverse events continue to be a public health burden. Future studies with additional time points are necessary to confirm trends and determine whether recent risk mitigation efforts had a beneficial impact on acetaminophen-related adverse events. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Jacqueline M Major
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Esther H Zhou
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Hui-Lee Wong
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - James P Trinidad
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Tracy M Pham
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Hina Mehta
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Yulan Ding
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Judy A Staffa
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Solomon Iyasu
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Cunlin Wang
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Mary E Willy
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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Altyar A, Kordi L, Skrepnek G. Clinical and economic characteristics of emergency department visits due to acetaminophen toxicity in the USA. BMJ Open 2015; 5:e007368. [PMID: 26353865 PMCID: PMC4567677 DOI: 10.1136/bmjopen-2014-007368] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To estimate the number of acetaminophen (APAP) toxicity-related emergency department (ED) visits, and to assess their associated clinical and economic burden in the USA from 2006 to 2010. DESIGN Cross-sectional, retrospective, large-scale database study. SETTING Non-federal, non-rehabilitation, community EDs in the USA. PARTICIPANTS Inclusion criteria included any listed diagnosis identifying poisoning by aromatic analgesics paracetamol/APAP or associated supplementary code. Generalised linear models were used to investigate the association between outcomes of inpatient admission, mortality, requirement of invasive mechanical ventilation, charges and inpatient lengths of stay based on patient, hospital and clinical characteristics. RESULTS Across the 625.2 million ED visits in the USA from 2006 to 2010, 411,811 APAP-related toxicity ED visits were observed, with 45.5% resulting in inpatient admission, 4.7% requiring invasive mechanical ventilation and 0.6% involving death. Overall, the incidence proportion was 27.10 per 100,000 US population, exceeding 70 per 100,000 at age 2 years and ages 16-18 years. The total national bill was $1.06 billion per year (US$ 2014), and predominantly involved females (65.5%) and intentional self-harm (58.4%), which were notably higher within the 12-20 years age category (female(12-20 years)=74.8%, intentional self-harm(12-20 years)=71.4%). Behavioural and mental health comorbidities were relatively common and associated with an increased relative risk of admission and likelihood of charges almost entirely across all age categories of ≥12 years within the multivariable analyses. The number of ED visits did not appreciably change over time, decreasing by <2% from 2006 to 2010 (n=1351). Multivariable results also suggested no consistent change in outcomes across the study's time horizon. CONCLUSIONS A substantial public health impact of APAP toxicity-related cases was observed in the US from 2006 to 2010, with incidence proportions peaking at age 2 years and ages 16-18 years. After controlling for numerous factors, no consistent change was observed over the 5-year time horizon concerning outcomes of admission, mortality, invasive mechanical ventilation, charges or length of stay.
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Affiliation(s)
- Ahmed Altyar
- The University of Arizona, Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, Tucson, Arizona, USA
- Currently at The Department of Clinical Pharmacy, King Abdulaziz University College of Pharmacy, Jeddah, Saudi Arabia
| | - Lama Kordi
- The University of Arizona, Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA
| | - Grant Skrepnek
- The University of Arizona, Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, Tucson, Arizona, USA
- Currently at The University of Oklahoma Health Sciences Center, College of Pharmacy & Stephenson Cancer Center, Oklahoma City, Oklahoma, USA
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Kubota Y, Hasegawa K, Taguchi H, Kitamura T, Nishiyama C, Iwami T, Nishiuchi T, Hiraide A. Characteristics and trends of emergency patients with drug overdose in Osaka. Acute Med Surg 2015; 2:237-243. [PMID: 29123730 DOI: 10.1002/ams2.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/16/2014] [Indexed: 11/08/2022] Open
Abstract
Aim Drug overdose is an important issue in emergency medicine. However, studies covering overdose patients transported by ambulance have not been sufficiently carried out. We attempted to clarify problems of suspected drug overdose patients transported by ambulance. Methods This is a prospective population-based cohort study. Data were collected by emergency medical service crews in Osaka City, Japan, between January 1998 and December 2010. Results Drug overdose cases increased annually from 1,136 in 1998 to 1,822 in 2010 (P < 0.0001 for trend). In these cases, the dominant age range was between 16 and 40 years and the age distribution did not change over time. The age of non-overdose cases increased (P < 0.0001 for trend), with patients aged ≥66 years becoming most common in recent years, reflecting the aging of society. Males comprised most non-overdose patients, but the percentage of females increased annually (P < 0.0001 in trend). Females comprised approximately 70% in overdose cases annually throughout the study period. The duration from the emergency call to the arrival at the hospital for overdose patients has increased markedly in recent years. It also takes more time to obtain acceptance from hospitals to care for patients of suspected overdose. Conclusion The characteristics of drug overdose patients are clearly different from those of non-overdose patients. Recent trends of drug overdose patients indicate the accelerated burden on emergency medical services system.
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Affiliation(s)
- Yoshie Kubota
- Department of Acute Medicine Faculty of Medicine Kinki University Boston Massachusetts
| | - Kohei Hasegawa
- Department of Emergency Medicine Harvard Medical School Massachusetts General Hospital Boston Massachusetts
| | - Hirokazu Taguchi
- Department of Acute Medicine Faculty of Medicine Kinki University Boston Massachusetts
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine Division of Environmental Medicine and Population Sciences Graduate School of Medicine Osaka University Osaka Japan
| | - Chika Nishiyama
- Department of Critical Care Nursing School of Human Health Science Graduate School of Medicine Kyoto University Health Service Kyoto Japan
| | - Taku Iwami
- Kyoto University Health Service Kyoto Japan
| | - Tatsuya Nishiuchi
- Department of Acute Medicine Faculty of Medicine Kinki University Boston Massachusetts
| | - Atsushi Hiraide
- Department of Acute Medicine Faculty of Medicine Kinki University Boston Massachusetts
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Preparation of hydrophilic C60(OH)10/2-hydroxypropyl-β-cyclodextrin nanoparticles for the treatment of a liver injury induced by an overdose of acetaminophen. Biomaterials 2015; 45:115-23. [DOI: 10.1016/j.biomaterials.2014.12.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/12/2014] [Accepted: 12/20/2014] [Indexed: 12/14/2022]
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Shimizu D, Ishitsuka Y, Miyata K, Tomishima Y, Kondo Y, Irikura M, Iwawaki T, Oike Y, Irie T. Protection afforded by pre- or post-treatment with 4-phenylbutyrate against liver injury induced by acetaminophen overdose in mice. Pharmacol Res 2014; 87:26-41. [PMID: 24951965 DOI: 10.1016/j.phrs.2014.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/06/2014] [Accepted: 06/06/2014] [Indexed: 12/23/2022]
Abstract
Acetaminophen (paracetamol, N-acetyl-p-aminophenol; APAP) is a widely used analgesic/antipyretic drug with few adverse effects at therapeutic doses; suicidal or unintentional overdose of APAP frequently induces severe hepatotoxicity. To explore a new and effective antidote for APAP hepatotoxicity, this study examined the effects of sodium 4-phenylbutyrate (4-PBA) on liver injury induced by APAP overdose in mice. Liver injury was induced in C57BL/6 male mice by intraperitoneal injection of APAP (400mg/kg). The effects of 4-PBA (100-200mg/kg) treatment at 1h before the APAP injection were evaluated with serum alanine aminotransferase (ALT) and blood ammonia levels, hepatic pathological changes, including histopathology, DNA damage, nitrotyrosine formation, and mRNA or protein expression involved in the development of hepatotoxicity, such as X-box binding protein-1 (XBP1), c-Jun N-terminal kinase (JNK), C/EBP homologous protein (CHOP) and B-cell lymphoma 2 interacting mediator of cell death (Bim). In addition, glutathione depletion and CYP2E1 protein expression, which are measures of the metabolic conversion of APAP to a toxic metabolite, were examined. Furthermore, we examined the effects of post-treatment with 4-PBA against APAP-induced hepatotoxicity in mice. When administered at 1h before APAP injection, 4-PBA significantly prevented the increase in serum ALT and blood ammonia levels, centrilobular necrosis of hepatocytes, DNA fragmentation, and nitrotyrosine formation induced by APAP in mice. 4-PBA also inhibited hepatic Xbp1 mRNA splicing and JNK phosphorylation induced by APAP, but did not suppress CHOP and Bim mRNA and protein expression. In addition, 4-PBA had little effect on hepatic glutathione depletion and CYP2E1 expression, parameters of toxic APAP metabolite production. Post-treatment with 4-PBA administration at 1 or 2h after APAP injection also attenuated the increase in serum ALT and blood ammonia levels and hepatic pathological changes in APAP-induced hepatotoxicity in mice. Although post-treatment with 4-PBA did not show any effects on hepatic Xbp1 mRNA splicing and JNK phosphorylation, it drastically attenuated the DNA fragmentation induced by APAP. The precise molecular mechanisms of the protection afforded by 4-PBA against APAP hepatotoxicity in mice are unclear, but they seem to involve inhibition of hepatocellular DNA fragmentation. We suggest that 4-PBA is a promising candidate as an antidote against APAP-induced liver injury.
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Affiliation(s)
- Daisuke Shimizu
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan.
| | - Keishi Miyata
- Department of Molecular Genetics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Yoshiro Tomishima
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Mitsuru Irikura
- Laboratory of Evidence-Based Pharmacotherapy, College of Pharmaceutical Sciences, Daiichi University, 22-1 Tamagawa-Cho, Minami-Ku, Fukuoka 815-8511, Japan
| | - Takao Iwawaki
- Iwawaki Lab, Advanced Scientific Research Leaders Development Unit, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuichi Oike
- Department of Molecular Genetics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Tetsumi Irie
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan; Center for Clinical Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
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Aritomi K, Ishitsuka Y, Tomishima Y, Shimizu D, Abe N, Shuto T, Irikura M, Kai H, Irie T. Evaluation of Three-Dimensional Cultured HepG2 Cells in a Nano Culture Plate System: an In Vitro Human Model of Acetaminophen Hepatotoxicity. J Pharmacol Sci 2014; 124:218-29. [DOI: 10.1254/jphs.13135fp] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Froberg BA, King KJ, Kurera TD, Monte AA, Prosser JM, Walsh SJ, Riffenburgh RH, Rusyniak DE, Tanen DA. Negative predictive value of acetaminophen concentrations within four hours of ingestion. Acad Emerg Med 2013; 20:1072-5. [PMID: 24127715 DOI: 10.1111/acem.12222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/02/2013] [Accepted: 05/23/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to ascertain whether acetaminophen (APAP) concentrations less than 100 μg/mL obtained between 1 and 4 hours after acute ingestion accurately predict a nontoxic 4-hour concentration. METHODS The authors performed a multicenter, prospective cohort study involving five emergency departments (EDs) participating in the ToxIC Research Network. Data were collected from May 2009 to December 2011. Patients with APAP concentrations <100 μg/mL drawn between 1 and 4 hours after acute ingestions, and concentrations drawn 4 or more hours after ingestions, were included in the study. Exclusion criteria included initial concentration >100 μg/mL, initial APAP concentration drawn prior to 1 hour, two undetectable APAP concentrations, the second concentration drawn prior to 4 hours, and unknown time of ingestion. Toxic concentrations 4 or more hours after ingestion were defined as concentrations that plotted above the 150 μg/mL line on the Rumack-Matthew nomogram. RESULTS Data were collected on 83 patients who met inclusion criteria. Of the 83 patients with APAP concentrations <100 μg/mL between 1 and 4 hours, one patient (1.2%) had a ≥ 4-hour toxic concentration. Negative predictive value (NPV) for an APAP concentration <100 μg/mL obtained between 1 and 4 hours after an acute ingestion was 98.8% (95% confidence interval [CI] = 93.5% to 99.8%). CONCLUSIONS An APAP concentration of <100 μg/mL obtained between 1 and 4 hours after ingestion has a high NPV for excluding toxic ingestion. We do not recommend reliance on concentrations obtained between 1 and 4 hours to exclude toxicity, because of a potential false-negative rate of 6.5%.
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Affiliation(s)
- Blake A. Froberg
- Department of Pediatrics and Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Kerry J. King
- Department of Emergency Medicine; Naval Medical Center San Diego; San Diego CA
| | - Theomal D. Kurera
- Department of Emergency Medicine; Naval Medical Center San Diego; San Diego CA
| | - Andrew A. Monte
- Department of Emergency Medicine; Denver Medical Center and Rocky Mountain Poison and Drug Center; Denver CO
| | - Jane M. Prosser
- Department of Emergency Medicine; Weill Cornell Medical Center; New York NY
| | - Steven J. Walsh
- Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA
| | | | - Daniel E. Rusyniak
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - David A. Tanen
- Department of Emergency Medicine; Naval Medical Center San Diego; San Diego CA
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Hui J, Li W, Guo Y, Yang Z, Wang Y, Yu C. Electrochemical sensor for sensitive detection of paracetamol based on novel multi-walled carbon nanotubes-derived organic–inorganic material. Bioprocess Biosyst Eng 2013; 37:461-8. [DOI: 10.1007/s00449-013-1013-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 07/08/2013] [Indexed: 01/12/2023]
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Sood S, Howell J, Sundararajan V, Angus PW, Gow PJ. Paracetamol overdose in Victoria remains a significant health-care burden. J Gastroenterol Hepatol 2013; 28:1356-60. [PMID: 23489151 DOI: 10.1111/jgh.12196] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Paracetamol is the most frequently used analgesic in Australia and can be purchased without a prescription. We aimed to investigate the epidemiology and outcome of paracetamol overdoses occurring in Victoria, Australia. METHODS The Victorian admitted episode dataset was examined for all patients who had a diagnosis of paracetamol poisoning (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification [ICD-10-AM]: T39.1) or paracetamol adverse effect in therapeutic use (Y45.5) from July 1, 2000 to June 30, 2007. Data extracted included all ICD-10 codes related to their admissions, gender, age range, date of admission, and cause of death (if applicable). RESULTS Over 7 years, there was a total of 14,662 hospital admissions for paracetamol overdose with a mean of 2095 cases per year. Accidental overdoses comprised 15% (n = 2149) of cases. The overdose rate fell from 46 cases per 100,000 in 2001 to 39 cases per 100,000 in 2006 (P < 0.001). Most overdoses occurred in women (71%), and patients between 15 and 50 years old comprised 78% of all cases. Complications and mortality were relatively uncommon, with only 26 deaths directly attributable to paracetamol overdose over the 7 years. No child under 15 years old died from their overdose. CONCLUSION Admission to Victorian hospitals with paracetamol overdose presents an enormous and in many cases preventable health-care burden. Fortunately, there has been a gradual fall in admissions, and most cases appear relatively benign. Further reductions in overdose could be achieved with increased awareness by physicians and the general public regarding the potential for accidental overdose, and increasing funding for mental health initiatives.
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Affiliation(s)
- Siddharth Sood
- Department of Gastroenterology, Austin Health, Heidelberg, Australia.
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Does Combination Treatment With Ibuprofen and Acetaminophen Improve Fever Control? Ann Emerg Med 2013; 61:569-70. [DOI: 10.1016/j.annemergmed.2012.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 10/04/2012] [Accepted: 10/19/2012] [Indexed: 11/18/2022]
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Ozagrel hydrochloride, a selective thromboxane A₂ synthase inhibitor, alleviates liver injury induced by acetaminophen overdose in mice. BMC Gastroenterol 2013; 13:21. [PMID: 23363429 PMCID: PMC3568068 DOI: 10.1186/1471-230x-13-21] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 01/28/2013] [Indexed: 12/12/2022] Open
Abstract
Background Overdosed acetaminophen (paracetamol, N-acetyl-p-aminophenol; APAP) causes severe liver injury. We examined the effects of ozagrel, a selective thromboxane A2 (TXA2) synthase inhibitor, on liver injury induced by APAP overdose in mice. Methods Hepatotoxicity was induced to ICR male mice by an intraperitoneal injection with APAP (330 mg/kg). The effects of ozagrel (200 mg/kg) treatment 30 min after the APAP injection were evaluated with mortality, serum alanine aminotransferase (ALT) levels and hepatic changes, including histopathology, DNA fragmentation, mRNA expression and total glutathione contents. The impact of ozagrel (0.001-1 mg/mL) on cytochrome P450 2E1 (CYP2E1) activity in mouse hepatic microsome was examined. RLC-16 cells, a rat hepatocytes cell line, were exposed to 0.25 mM N-acetyl-p-benzoquinone imine (NAPQI), a hepatotoxic metabolite of APAP. In this model, the cytoprotective effects of ozagrel (1–100 muM) were evaluated by the WST-1 cell viability assay. Results Ozagel treatment significantly attenuated higher mortality, elevated serum alanine aminotransferase levels, excessive hepatic centrilobular necrosis, hemorrhaging and DNA fragmentation, as well as increase in plasma 2,3-dinor thromboxane B2 levels induced by APAP injection. Ozagrel also inhibited the hepatic expression of cell death-related mRNAs induced by APAP, such as jun oncogene, FBJ osteosarcoma oncogene (fos) and C/EBP homologous protein (chop), but did not suppress B-cell lymphoma 2-like protein11 (bim) expression and hepatic total glutathione depletion. These results show ozagrel can inhibit not all hepatic changes but can reduce the hepatic necrosis. Ozagrel had little impact on CYP2E1 activity involving the NAPQI production. In addition, ozagrel significantly attenuated cell injury induced by NAPQI in RLC-16. Conclusions We demonstrate that the TXA2 synthase inhibitor, ozagrel, dramatically alleviates liver injury induced by APAP in mice, and suggest that it is a promising therapeutic candidate for the treatment of APAP-induced liver injury.
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O’Neil CK, Hanlon JT, Marcum ZA. Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics. THE AMERICAN JOURNAL OF GERIATRIC PHARMACOTHERAPY 2012; 10:331-42. [PMID: 23036838 PMCID: PMC3529168 DOI: 10.1016/j.amjopharm.2012.09.004] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 09/10/2012] [Accepted: 09/10/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Osteoarthritis (OA) is the most common cause of disability in older adults, and although analgesic use can be helpful, it can also result in adverse drug events. OBJECTIVE To review the recent literature to describe potential adverse drug events associated with analgesics commonly used by older adults with OA. METHODS To identify articles for this review, a systematic search of the English-language literature from January 2001 to June 2012 was conducted using PubMed, MEDLINE, EBSCO, and the Cochrane Database of Systematic Reviews for publications related to the medical management of OA. Search terms used were "analgesics," "acetaminophen," "nonsteroidal anti-inflammatory drugs" (NSAIDs), "opioids," "pharmacokinetics," "pharmacodynamics," and "adverse drug events." The search was restricted to those articles that concerned humans aged ≥65 years. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that examined analgesic use in older adults. RESULTS There are limited data to suggest that non-frail elders are more likely than their younger counterparts to develop acetaminophen-induced hepatotoxicity. However, decreased hepatic phase II metabolism in frail elders may result in increased risk of hepatotoxicity. It is now well established that older adults are at higher risk of NSAID-induced gastrointestinal toxicity and renal insufficiency. Insofar as opioids, the data that suggest an increased risk of falls, fractures, or delirium need to be tempered by the potential risk of inadequately treating severe chronic OA-related pain. CONCLUSIONS Acetaminophen is the mainstay frontline analgesic for treating OA-related pain in older adults. NSAIDs should be limited to short-term use only, and for moderate to severe OA-related pain, opioids may be preferable in individuals without substance abuse or dependence issues.
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Affiliation(s)
- Christine K. O’Neil
- Department of Pharmacy Practice, School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
| | - Joseph T. Hanlon
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Geriatric Pharmaceutical Outcomes and Geroinformatics Research and Training Program, University of Pittsburgh, Pittsburgh, PA
- Departments of Biomedical Informatics and Epidemiology, University of Pittsburgh, Pittsburgh, PA
- Geriatric Research, Education and Clinical Center, and Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- The Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Zachary A. Marcum
- Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Geriatric Pharmaceutical Outcomes and Geroinformatics Research and Training Program, University of Pittsburgh, Pittsburgh, PA
- The Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
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Wolf MS, King J, Jacobson K, Di Francesco L, Bailey SC, Mullen R, McCarthy D, Serper M, Davis TC, Parker RM. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med 2012; 27:1587-93. [PMID: 22638604 PMCID: PMC3509295 DOI: 10.1007/s11606-012-2096-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 02/07/2012] [Accepted: 03/14/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is increasing concern over the risk of consumer unintentional misuse of non-prescription (a.k.a. 'over-the-counter') medications containing acetaminophen, which could lead to acute liver failure. OBJECTIVE To determine the prevalence of potential misuse and overdose of over-the-counter medications containing acetaminophen, either alone or in combination. DESIGN Cross-sectional, structured interviews with literacy assessment. SETTING One academic and one community-based general internal medicine practice in Chicago, IL, and one academic general internal medicine practice and a public hospital clinic in Atlanta, GA. PATIENTS Five hundred adults seeking primary care, ages 18-80. MEASUREMENT Demonstration of how and when patients would take over-the-counter medications containing acetaminophen, alone or in combination with one another, over a 24-hour period. RESULTS Overall, 23.8 % of participants demonstrated they would overdose on a single over-the-counter acetaminophen product by exceeding a dose of four grams in a 24-hour period; 5.2 % made serious errors by dosing out more than six grams. In addition, 45.6 % of adults demonstrated they would overdose by 'double-dipping' with two acetaminophen-containing products. In multivariable analyses, limited literacy (Relative Risk Ratio (RR) 1.65, 95 % Confidence Interval (CI) 1.03-2.66) and heavy acetaminophen use in the past six months (RR 1.70, 95 % CI 1.10-2.64) were independently associated with overdosing over-the-counter products. CONCLUSION Misunderstanding of the active ingredient and proper instructions for over-the-counter medications containing acetaminophen is common. The potential for errors and adverse events associated with unintentional misuse of these products is substantial, particularly among heavy users of acetaminophen and those with limited literacy.
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Affiliation(s)
- Michael S Wolf
- Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.
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Kjartansdottir I, Bergmann OM, Arnadottir RS, Björnsson ES. Paracetamol intoxications: a retrospective population-based study in Iceland. Scand J Gastroenterol 2012; 47:1344-52. [PMID: 22827594 DOI: 10.3109/00365521.2012.703236] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Paracetamol is the most common cause of acute liver failure (ALF) in many countries. Much data on paracetamol toxicity originate from liver transplant centers and tertiary referral institutions. The authors analyzed the population-based annual incidence of paracetamol overdoses and ALF, and described the risk factors for hepatotoxicity. METHODS A search was undertaken for the diagnosis of paracetamol overdoses in the diagnoses registry of the National University Hospital of Iceland from 2004 to 2009 serving a population of 219,249 inhabitants. Relevant information was collected from medical records. RESULTS A total of 1913 drug-related poisoning episodes were identified and reviewed, 352 (18%) involved paracetamol overdoses. The annual incidence of paracetamol overdoses declined from 30.0 (2004) to 16.0/100,000 per year (2009) (p < 0.05). The female/male ratio was 3.0 and the largest age group was 16-25 years. After the initial examination, 26% were discharged home. Hospitalized index visits were 182 with accidental overdoses constituting 16 (9%) with no gender difference. Compared with intentional overdose the accidental group had higher aminotransferases (p < 0.005). ALF occurred in 3.8% (7/182) of the index visits and the incidence was 0.7/100,000 per year. In the intentional group, 1.2% (2/163) developed ALF versus 25% (4/16) of the accidental group (p = 0.001). Only one patient died from ALF and none underwent liver transplantation. CONCLUSION The annual incidence of paracetamol overdoses was high in this population-based study but declined. Young females with intentional overdose accounted for most of the cases, whereas accidental overdoses were more common in older patients. The occurrence of ALF was low and mostly associated with accidental overdose.
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Clark R, Fisher JE, Sketris IS, Johnston GM. Population prevalence of high dose paracetamol in dispensed paracetamol/opioid prescription combinations: an observational study. BMC CLINICAL PHARMACOLOGY 2012; 12:11. [PMID: 22709372 PMCID: PMC3416683 DOI: 10.1186/1472-6904-12-11] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 06/18/2012] [Indexed: 02/06/2023]
Abstract
Background Paracetamol (acetaminophen) is generally considered a safe medication, but is associated with hepatotoxicity at doses above doses of 4.0 g/day, and even below this daily dose in certain populations. Methods The Nova Scotia Prescription Monitoring Program (NSPMP) in the Canadian province of Nova Scotia is a legislated organization that collects dispensing information on all out-of-hospital prescription controlled drugs dispensed for all Nova Scotia residents. The NSPMP provided data to track all paracetamol/opioids redeemed by adults in Nova Scotia, from July 1, 2005 to June 30, 2010. Trends in the number of adults dispensed these prescriptions and the numbers of prescriptions and tablets dispensed over this period were determined. The numbers and proportions of adults who filled prescriptions exceeding 4.0 g/day and 3.25 g/day were determined for the one-year period July 1, 2009 to June 30, 2010. Data were stratified by sex and age (<65 versus 65+). Results Both the number of prescriptions filled and the number of tablets dispensed increased over the study period, although the proportion of the adult population who filled at least one paracetamol/opioid prescription was lower in each successive one-year period. From July 2009 to June 2010, one in 12 adults (n = 59,197) filled prescriptions for over 13 million paracetamol/opioid tablets. Six percent (n = 3,786) filled prescriptions that exceeded 4.0 g/day and 18.6% (n = 11,008) exceeded 3.25 g/day of paracetamol at least once. These findings exclude non-prescription paracetamol and paracetamol–only prescribed medications. Conclusions A substantial number of individuals who redeem prescriptions for paracetamol/opioid combinations may be at risk of paracetamol-related hepatotoxicity. Healthcare professionals must be vigilant when prescribing and dispensing these medications in order to reduce the associated risks.
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Affiliation(s)
- Roderick Clark
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
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Kelkar M, Cleves MA, Foster HR, Hogan WR, James LP, Martin BC. Acute and chronic acetaminophen use and renal disease: a case-control study using pharmacy and medical claims. JOURNAL OF MANAGED CARE PHARMACY : JMCP 2012; 18:234-46. [PMID: 22468732 PMCID: PMC4000171 DOI: 10.18553/jmcp.2012.18.3.234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Studies have examined the association between acetaminophen (APAP) use and renal disease; however, their interpretation is limited by a number of methodological issues. OBJECTIVE To study the association between acute and chronic prescription-acquired APAP use and renal disease. METHODS This was a retrospective case-control study of medical and pharmacy claims of a 10% random sample of the enrollees from the IMS LifeLink Health Plans commercial claims dataset for dates of service from January 1, 1997, through December 31, 2009. Subjects were continuously enrolled and aged 18 years or older. Cases had at least 1 incident claim of renal disease defined by ICD-9-CM codes in the primary diagnosis field. Controls were randomly selected from individuals without evidence of renal disease, liver disease, or asthma in medical claims and matched to cases in a 3-to-1 ratio based on 3 variables (age, gender, and geographic region). APAP exposure, dosage, and duration of use were measured in the 7 and 30 days (acute) and in the 1-year (chronic) look-back periods. Multivariable conditional logistic regression was used to estimate the risk of APAP exposure adjusted for comorbidities, use of other nephrotoxic drugs, and health system factors. RESULTS There were 4,724 cases and 14,172 controls with a mean (SD) age of 60.8 (17.8) years, and 52.6% were males; 10.9% of cases and 4.2% of controls had APAP exposure in the 30 days pre-index with mean potential maximum daily dosages of 3,846.5 mg and 3,190.8 mg, respectively. Acute APAP exposure was significantly associated with renal disease, and the risk decreased with longer look-back periods (7 days: adjusted odds ratio [OR] = 1.93, 95% CI = 1.61-2.30); 30 days: OR = 1.71, 95% CI = 1.48-1.97). Cumulative APAP dosage greater than 1 kg and APAP use for longer than 30 days in the pre-index year were not significantly associated with an increased risk of renal disease (both P values = 0.900). CONCLUSIONS Acute prescription-acquired APAP use was associated with renal disease, while chronic use was not. Because this study assessed APAP use in pharmacy claims, further research accounting for over-the-counter APAP use is warranted before the safety of chronic APAP consumption can be firmly established.
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Affiliation(s)
- Mugdha Kelkar
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
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de Achaval S, Suarez-Almazor M. Acetaminophen overdose: a little recognized public health threat. Pharmacoepidemiol Drug Saf 2011; 20:827-9. [PMID: 21717529 DOI: 10.1002/pds.2162] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 04/04/2011] [Accepted: 04/07/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Sofia de Achaval
- General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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