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Alaska YA, Alghadeer SM, Alrabiah AA, Harb A, Almadi B. Assessment of N-acetylcysteine use for acetaminophen overdose in the emergency department of a community teaching hospital: A pilot study. Saudi J Anaesth 2023; 17:168-173. [PMID: 37260659 PMCID: PMC10228870 DOI: 10.4103/sja.sja_707_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 03/11/2023] Open
Abstract
Introduction N-acetylcysteine (NAC) is the first-line treatment for acetaminophen (APAP) overdose. However, using NAC inappropriately is associated with an increased risk of adverse effects as well as a substantial increase in hospitalization and healthcare costs. This study aims to assess NAC utilization for acute APAP overdose in the emergency department of a community teaching hospital in Saudi Arabia. Methods A retrospective chart review in which the patients initiated on an NAC secondary to acute APAP overdose at KSUMC during the period of June 2015 till November 2018 were included and assessed based on developed validated evident-based protocol for administering NAC for acute APAP ingestion. Results A total of 29 patients received NAC treatment for acute APAP overdose; 15 of which were adults, and 14 were pediatrics. Appropriate prescribing of NAC was observed in 14 (48.28%) patients, whereas NAC was inappropriately indicated for 15 (51.72%) patients; 9 of them were adults and 6 patients were pediatric. APAP-Ingestion <150 mg/kg (<200 mg/kg in children) was the most common reason for inappropriate use (n = 7, 46.67%) followed by administering NAC <4 hours post-APAP ingestion (n = 4, 26.67%). Conclusion Improper NAC administration appears to be a significant issue among patients with APAP overdose. The utilization of a protocol for the management of APAP overdose will reduce the unnecessary usage of NAC.
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Affiliation(s)
- Yasser A. Alaska
- Department of Emergency Medicine - College of Medicine, King Saud University (KSU) and King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia
| | - Sultan M. Alghadeer
- Department of Clinical Pharmacy-College of Pharmacy, King Saud University (KSU), Riyadh, Saudi Arabia
| | - Abdulaziz A. Alrabiah
- Department of Emergency Medicine - College of Medicine, King Saud University (KSU) and King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia
| | - Abdulaziz Harb
- Department of Clinical Pharmacy-College of Pharmacy, King Saud University (KSU), Riyadh, Saudi Arabia
| | - Bana Almadi
- Department of Clinical Pharmacy-College of Pharmacy, King Saud University (KSU), Riyadh, Saudi Arabia
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2
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Mullins ME, Yu M, O’Grady L, Khan S, Schwarz ES. Adverse reactions in patients treated with the one-bag method of N-acetylcysteine for acetaminophen ingestion. TOXICOLOGY COMMUNICATIONS 2020. [DOI: 10.1080/24734306.2020.1770498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Michael E. Mullins
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Mary Yu
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Lauren O’Grady
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Shariq Khan
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Evan S. Schwarz
- Division of Emergency Medicine, Section of Medical Toxicology, Washington University School of Medicine, Saint Louis, MO, USA
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Sharif MA, Bayraktutan U, Young IS, Soong CV. N-Acetylcysteine Does Not Improve the Endothelial and Smooth Muscle Function in the Human Saphenous Vein. Vasc Endovascular Surg 2019; 41:239-45. [PMID: 17595391 DOI: 10.1177/1538574407299618] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Oxidative stress can lead to vein graft dysfunction in the saphenous vein. This ex vivo study is aimed to compare the effects of increasing concentrations of the antioxidant N-acetylcysteine (NAC) with heparinized saline (HS) on endothelial and smooth muscle function in the human saphenous vein. Long saphenous vein segment obtained during infrainguinal bypass surgery was divided into 7 rings; 1 immersed in HS and the remaining 6 in increasing NAC concentrations (0.0025%, 0.005%, 0.01%, 0.02%, 0.03%, and 0.04%). Rings were mounted in an organ bath, and relaxant responses to acetylcholine and sodium nitroprusside were assessed through isometric tension studies. Endothelium-dependent relaxations were observed in 77 vein segments from 11 patients. No significant difference was seen in veins treated with either lower NAC concentrations (0.0025%, 0.005%, 0.01%, 0.02%, and 0.03%) or HS. However, HS-treated veins showed significantly better relaxation compared to those treated with maximum (0.04%) NAC ( P < .05). Endothelium-independent relaxations were observed in 91 segments from 13 patients. No difference in relaxation was observed between veins treated with HS or any of the NAC concentrations. In conclusion, lower NAC concentrations do not offer better endothelial protection than HS, whereas the highest NAC concentration has a detrimental effect on endothelium-dependent relaxation. Moreover, NAC did not show beneficial effect on direct smooth muscle relaxation.
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Affiliation(s)
- Muhammad Anees Sharif
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast, Northern Ireland, UK.
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4
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Yarema M, Chopra P, Sivilotti MLA, Johnson D, Nettel-Aguirre A, Bailey B, Victorino C, Gosselin S, Purssell R, Thompson M, Spyker D, Rumack B. Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning. J Med Toxicol 2018; 14:120-127. [PMID: 29423816 DOI: 10.1007/s13181-018-0653-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Anaphylactoid reactions to intravenous (IV) N-acetylcysteine (NAC) are well-recognized adverse events during treatment for acetaminophen (APAP) poisoning. Uncertainty exists regarding their incidence, severity, risk factors, and management. We sought to determine the incidence, risk factors, and treatment of anaphylactoid reactions to IV NAC in a large, national cohort of patients admitted to hospital for acetaminophen overdose. METHODS This retrospective medical record review included all patients initiated on the 21-h IV NAC protocol for acetaminophen poisoning in 34 Canadian hospitals between February 1980 and November 2005. The primary outcome was any anaphylactoid reaction, defined as cutaneous (urticaria, pruritus, angioedema) or systemic (hypotension, respiratory symptoms). We examined the incidence, severity and timing of these reactions, and their association with patient and overdose characteristics using multivariable analysis. RESULTS An anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses, of which 398 (75.4%) were cutaneous. Five hundred four (95.4%) reactions occurred during the first 5 h. Of 403 patients administered any medication for these reactions, 371 (92%) received an antihistamine. Being female (adjusted OR 1.24 [95%CI 1.08, 1.42]) and having taken a single, acute overdose (1.24 [95%CI 1.10, 1.39]) were each associated with more severe reactions, whereas higher serum APAP concentrations were associated with fewer reactions (0.79 [95%CI 0.68, 0.92]). CONCLUSION Anaphylactoid reactions to the 21-h IV NAC protocol were uncommon and involved primarily cutaneous symptoms. While the protective effects of higher APAP concentrations are of interest in understanding the pathophysiology, none of the associations identified are strong enough to substantially alter the threshold for NAC initiation.
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Affiliation(s)
- Mark Yarema
- Poison and Drug Information Service, Foothills Medical Centre, 1403-29th St NW, Calgary, Alberta, T2N 2T9, Canada. .,Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, AB, Canada. .,Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada.
| | - Puja Chopra
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine, and of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.,Ontario Poison Centre, Toronto, ON, Canada
| | - David Johnson
- Poison and Drug Information Service, Foothills Medical Centre, 1403-29th St NW, Calgary, Alberta, T2N 2T9, Canada.,Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Alberto Nettel-Aguirre
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute for Child and Maternal Health, Calgary, AB, Canada
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte Justine, Montréal, Quebec, Canada
| | | | | | - Roy Purssell
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Daniel Spyker
- Department of Emergency Medicine, Oregon Health Sciences University, Portland, OR, USA
| | - Barry Rumack
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, USA
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Merl W, Koutsogiannis Z, Kerr D, Kelly AM. How Safe is Intravenous N-Acetylcysteine for the Treatment of Paracetamol Poisoning? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790701400402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Paracetamol poisoning remains one of the most common and potentially lethal ingestions. N-acetylcysteine (NAC) has been proven to be a highly effective antidote. The aim of this study was to determine the rate of adverse drug reactions (ADR) to intravenous (IV) NAC. Our hypothesis was that IV NAC for the treatment of paracetamol toxicity has a low rate of adverse events. Methods This was an observational cohort study undertaken by explicit retrospective medical record review. It included patients who presented to the emergency department with paracetamol overdose over the ten-year period from July 1995 to June 2004. The primary outcome measure was the occurrence of an ADR during NAC administration. Adverse drug reactions were classified as minor (including flushing, urticaria, pruritus, bronchospasm, tachycardia, and non-ischaemic chest pain) and major (including hypotension, angio-oedema and death). Data analysis was by descriptive statistics and chi-square analysis using univariate analysis, Fisher's exact test and Mann-Whitney U-test. Inter-rater agreement was checked for 9% of the sample. Results There were 470 cases of paracetamol poisoning. Of these, 320 received IV NAC. Thirty-six (11%, 95% CI 8–15%) of these patients developed ADRs. There were two major ADRs, one hypotension and one angio-oedema (0.6%, 95% CI 0.02–2%). Two patients died during hospitalisation, but neither had an ADR to NAC. The most common ADRs were urticaria (20), flushing (15), bronchospasm (12), and pruritus (3). None of the variables analysed was a clinically significant predictor of increased ADR risk. Conclusion Adverse drug reactions after IV NAC infusion occur commonly, but most are minor. Treatment of paracetamol poisoning with IV NAC appears to be safe, however a large prospective study would be required to confirm this.
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Benedé S, Garrido-Arandia M, Martín-Pedraza L, Bueno C, Díaz-Perales A, Villalba M. Multifactorial Modulation of Food-Induced Anaphylaxis. Front Immunol 2017; 8:552. [PMID: 28559894 PMCID: PMC5432630 DOI: 10.3389/fimmu.2017.00552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 04/25/2017] [Indexed: 01/26/2023] Open
Abstract
Prevalence of food-induced anaphylaxis increases progressively and occurs in an unpredictable manner, seriously affecting the quality of life of patients. Intrinsic factors including age, physiological, and genetic features of the patient as well as extrinsic factors such as the intake of drugs and exposure to environmental agents modulate this disorder. It has been proven that diseases, such as mastocytosis, defects in HLA, or filaggrin genes, increase the risk of severe allergic episodes. Certain allergen families such as storage proteins, lipid transfer proteins, or parvalbumins have also been linked to anaphylaxis. Environmental factors such as inhaled allergens or sensitization through the skin can exacerbate or trigger acute anaphylaxis. Moreover, the effect of dietary habits such as the early introduction of certain foods in the diet, and the advantage of the breastfeeding remain as yet unresolved. Interaction of allergens with the intestinal cell barrier together with a set of effector cells represents the primary pathways of food-induced anaphylaxis. After an antigen cross-links the IgEs on the membrane of effector cells, a complex intracellular signaling cascade is initiated, which leads cells to release preformed mediators stored in their granules that are responsible for the acute symptoms of anaphylaxis. Afterward, they can also rapidly synthesize lipid compounds such as prostaglandins or leukotrienes. Cytokines or chemokines are also released, leading to the recruitment and activation of immune cells in the inflammatory microenvironment. Multiple factors that affect food-induced anaphylaxis are discussed in this review, paying special attention to dietary habits and environmental and genetic conditions.
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Affiliation(s)
- Sara Benedé
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
| | - María Garrido-Arandia
- Centro de Biotecnología y Genómica de Plantas (UPM-INIA), Campus de Montegancedo, Pozuelo de Alarcón, Madrid, Spain
| | - Laura Martín-Pedraza
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
| | - Cristina Bueno
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
| | - Araceli Díaz-Perales
- Centro de Biotecnología y Genómica de Plantas (UPM-INIA), Campus de Montegancedo, Pozuelo de Alarcón, Madrid, Spain
| | - Mayte Villalba
- Dpto. Bioquímica y Biología Molecular I, Universidad Complutense de Madrid, Madrid, Spain
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7
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Zyoud SH, Waring WS, Al-Jabi SW, Sweileh WM, Awang R. The 100 most influential publications in paracetamol poisoning treatment: a bibliometric analysis of human studies. SPRINGERPLUS 2016; 5:1534. [PMID: 27652107 PMCID: PMC5019997 DOI: 10.1186/s40064-016-3240-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Analysis of the most influential publications within paracetamol poisoning treatment can be helpful in recognizing main and novel treatment issues within the field of toxicology. The current study was performed to recognize and describe the most highly cited articles related to paracetamol poisoning treatment. METHODS The 100 most highly cited articles in paracetamol poisoning treatment were identified from the Scopus database in November 2015. All eligible articles were read for basic information, including total number of citations, average citations per year, authors' names, journal name, impact factors, document types and countries of authors of publications. RESULTS The median number of citations was 75 (interquartile range 56-137). These publications were published between 1974 and 2013. The average number of years since publication was 17.6 years, and 45 of the publications were from the 2000s. A significant, modest positive correlation was found between years since publication and the number of citations among the top 100 cited articles (r = 0.316; p = 0.001). A total of 55 journals published these 100 most cited articles. Nine documents were published in Clinical Toxicology, whereas eight documents were published in Annals of Emergency Medicine. Citations per year since publication for the top 100 most-cited articles ranged from 1.5 to 42.6 and had a mean of 8.5 citations per year and a median of 5.9 with an interquartile range of 3.75-10.35. In relation to the origin of the research publications, they were from 8 countries. The USA had the largest number of articles, 47, followed by the UK and Australia with 38 and nine articles respectively. CONCLUSIONS This study is the first bibliometric assessment of the top 100 cited articles in toxicology literature. Interest in paracetamol poisoning as a serious clinical problem continues to grow. Research published in high-impact journals and from high income countries is most likely to be cited in published paracetamol research.
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Affiliation(s)
- Sa’ed H. Zyoud
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Pulau Pinang, Penang Malaysia
| | - W. Stephen Waring
- Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, Wigginton Road, York, YO31 8HE UK
| | - Samah W. Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Waleed M. Sweileh
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Rahmat Awang
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Pulau Pinang, Penang Malaysia
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8
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Bailey GP, Najafi J, Elamin MEMO, Waring WS, Thomas SHL, Archer JRH, Wood DM, Dargan PI. Delays during the administration of acetylcysteine for the treatment of paracetamol overdose. Br J Clin Pharmacol 2016; 82:1358-1363. [PMID: 27412926 DOI: 10.1111/bcp.13063] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/23/2016] [Accepted: 07/09/2016] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The licensed intravenous acetylcysteine regimen for treating paracetamol overdose in most countries uses three separate infusions over 21 h. This complex regimen, requiring different infusion concentrations and rates, has been associated with administration errors. The aim of the present study was to assess the extent of administration delays occurring during this acetylcysteine regimen. METHOD A 6-month retrospective observational study was conducted at three English teaching hospitals with clinical toxicology services from October 2014. Patients aged 16 years and over, treated with intravenous acetylcysteine for paracetamol overdose, were included. The start times for infusions were recorded and the delays compared with the prescribed infusion times were calculated. Anaphylactoid reactions, intravenous cannula problems, overdose intent and smoking status were recorded to assess their contribution to delays. RESULTS From 263 cases identified, 198 met the study inclusion criteria. The median time between the start of infusions 1 and 3 was delayed from the intended 5 h by a median (interquartile range) of 90 (50-163) min, with 135 (68%) cases delayed by more than 1 h. Significantly longer delays were observed in patients with anaphylactoid reactions [median delay 267 (217-413) min, n = 8] and accidental/supratherapeutic overdose [median delay 170 (95-260) min, n = 29]. There were no significant differences between smokers and nonsmokers, or for patients with intravenous cannula problems. CONCLUSION Long delays were identified during the three-infusion acetylcysteine regimen for the treatment of paracetamol overdose. These were of clinical significance and could lead to periods of subtherapeutic plasma acetylcysteine concentrations and potentially avoidable hepatotoxicity, as well as delaying hospital discharge.
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Affiliation(s)
- George P Bailey
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Emergency Department, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Javad Najafi
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Simon H L Thomas
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, 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 and King's Health Partners, London, UK. .,Faculty of Life Sciences and Medicine, King's College London, London, UK.
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10
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Chiew AL, Isbister GK, Duffull SB, Buckley NA. Evidence for the changing regimens of acetylcysteine. Br J Clin Pharmacol 2016; 81:471-81. [PMID: 26387650 PMCID: PMC4767192 DOI: 10.1111/bcp.12789] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 01/01/2023] Open
Abstract
Paracetamol overdose prior to the introduction of acetylcysteine was associated with significant morbidity. Acetylcysteine is now the mainstay of treatment for paracetamol poisoning and has effectively reduced rates of hepatotoxicity and death. The current three-bag intravenous regimen with an initial high loading dose was empirically derived four decades ago and has not changed since. This regimen is associated with a high rate of adverse effects due mainly to the high initial peak acetylcysteine concentration. Furthermore, there are concerns that the acetylcysteine concentration is not adequate for 'massive' overdoses and that the dose and duration may need to be altered. Various novel regimens have been proposed, looking to address these issues. Many of these modified regimens aim to decrease the rate of adverse reactions by slowing the loading dose and thereby decrease the peak concentration. We used a published population pharmacokinetic model of acetylcysteine to simulate these modified regimens. We determined mean peak and 20 h acetylcysteine concentrations and area under the under the plasma concentration-time curve to compare these regimens. Those regimens that resulted in a lower peak acetylcysteine concentration have been shown in studies to have a lower rate of adverse events. However, these studies were too small to show whether they are as effective as the traditional regimen. Further research is still needed to determine the optimum dose and duration of acetylcysteine that results in the fewest side-effects and treatment failures. Indeed, a more patient-tailored approach might be required, whereby the dose and duration are altered depending on the paracetamol dose ingested or paracetamol concentrations.
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Affiliation(s)
- Angela L Chiew
- Clinical and Experimental Toxicology Unit, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
| | - Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | | | - Nicholas A Buckley
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
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11
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Wong G, Lee E, Irwin M. Contrast induced nephropathy in vascular surgery. Br J Anaesth 2016; 117:ii63-ii73. [DOI: 10.1093/bja/aew213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Isbister GK, Downes MA, Mcnamara K, Berling I, Whyte IM, Page CB. A prospective observational study of a novel 2-phase infusion protocol for the administration of acetylcysteine in paracetamol poisoning. Clin Toxicol (Phila) 2015; 54:120-6. [DOI: 10.3109/15563650.2015.1115057] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle
| | - Michael A. Downes
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle
| | - Kylie Mcnamara
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle
| | - Ingrid Berling
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle
| | - Ian M. Whyte
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle
| | - Colin B. Page
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle
- Emergency Department, Princess Alexandra Hospital, Queensland, Australia
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13
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Karimzadeh I, Khalili H, Sagheb MM, Farsaei S. A double-blinded, placebo-controlled, multicenter clinical trial ofN-acetylcysteine for preventing amphotericin B-induced nephrotoxicity. Expert Opin Drug Metab Toxicol 2015; 11:1345-55. [DOI: 10.1517/17425255.2015.1042363] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Bateman DN, Carroll R, Pettie J, Yamamoto T, Elamin MEMO, Peart L, Dow M, Coyle J, Cranfield KR, Hook C, Sandilands EA, Veiraiah A, Webb D, Gray A, Dargan PI, Wood DM, Thomas SHL, Dear JW, Eddleston M. Effect of the UK's revised paracetamol poisoning management guidelines on admissions, adverse reactions and costs of treatment. Br J Clin Pharmacol 2015; 78:610-8. [PMID: 24666324 PMCID: PMC4243911 DOI: 10.1111/bcp.12362] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 02/09/2014] [Indexed: 12/19/2022] Open
Abstract
Aims In September 2012 the UK’s Commission on Human Medicines (CHM) recommended changes in the management of paracetamol poisoning: use of a single ‘100 mg l−1’ nomogram treatment line, ceasing risk assessment, treating all staggered/uncertain ingestions and increasing the duration of the initial acetylcysteine (NAC) infusion from 15 to 60 min. We evaluated the effect of this on presentation, admission, treatment, adverse reactions and costs of paracetamol poisoning. Methods Data were prospectively collected from adult patients presenting to three large UK hospitals from 3 September 2011 to 3 September 2013 (year before and after change). Infusion duration effect on vomiting and anaphylactoid reactions was examined in one centre. A cost analysis from an NHS perspective was performed for 90 000 patients/annum with paracetamol overdose. Results There were increases in the numbers presenting to hospital (before 1703, after 1854; increase 8.9% [95% CI 1.9, 16.2], P = 0.011); admitted (1060/1703 [62.2%] vs. 1285/1854 [69.3%]; increase 7.1% [4.0, 10.2], P < 0.001) and proportion treated (626/1703 [36.8%] vs. 926/1854 [50.0%]; increase: 13.2% [95% CI 10.0, 16.4], P < 0.001). Increasing initial NAC infusion did not change the proportion of treated patients developing adverse reactions (15 min 87/323 [26.9%], 60 min 145/514 [28.2%]; increase: 1.3% [95% CI –4.9, 7.5], P = 0.682). Across the UK the estimated cost impact is £8.3 million (6.4 million–10.2 million) annually, with a cost-per-life saved of £17.4 million (13.4 million–21.5 million). Conclusions The changes introduced by the CHM in September 2012 have increased the numbers of patients admitted to hospital and treated with acetylcysteine without reducing adverse reactions. A safety and cost-benefit review of the CHM guidance is warranted, including novel treatment protocols and biomarkers in the assessment of poisoning.
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Affiliation(s)
| | - Estabrak Jiad
- Senior House Officer in Stroke Medicine in the Department of Stroke Medicine, National Hospital for Neurology and Neurosurgery, London
| | - Jacob F de Wolff
- Consultant Acute Physician in the Department of Acute Medicine, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ
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Abstract
Contrast-induced nephropathy (CIN) is a serious complication of angiographic procedures resulting from the administration of contrast media (CM). It is the third most common cause of hospital acquired acute renal injury and represents about 12% of the cases. CIN is defined as an elevation of serum creatinine (Scr) of more than 25% or ≥0.5 mg/dl (44 μmol/l) from baseline within 48 h. More sensitive markers of renal injury are desired, therefore, several biomarkers of tubular injury are under evaluation. Multiple risk factors may contribute to the development of CIN; these factors are divided into patient- and procedure-related factors. Treatment of CIN is mainly supportive, consisting mainly of careful fluid and electrolyte management, although dialysis may be required in some cases. The available treatment option makes prevention the corner stone of management. This article will review the recent evidence concerning CIN incidence, diagnosis, and prevention strategies as well as its treatment and prognostic implications.
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Affiliation(s)
- Nazar M A Mohammed
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Mahfouz
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Katafan Achkar
- Department of Nephrology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ihsan M Rafie
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rachel Hajar
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Heard K, Rumack BH, Green JL, Bucher-Bartelson B, Heard S, Bronstein AC, Dart RC. A single-arm clinical trial of a 48-hour intravenous N-acetylcysteine protocol for treatment of acetaminophen poisoning. Clin Toxicol (Phila) 2014; 52:512-8. [PMID: 24708414 DOI: 10.3109/15563650.2014.902955] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acetylcysteine prevents hepatic injury when administered soon after acetaminophen overdose. The most commonly used treatment protocols are a 72-hour oral and a 21-hour intravenous (IV) protocol. Between 1984 and 1994, 409 patients were enrolled in a study to describe the outcomes of patients who were treated using a 48-hour IV protocol. In 1991, an interim analysis reported the first 223 patients. The objective of this manuscript is to report the rates of hepatotoxicity and adverse events occurring during a 48-hour IV acetylcysteine protocol in the entire 409 patient cohort. METHODS This was a multicenter, single-arm, open-label clinical trial enrolling patients who presented with a toxic serum acetaminophen concentration within 24 h of acute acetaminophen ingestion. Patients were treated with 140 mg/kg loading dose followed by 70 mg/kg every 4 h for 12 doses. Serum aminotransferase activities were measured every 8 h during the protocol, and adverse events were recorded. The primary outcome was the percentage of subjects who developed hepatotoxicity defined as a peak serum aminotransferase greater than 1000 IU/L. RESULTS Four hundred and nine patients were enrolled, and 309 met inclusion for the outcome analysis. The overall percentage of patients developing hepatotoxicity was 18.1%, and 3.4% of patients treated within 10 h developed hepatotoxicity. One acetaminophen-related death occurred in a patient treated at 22 h. Adverse events occurred in 28.9% of enrolled subjects; the most common adverse events were nausea, vomiting, and flushing, and no events were rated as serious by the investigator. CONCLUSIONS Acetaminophen-overdosed patients treated with IV acetylcysteine administered as 140 mg/kg loading dose followed by 70 mg/kg every 4 h for 12 doses had a low rate of hepatotoxicity and few adverse events. This protocol delivers a higher dose of acetylcysteine which may be useful in selected cases involving very large overdoses.
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Affiliation(s)
- K Heard
- Rocky Mountain Poison and Drug Center , Denver, CO , USA
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Bateman DN, Dear JW, Thanacoody HKR, Thomas SHL, Eddleston M, Sandilands EA, Coyle J, Cooper JG, Rodriguez A, Butcher I, Lewis SC, Vliegenthart ADB, Veiraiah A, Webb DJ, Gray A. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial. Lancet 2014; 383:697-704. [PMID: 24290406 DOI: 10.1016/s0140-6736(13)62062-0] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Paracetamol poisoning is common worldwide. It is treated with intravenous acetylcysteine, but the standard regimen is complex and associated with frequent adverse effects related to concentration, which can cause treatment interruption. We aimed to ascertain whether adverse effects could be reduced with either a shorter modified acetylcysteine schedule, antiemetic pretreatment, or both. METHODS We undertook a double-blind, randomised factorial study at three UK hospitals, between Sept 6, 2010, and Dec 31, 2012. We randomly allocated patients with acute paracetamol overdose to either the standard intravenous acetylcysteine regimen (duration 20·25 h) or a shorter (12 h) modified protocol, with or without intravenous ondansetron pretreatment (4 mg). Masking was achieved by infusion of 5% dextrose (during acetylcysteine delivery) or saline (for antiemetic pretreatment). Randomisation was done via the internet and included a minimisation procedure by prognostic factors. The primary outcome was absence of vomiting, retching, or need for rescue antiemetic treatment at 2 h. Prespecified secondary outcomes included a greater than 50% increase in alanine aminotransferase activity over the admission value. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov (identifier NCT01050270). FINDINGS Of 222 patients who underwent randomisation, 217 were assessable 2 h after the start of acetylcysteine treatment. Vomiting, retching, or need for rescue antiemetic treatment at 2 h was reported in 39 of 108 patients assigned to the shorter modified protocol compared with 71 of 109 allocated to the standard acetylcysteine regimen (adjusted odds ratio 0·26, 97·5% CI 0·13-0·52; p<0·0001), and in 45 of 109 patients who received ondansetron compared with 65 of 108 allocated placebo (0·41, 0·20-0·80; p=0·003). Severe anaphylactoid reactions were recorded in five patients assigned to the shorter modified acetylcysteine regimen versus 31 who were allocated to the standard protocol (adjusted common odds ratio 0·23, 97·5% CI 0·12-0·43; p<0·0001). The proportion of patients with a 50% increase in alanine aminotransferase activity did not differ between the standard (9/110) and shorter modified (13/112) regimens (adjusted odds ratio 0·60, 97·5% CI 0·20-1·83); however, the proportion was higher with ondansetron (16/111) than with placebo (6/111; 3·30, 1·01-10·72; p=0·024). INTERPRETATION In patients with paracetamol poisoning, a 12 h modified acetylcysteine regimen resulted in less vomiting, fewer anaphylactoid reactions, and reduced need for treatment interruption. This study was not powered to detect non-inferiority of the shorter protocol versus the standard approach; therefore, further research is needed to confirm the efficacy of the 12 h modified acetylcysteine regimen. FUNDING Chief Scientist Office of the Scottish Government.
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Affiliation(s)
- D Nicholas Bateman
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - James W Dear
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK; British Heart Foundation Centre for Cardiovascular Science, Edinburgh University, Edinburgh, UK
| | - H K Ruben Thanacoody
- Institute of Cellular Medicine, Newcastle University, and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Simon H L Thomas
- Institute of Cellular Medicine, Newcastle University, and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael Eddleston
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK; British Heart Foundation Centre for Cardiovascular Science, Edinburgh University, Edinburgh, UK
| | - Euan A Sandilands
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Judy Coyle
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Isabella Butcher
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steff C Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Aravindan Veiraiah
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David J Webb
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh University, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Brown DA, Sabbah HN, Shaikh SR. Mitochondrial inner membrane lipids and proteins as targets for decreasing cardiac ischemia/reperfusion injury. Pharmacol Ther 2013; 140:258-66. [DOI: 10.1016/j.pharmthera.2013.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 01/06/2023]
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Panesar SS, Javad S, de Silva D, Nwaru BI, Hickstein L, Muraro A, Roberts G, Worm M, Bilò MB, Cardona V, Dubois AEJ, Dunn Galvin A, Eigenmann P, Fernandez-Rivas M, Halken S, Lack G, Niggemann B, Santos AF, Vlieg-Boerstra BJ, Zolkipli ZQ, Sheikh A. The epidemiology of anaphylaxis in Europe: a systematic review. Allergy 2013; 68:1353-61. [PMID: 24117770 DOI: 10.1111/all.12272] [Citation(s) in RCA: 225] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anaphylaxis is an acute, potentially fatal, multi-organ system, allergic reaction caused by the release of chemical mediators from mast cells and basophils. Uncertainty exists around epidemiological measures of incidence and prevalence, risk factors, risk of recurrence, and death due to anaphylaxis. This systematic review aimed to (1) understand and describe the epidemiology of anaphylaxis and (2) describe how these characteristics vary by person, place, and time. METHODS Using a highly sensitive search strategy, we identified systematic reviews of epidemiological studies, descriptive and analytical epidemiological investigations, and studies involving analysis of routine data. RESULTS Our searches identified a total of 5,843 potentially eligible studies, of which 49 satisfied our inclusion criteria. Of these, three were suitable for pooled estimates of prevalence. The incidence rates for all-cause anaphylaxis ranged from 1.5 to 7.9 per 100,000 person-years. These data indicated that an estimated 0.3% (95% CI 0.1-0.5) of the population experience anaphylaxis at some point in their lives. Food, drugs, stinging insects, and latex were the most commonly identified triggers. CONCLUSIONS Anaphylaxis is a common problem, affecting an estimated 1 in 300 of the European population at some time in their lives. Future research needs to focus on better understanding of the trends across Europe and identifying those most likely to experience fatal reactions.
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Affiliation(s)
- S. S. Panesar
- Allergy & Respiratory Research Group; Center for Population Health Sciences; The University of Edinburgh; Edinburgh UK
| | - S. Javad
- School of Public Health; Imperial College; London UK
| | | | - B. I. Nwaru
- School of Health Sciences; University of Tampere; Tampere Finland
| | - L. Hickstein
- Biometry and Epidemiology; Institute for Medical Informatics; University of Munich; Munich Germany
| | - A. Muraro
- Department of Pediatrics; Center for Food Allergy Diagnosis and Treatment; Veneto Region; University of Padua; Padua Italy
| | - G. Roberts
- David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport; Isle of Wight UK
- NIHR Southampton Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; Human Development and Health and Clinical Experimental Sciences Academic Units; University of Southampton; Southampton UK
| | - M. Worm
- Allergy-Center-Charité; Department of Dermatology and Allergy; Charité Universitätsmedizin Berlin; Berlin Germany
| | - M. B. Bilò
- Allergy Unit; Department Internal Medicine; University Hospital; Ospedali Riuniti; Ancona Italy
| | - V. Cardona
- Allergy Section; Department of Internal Medicine; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - A. E. J. Dubois
- Department of Pediatric Pulmonology and Pediatric Allergy; University of Groningen; University Medical Center Groningen; GRIAC Research Institute; Groningen the Netherlands
| | - A. Dunn Galvin
- Department of Paediatrics and Child Health; University College; Cork Ireland
| | - P. Eigenmann
- University Hospitals of Geneva; Geneva Switzerland
| | - M. Fernandez-Rivas
- Department of Allergy; Hospital Clinico San Carlos; IdISSC; Madrid Spain
| | - S. Halken
- Hans Christian Andersen Children's Hospital; Odense University Hospital; Odense Denmark
| | - G. Lack
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
| | - B. Niggemann
- Allergy Center Charité; University Hospital Charité; Berlin Germany
| | - A. F. Santos
- Department of Pediatric Allergy; Division of Asthma; Allergy & Lung Biology; King's College; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Department of Immunoallergology; Coimbra University Hospital; Coimbra Portugal
| | - B. J. Vlieg-Boerstra
- Department of Pediatric Respiratory Medicine and Allergy; Emma Children's Hospital; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
| | - Z. Q. Zolkipli
- NIHR Southampton Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; Human Development and Health and Clinical Experimental Sciences Academic Units; University of Southampton; Southampton UK
| | - A. Sheikh
- Allergy & Respiratory Research Group; Center for Population Health Sciences; The University of Edinburgh; Edinburgh UK
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital/Harvard Medical School; Boston MA USA
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Carroll R, Benger J, Bramley K, Williams S, Griffin L, Potokar J, Gunnell D. Epidemiology, management and outcome of paracetamol poisoning in an inner city emergency department. Emerg Med J 2013; 32:155-60. [PMID: 24099830 DOI: 10.1136/emermed-2013-202518] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Paracetamol poisoning accounts for just under half of all self-poisoning cases that present to hospitals in England. Treatment with acetylcysteine is routine, yet recommendations regarding its use vary internationally and have recently been revised in England and Wales. METHODS Data on all cases of paracetamol poisoning presenting to an adult inner city emergency department between May 2011 and April 2012 were prospectively collected using the Bristol Self-harm Surveillance Register. RESULTS Paracetamol overdoses accounted for 44% of adult self-poisoning cases. A quarter (26.9%) of patients required treatment with acetylcysteine and it was estimated that recent changes in treatment guidelines would increase that proportion to 32.6%. Paracetamol concentration was positively associated with the risk of any adverse reaction to acetylcysteine. 22.5% of patients experienced anaphylactoid reactions to acetylcysteine. There was no clear evidence of an association between risk of anaphylactoid reaction and blood paracetamol levels. Patients presenting with blood paracetamol levels greater than 200 mg/L at 4 h post-ingestion were at greater risk of repeat self-harm (HR 2.17, 95% CI 1.11 to 4.21, p=0.033). DISCUSSION The recent changes in UK treatment guidelines are expected to increase the proportion of our population requiring acetylcysteine by 5.7%. We found no clear evidence that risk of anaphylactoid or more general adverse reaction to acetylcysteine was increased in patients presenting with lower blood paracetamol concentrations. Blood paracetamol level was highlighted as a potentially useful clinical indicator for risk of repeat self-harm.
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Affiliation(s)
- R Carroll
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Benger
- Emergency Department, Bristol Royal Infirmary, Bristol, UK Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - K Bramley
- Liaison Psychiatry, Bristol Royal Infirmary, Bristol, UK
| | - S Williams
- Liaison Psychiatry, Bristol Royal Infirmary, Bristol, UK
| | - L Griffin
- Liaison Psychiatry, Bristol Royal Infirmary, Bristol, UK
| | - J Potokar
- School of Social and Community Medicine, University of Bristol, Bristol, UK Liaison Psychiatry, Bristol Royal Infirmary, Bristol, UK
| | - D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Chousterman BG, Bouadma L, Moutereau S, Loric S, Alvarez-Gonzalez A, Mekontso-Dessap A, Laissy JP, Rahmouni A, Katsahian S, Brochard L, Schortgen F. Prevention of contrast-induced nephropathy by N-acetylcysteine in critically ill patients: Different definitions, different results. J Crit Care 2013; 28:701-9. [DOI: 10.1016/j.jcrc.2013.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/11/2013] [Accepted: 03/13/2013] [Indexed: 11/24/2022]
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Biary R, Hoffman RS. Response to Letter: Identification of patients at risk of anaphylactoid reactions to N-acetylcysteine in the treatment paracetamol overdose. Clin Toxicol (Phila) 2013; 51:812. [DOI: 10.3109/15563650.2013.834345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schmidt LE. Identification of patients at risk of anaphylactoid reactions to N-acetylcysteine in the treatment of paracetamol overdose. Clin Toxicol (Phila) 2013; 51:467-72. [PMID: 23697458 DOI: 10.3109/15563650.2013.799677] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT N-acetylcysteine (NAC) is acknowledged as an effective antidote for paracetamol overdose. However, adverse effects to NAC are common and may be a point of concern for the patient and the treating physician. OBJECTIVE The aim of the present study was to further analyse possible risk factors of anaphylactoid adverse effects to intravenous NAC in order to identify individual patients or groups of patients at particular risk. METHODS This study is an observational case series of adverse effects to NAC administered according to the standard guidelines in patients who presented with paracetamol overdose between March 1999 and September 2011. RESULTS A total of 1218 admissions for paracetamol overdose receiving intravenous NAC were recorded in 950 patients. Anaphylactoid adverse effects occurred in 18.6%. The proportion of cases with adverse effects gradually declined from 25.9% in cases with undetectable p-paracetamol to 6.3% in cases with p-paracetamol above 1.5 mmol/L (226 μg/mL) (Spearman Rank R-test: p < 0.00001). The proportion of cases with adverse effects was significantly higher in cases of non-Danish origin than that of Danish origin (28.5% vs. 15.1%; Chi-square: p < 0.00001). In patients with repeated exposure to NAC, the rate of adverse effects on re-exposure was significantly higher in patients with a previous reaction to NAC compared to those without a previous reaction (Rate Ratio 6.2; 95% CI 2.9-17.1). CONCLUSION The development of anaphylactoid adverse effects to intravenous NAC was strongly associated with a low p-paracetamol, non-Danish origin and a history of previous reaction to NAC. These adverse effects are common, but usually mild and easily manageable. The incidence of adverse effects may be reduced by pre-treating selected patients with antihistamines, in particular those with a previous reaction to NAC.
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Affiliation(s)
- Lars E Schmidt
- Division of Gastroenterology, Department of Internal Medicine, Glostrup Hospital, Glostrup, Denmark.
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Noh JR, Kim YH, Hwang JH, Gang GT, Kim KS, Lee IK, Yun BS, Lee CH. Davallialactone protects against acetaminophen overdose-induced liver injuries in mice. Food Chem Toxicol 2013; 58:14-21. [PMID: 23583805 DOI: 10.1016/j.fct.2013.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 03/14/2013] [Accepted: 04/04/2013] [Indexed: 01/22/2023]
Abstract
Oxidative stress is closely associated with acetaminophen (APAP)-induced toxicity. Davallialactone (DAVA), a hispidin analog derived from the mushroom Inonotus xeranticus, has antioxidant properties. This study evaluated whether DAVA plays protective roles against APAP hepatotoxicity in mice. Pretreatments with DAVA (10 mg/kg) prior to exposures of mice to a hepatotoxic dose of 600 mg/kg APAP significantly increased survival rate compared to APAP alone. To verify this effect, mice were treated with 400 mg/kg APAP 30 min after DAVA administration and were then sacrificed after 0.5, 1, 3, and 6 h. APAP alone caused severe liver injuries as characterized by increased plasma GOT and GPT levels, ATP and GSH depletion, and peroxynitrite and 4-HNE formations. These liver damages induced by APAP were significantly attenuated by DAVA pretreatments. The GSH/GSSG ratio nearly recovered to the levels observed in non-APAP-treated mice at 6h after APAP treatment in DAVA-pretreated mice. Furthermore, while hepatic ROS levels were increased by APAP exposures, pretreatments with DAVA completely blocked ROS formation. In addition, APAP-induced sustained activations of JNK and ERK were remarkably reduced by DAVA pretreatment. In conclusion, these results suggest that DAVA plays protective roles against APAP-mediated hepatotoxicity through function as ROS scavenger.
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Affiliation(s)
- Jung-Ran Noh
- Laboratory Animal Center, Korea Research Institute of Bioscience and Biotechnology, 125 Gwahak-ro, Yuseong-gu, Daejeon 305-806, Republic of Korea
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Thanacoody HKR, Gray A, Dear JW, Coyle J, Sandilands EA, Webb DJ, Lewis S, Eddleston M, Thomas SH, Bateman DN. Scottish and Newcastle antiemetic pre-treatment for paracetamol poisoning study (SNAP). BMC Pharmacol Toxicol 2013; 14:20. [PMID: 23556549 PMCID: PMC3626543 DOI: 10.1186/2050-6511-14-20] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/07/2013] [Indexed: 11/10/2022] Open
Abstract
Background Paracetamol (acetaminophen) poisoning remains the commonest cause of acute liver injury in Europe and North America. The intravenous (IV) N-acetylcysteine (NAC) regimen introduced in the 1970s has continued effectively unchanged. This involves 3 different infusion regimens (dose and time) lasting over 20 hours. The same weight-related dose of NAC is used irrespective of paracetamol dose. Complications include frequent nausea and vomiting, anaphylactoid reactions and dosing errors. We designed a randomised controlled study investigating the efficacy of antiemetic pre-treatment (ondansetron) using standard NAC and a modified, shorter, regimen. Methods/Design We designed a double-blind trial using a 2 × 2 factorial design involving four parallel groups. Pre-treatment with ondansetron 4 mg IV was compared against placebo on nausea and vomiting following the standard (20.25 h) regimen, or a novel 12 h NAC regimen in paracetamol poisoning. Each delivered 300 mg/kg bodyweight NAC. Randomisation was stratified on: paracetamol dose, perceived risk factors, and time to presentation. The primary outcome was the incidence of nausea and vomiting following NAC. In addition the frequency of anaphylactoid reactions and end of treatment liver function documented. Where clinically necessary further doses of NAC were administered as per standard UK protocols at the end of the first antidote course. Discussion This study is primarily designed to test the efficacy of prophylactic anti-emetic therapy with ondansetron, but is the first attempt to formally examine new methods of administering IV NAC in paracetamol overdose. We anticipate, from volunteer studies, that nausea and vomiting will be less frequent with the new NAC regimen. In addition as anaphylactoid response appears related to plasma concentrations of both NAC and paracetamol anaphylactoid reactions should be less likely. This study is not powered to assess the relative efficacy of the two NAC regimens, however it will give useful information to power future studies. As the first formal randomised clinical trial in this patient group in over 30 years this study will also provide information to support further studies in patients in paracetamol overdose, particularly, when linked with modern novel biomarkers of liver damage, patients at different toxicity risk. Trial registration EudraCT number 2009-017800-10, ClinicalTrials.gov IdentifierNCT01050270
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Lameire N, Kellum JA. Contrast-induced acute kidney injury and renal support for acute kidney injury: a KDIGO summary (Part 2). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:205. [PMID: 23394215 PMCID: PMC4056805 DOI: 10.1186/cc11455] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever international multidisciplinary clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. Two topics, contrast-induced AKI and management of renal replacement therapy, deserve special attention because of the frequency in which they are encountered and the availability of evidence. Recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided. This review is an abridged version of the guideline and provides additional rationale and commentary for those recommendation statements that most directly impact the practice of critical care.
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Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 663] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
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Hanly LN, Chen N, Aleksa K, Cutler M, Bajcetic M, Palassery R, Regueira O, Turner C, Baw B, Malkin B, Freeman D, Rieder MJ, Vasylyeva TL, Koren G. N-acetylcysteine as a novel prophylactic treatment for ifosfamide-induced nephrotoxicity in children: translational pharmacokinetics. J Clin Pharmacol 2011; 52:55-64. [PMID: 21263015 DOI: 10.1177/0091270010391790] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ifosfamide (IFO), which is used in the treatment of pediatric solid tumors, causes high rates of nephrotoxicity. N-acetylcysteine (NAC), an antidote for acetaminophen overdose, has been shown to prevent IFO-induced renal cell death and nephrotoxicity in both LLCPK-1 cells and a rat model. To facilitate the use of NAC in preventing IFO-induced nephrotoxicity in children, the authors compared the systemic exposure to NAC in children treated for acetaminophen overdose to the systemic exposure of the therapeutically effective rat model. The mean systemic exposure in the rat model was 18.72 mM·h (range, 9.92-30.02 mM·h), compared to the mean systemic exposure found in treated children (14.48 mM·h; range, 6.22-32.96 mM·h). They also report 2 pediatric cases in which NAC-attenuated acute renal failure associated with IFO when given concurrently with their chemotherapy treatment. Systemic exposure to NAC measured in 1 of these cases was comparable to that in the children treated for acetaminophen overdose. These results corroborate NAC's potential to protect against IFO-induced nephrotoxicity in children when used in its clinically approved dose schedule and supports a clinical trial in children.
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Affiliation(s)
- Lauren N Hanly
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. Effects of delay in infusion of N-acetylcysteine on appearance of adverse drug reactions after acetaminophen overdose: a retrospective study. Pharmacoepidemiol Drug Saf 2010; 19:1064-70. [PMID: 20712021 DOI: 10.1002/pds.1955] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the relationship between different types of adverse drug reaction (ADR) and late time to N-acetylcysteine (NAC) infusion in patients presenting to the hospital with acetaminophen overdose. METHODS This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years (1 January 2004 to 31 December 2008). The primary outcome of interest was the relationship between ADR, if any, and late time to NAC infusion. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. RESULTS Of 305 patients with acetaminophen overdose, 146 (47.9%) were treated with intravenous NAC and 139 (45.6%) were included in this study. Different types of ADR were observed in 94 (67.6%) patients. Late time to NAC infusion was significantly associated with cutaneous anaphylactoid reactions when compared to patients without this type of ADR (p < 0.001). However, there were no significant differences in time to NAC infusion between patients with and without the following ADR: gastrointestinal reactions (p = 0.11), respiratory reactions (p = 0.77), central nervous reactions (p = 0.64), and cardiovascular reactions (p = 0.63). CONCLUSION Late time to NAC infusion is a risk factor for developing cutaneous anaphylactoid reactions, suggesting, rather than proving, that early NAC infusion (≤ 8 hours) may be protective against this type of ADR.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Khan HRM, Sawalha AF, Sweileh WM, Al-Jabi SW. Relationship between serum acetaminophen concentration and N-acetylcysteine-induced adverse drug reactions. Basic Clin Pharmacol Toxicol 2010; 107:718-23. [PMID: 20374238 DOI: 10.1111/j.1742-7843.2010.00567.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Intravenous N-acetylcysteine is usually regarded as a safe antidote. However, during the infusion of the loading dose, different types of adverse drug reactions (ADR) may occur. The objective of this study was to investigate the relation between the incidence of different types of ADR and serum acetaminophen concentration in patients presenting to the hospital with acetaminophen overdose. This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years (1 January 2004 to 31 December 2008). Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. Of 305 patients with acetaminophen overdose, 146 (47.9%) were treated with intravenous N-acetylcysteine and 139 (45.6%) were included in this study. Different types of ADR were observed in 94 (67.6%) patients. Low serum acetaminophen concentrations were significantly associated with cutaneous anaphylactoid reactions but not other types of ADR. Low serum acetaminophen concentration was significantly associated with flushing (p < 0.001), rash (p < 0.001) and pruritus (p < 0.001). However, there were no significant differences in serum acetaminophen concentrations between patients with and without the following ADR: gastrointestinal reactions (p = 0.77), respiratory reactions (p = 0.96), central nervous reactions (p = 0.82) and cardiovascular reactions (p = 0.37). In conclusion, low serum acetaminophen concentrations were associated with higher cutaneous anaphylactoid reactions. Such high serum acetaminophen concentrations may be protective against N-acetylcysteine-induced cutaneous ADR.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, Clinical Toxicology Programme, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Bebarta VS, Kao L, Froberg B, Clark RF, Lavonas E, Qi M, Delgado J, McDonagh J, Arnold T, Odujebe O, O'Malley G, Lares C, Aguilera E, Dart R, Heard K, Stanford C, Kokko J, Bogdan G, Mendoza C, Mlynarchek S, Rhyee S, Hoppe J, Haur W, Tan HH, Tran NN, Varney S, Zosel A, Buchanan J, Al-Helial M. A multicenter comparison of the safety of oral versus intravenous acetylcysteine for treatment of acetaminophen overdose. Clin Toxicol (Phila) 2010; 48:424-30. [PMID: 20524832 DOI: 10.3109/15563650.2010.486381] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Oral and intravenous (IV) N-acetylcysteine (NAC) are used for the treatment of acetaminophen poisoning. The objective of this multicenter study was to compare the safety of these two routes of administration. METHODS We conducted a multicenter chart review of all patients treated with NAC for acetaminophen poisoning. The primary safety outcome was the percentage of patients with NAC-related adverse events. RESULTS A total of 503 subjects were included in the safety analysis (306 IV-only, 145 oral-only, and 52 both routes). There were no serious adverse events related to NAC for either route. Nausea and vomiting were the most common related adverse events and were more common with oral treatment (23 vs. 9%). Anaphylactoid reactions were more common with IV administration (6 vs. 2%). CONCLUSIONS IV and oral NAC are generally mild adverse drug reactions.
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Affiliation(s)
- Vikhyat S Bebarta
- Toxicology Investigator Network Authorship Group Wilford Hall Medical Center, USA
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Zyoud SH, Awang R, Syed Sulaiman SA, Sweileh WM, Al-Jabi SW. Incidence of adverse drug reactions induced by N-acetylcysteine in patients with acetaminophen overdose. Hum Exp Toxicol 2010; 29:153-60. [PMID: 20071472 DOI: 10.1177/0960327109359642] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intravenous N-acetylcysteine (IV-NAC) is widely recognized as the antidote of choice for acetaminophen overdose. However, its use is not without adverse drug reactions (ADR) that might affect therapeutic outcome or lead to treatment delay. OBJECTIVE The aim of this study was to investigate the type and incidence of ADR induced by IV-NAC in patients treated for acetaminophen overdose. METHODS This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 4 years (1 January 2005 to 31 December 2008). The primary outcome of interest in this study was the occurrence of ADR during NAC administration. Pearson chi-square test or Fisher's exact test, student's t test, and Mann-Whitney U test were used in univariate analysis. SPSS 15 was used for data analysis. RESULTS Two hundred and fifty five patients were studied. Different types of ADR were observed in 119 (46.7%) cases. Of those patients, 83 (69.7%) had been treated with IV-NAC versus 36 (30.3%) who had not (p < .001). The following ADR were significantly associated with IV-NAC administration: vomiting (p = .001), flushing (p < .001), rash (p < .001), pruritus (p < .001), chest pain (p = .001), bronchospasm (p = .03), coughing (p = .01), headache (p = .001), dizziness (p < .001), convulsion (p = .03), and hypotension (p = .001). ADR were mild in 54 (43.2%), moderate in 17 (13.6%), and severe in 12 (9.6%) patients. There were no ADR in 42 (33.6%) patients. Comparative results of the characteristics of patients who reacted to IV-NAC and nonreactors showed that patients with ADR had no significant difference in age, gender, ethnicity, amount ingested, latency time, and acetaminophen level than nonreactors. CONCLUSION ADR to IV-NAC were common among patients with acetaminophen overdose, but mostly minor and all reported adverse reactions were easily managed.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, Clinical Toxicology, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Coulson J, Thompson JP. Paracetamol (acetaminophen) attenuatesin vitromast cell and peripheral blood mononucleocyte cell histamine release induced byN-acetylcysteine. Clin Toxicol (Phila) 2010; 48:111-4. [DOI: 10.3109/15563650903520959] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yarema MC, Johnson DW, Berlin RJ, Sivilotti MLA, Nettel-Aguirre A, Brant RF, Spyker DA, Bailey B, Chalut D, Lee JS, Plint AC, Purssell RA, Rutledge T, Seviour CA, Stiell IG, Thompson M, Tyberg J, Dart RC, Rumack BH. Comparison of the 20-hour intravenous and 72-hour oral acetylcysteine protocols for the treatment of acute acetaminophen poisoning. Ann Emerg Med 2009; 54:606-14. [PMID: 19556028 DOI: 10.1016/j.annemergmed.2009.05.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/07/2009] [Accepted: 05/07/2009] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To compare outcomes after acute acetaminophen poisoning in 2 large cohorts of patients treated with either the 20-hour intravenous or 72-hour oral acetylcysteine protocol. METHODS We conducted a retrospective cohort study with historical control comparing patients treated with one of 2 acetylcysteine regimens. Data for the 20-hour group were obtained from a medical record review of patients on whom the 20-hour intravenous protocol was initiated in Canadian hospitals from 1980 to 2005. The 72-hour group consisted of a historical cohort of patients treated in US hospitals with the 72-hour oral protocol from 1976 to 1985. The primary outcome was hepatotoxicity (aminotransferase levels >1,000 IU/L). RESULTS Of the 4,048 patients analyzed, 2,086 were in the 20-hour group and 1,962 were in the 72-hour group. The incidence of hepatotoxicity was 13.9% in the 20-hour group and 15.8% in the 72-hour group (-1.9% absolute difference; 95% confidence interval [CI] -4.2 to 0.3). The relative risk of hepatotoxicity was lower in the 20-hour group when acetylcysteine was initiated within 12 hours of ingestion. The relative risk was lower in the 72-hour group when acetylcysteine was initiated later than 18 hours after ingestion. There was no significant risk difference between groups when acetylcysteine treatment was started 12 to 18 hours after ingestion. One patient in the 20-hour group received a liver transplant and died because of acetaminophen toxicity compared with no liver transplants and 3 deaths in the 72-hour group. Anaphylactoid reactions to intravenous acetylcysteine were reported in 148 of 2,086 patients (7.1%; 95% CI 6.1% to 8.3%). This study is limited by comparison of 2 separate data sets from different countries and study years. CONCLUSION The risk of hepatotoxicity differed between the 20-hour and 72-hour protocols according to the time to initiation of acetylcysteine. It favored the 20-hour protocol for patients presenting early and favored the 72-hour protocol for patients presenting late after acute acetaminophen overdose.
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Affiliation(s)
- Mark C Yarema
- Division of Emergency Medicine and Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abstract
INTRODUCTION Paracetamol (acetaminophen) is one of the most common agents deliberately ingested in self-poisoning episodes and a leading cause of acute liver failure in the western world. Acetylcysteine is widely acknowledged as the antidote of choice for paracetamol poisoning, but its use is not without risk. Adverse reactions, often leading to treatment delay, are frequently associated with both intravenous and oral acetylcysteine and are a common source of concern among treating physicians. METHODS A systematic literature review investigating the incidence, clinical features, and mechanisms of adverse effects associated with acetylcysteine. RESULTS A variety of adverse reactions to acetylcysteine have been described ranging from nausea to death, most of the latter due to incorrect dosing. The pattern of reactions differs with oral and intravenous dosing, but reported frequency is at least as high with oral as intravenous. The reactions to the intravenous preparation result in similar clinical features to true anaphylaxis, including rash, pruritus, angioedema, bronchospasm, and rarely hypotension, but are caused by nonimmunological mechanisms. The precise nature of this reaction remains unclear. Histamine now seems to be an important mediator of the response, and there is evidence of variability in patient susceptibility, with females, and those with a history of asthma or atopy are particularly susceptible. Quantity of paracetamol ingestion, measured through serum paracetamol concentration, is also important as higher paracetamol concentrations protect patients against anaphylactoid effects. Most anaphylactoid reactions occur at the start of acetylcysteine treatment when concentrations are highest. Acetylcysteine also affects clotting factor activity, and this affects the interpretation of minor disturbances in the International Normalized Ratio in the context of paracetamol overdose. CONCLUSION This review discusses the incidence, clinical features, underlying pathophysiological mechanisms, and treatment of adverse reactions to acetylcysteine and identifies particular "at-risk" patient groups. Given the commonality of adverse reactions associated with acetylcysteine, it is important to ensure that any adverse event does not preclude patients from receiving maximal hepatic protection, particularly in the context of significant paracetamol ingestion. Further work on mechanisms should allow specific therapies to be developed.
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Affiliation(s)
- E A Sandilands
- NPIS Edinburgh - SPIB, Royal Infirmary of Edinburgh, UK.
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Cassidy N, Tracey JA, Drew SA. Cardiac arrest following therapeutic administration ofN-acetylcysteine for paracetamol overdose. Clin Toxicol (Phila) 2008; 46:921. [DOI: 10.1080/15563650802054063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Whyte AJ, Kehrl T, Brooks DE, Katz KD, Sokolowski D. Safety and effectiveness of acetadote for acetaminophen toxicity. J Emerg Med 2008; 39:607-11. [PMID: 19022608 DOI: 10.1016/j.jemermed.2008.05.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 04/29/2008] [Accepted: 05/08/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acetaminophen (APAP) toxicity is commonly encountered in the Emergency Department. Until 2004, treatment consisted of either oral N-acetylcysteine (NAC) or filtered oral NAC administered intravenously (i.v.). Intravenous acetylcysteine (Acetadote) is a new Food and Drug Administration-approved i.v. formulation of acetylcysteine manufactured by Cumberland Pharmaceuticals in Nashville, Tennessee. Little post-marketing data exists on the effectiveness and safety of i.v. acetylcysteine. OBJECTIVES We evaluated the clinical presentations and outcomes of patients treated with i.v. acetylcysteine for APAP toxicity. METHODS We performed a retrospective chart review of patients treated with i.v. acetylcysteine for APAP ingestion. The primary outcome measures were: adverse reactions to and effectiveness of i.v. acetylcysteine, as defined by elevation of transaminases, liver failure, renal failure, death, and hospital length of stay (LOS). Data collected included: comorbidities, allergies, intentionality, timing and dosing of i.v. acetylcysteine, hospital LOS, transaminases > 1000 IU/L, development of liver failure requiring transplant, development of renal failure requiring hemodialysis, death, and anaphylactoid reactions. RESULTS Sixty-four patients met our study criteria. Overall, 16 (25%) patients developed transaminases > 1000 IU/L, 4 (6%) of them died and 2 (3%) received liver transplants. Of the 15 patients (23%) treated within 8 h, none died or developed liver or renal failure, and only 1 developed transient transaminase elevation > 1000 IU/L. In the patients treated outside of 8 h, the median LOS was 3 days, whereas the group treated within 8 h had a median LOS of only 1 day. Six (9%) patients developed anaphylactoid reactions, 2 of whom received the i.v. acetylcysteine bolus over 15 min. Five of these patients were treated pharmacologically and completed treatment, and one had treatment discontinued for undocumented reasons. CONCLUSION Intravenous acetylcysteine seemed to be a safe and effective formulation of N-acetylcysteine.
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Affiliation(s)
- Allyson J Whyte
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania 15213, USA
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Pakravan N, Waring WS, Sharma S, Ludlam C, Megson I, Bateman DN. Risk factors and mechanisms of anaphylactoid reactions to acetylcysteine in acetaminophen overdose. Clin Toxicol (Phila) 2008; 46:697-702. [DOI: 10.1080/15563650802245497] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Waring WS, Stephen AF, Robinson OD, Dow MA, Pettie JM. Lower incidence of anaphylactoid reactions to N-acetylcysteine in patients with high acetaminophen concentrations after overdose. Clin Toxicol (Phila) 2008; 46:496-500. [PMID: 18584360 DOI: 10.1080/15563650701864760] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Mechanisms responsible for anaphylactoid reactions to N-acetylcysteine (NAC) are poorly understood, and acetaminophen itself may play an important role. The present study examined the relationship between serum acetaminophen concentrations and risk of anaphylactoid reactions. METHODS Prospective study of adverse reactions to NAC administered according to standardized clinical protocols in patients who present to hospital after acute acetaminophen overdose. Subgroups were defined by serum acetaminophen concentrations 0 to 100 mg/L, 101 to 150 mg/L, 151 to 200 mg/L, 201 to 300 mg/L, and >300 mg/L. RESULTS There were 362 patients, and anaphylactoid reactions occurred in 14.9%. Anaphylactoid reactions occurred less commonly in patients with high serum acetaminophen concentrations (p = 0.046 by Cochran-Armitage trend test) and high equivalent 4 h acetaminophen concentrations (p = 0.004). DISCUSSION High serum acetaminophen concentrations were associated with fewer anaphylactoid reactions, suggesting that these might in some way be protective. The biological basis needs further exploration so as to allow a better understanding of the mechanisms responsible for adverse reactions to NAC treatment.
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Affiliation(s)
- W Stephen Waring
- Scottish Poisons Information Bureau, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
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Zolnierz M, Sesin P. Computer-Generated IV/Oral Acetylcysteine for Acetaminophen Overdose Physician Order Form. Hosp Pharm 2006. [DOI: 10.1310/hpj4110-952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hynninen MS, Niemi TT, Pöyhiä R, Raininko EI, Salmenperä MT, Lepäntalo MJ, Railo MJ, Tallgren MK. N-Acetylcysteine for the Prevention of Kidney Injury in Abdominal Aortic Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial. Anesth Analg 2006; 102:1638-45. [PMID: 16717300 DOI: 10.1213/01.ane.0000219590.79796.66] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this prospective, randomized, placebo-controlled, double-blind trial we studied the effects of IV N-acetylcysteine for prevention of renal injury in patients undergoing abdominal aortic surgery. Seventy patients without previously documented renal dysfunction were randomly allocated to receive either N-acetylcysteine (150 mg/kg mixed in 250 mL of 5% dextrose infused in 20 min, followed by an infusion of 150 mg/kg in 250 mL of 5% dextrose over 24 h) or placebo. The infusion was started after the induction of anesthesia. The primary outcome measure was renal injury as measured by the increases in urinary N-acetyl-beta-d-glucosaminidase (NAG)/creatinine ratio (indicator of renal tubular injury) and urinary albumin/creatinine ratio (indicator of glomerular injury). Renal function was assessed by measuring plasma creatinine and serum cystatin C concentrations. The urinary NAG/creatinine ratio increased significantly from baseline to before crossclamp and remained increased on day 5 in both groups. The urinary albumin/creatinine ratio increased significantly from baseline to 6 h after declamping in the N-acetylcysteine group. However, the changes in the NAG/creatinine ratio and the albumin/creatinine ratio were not significantly different between the two groups. Plasma creatinine and serum cystatin C values remained unchanged during the study period in both groups. In conclusion, N-acetylcysteine did not offer any significant protection from renal injury during elective aortic operation in patients with normal preoperative renal function, and some degree of tubular injury seems to occur before aortic crossclamp.
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Affiliation(s)
- Marja S Hynninen
- Department of Anesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.
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Abstract
Acetaminophen (acetyl-para-amino-phenol or APAP), an antipyretic and analgesic, is a common component in hundreds of over-the-counter and prescription medications. The wide usage of this drug results in many potentially toxic exposures. It is therefore critical for the clinician to be comfortable with the diagnosis and treatment of APAP toxicity. Prompt recognition of APAP overdose and institution of appropriate therapy are essential to preventing morbidity and mortality.
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Affiliation(s)
- Adam K Rowden
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908, USA.
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Abstract
APAP is likely to remain a common toxic exposure and continue to cause significant morbidity and mortality. To minimize the harm to patients, it is necessary for the clinician to be aware of the current diagnostic and therapeutic management of APAP poisoning. Despite the bulk of literature on APAP, management strategies are likely to continue to change as more studies are conducted to improve our understanding of nonacute ingestions and the role of prognostic markers in defining those most at risk for life-threatening hepatotoxicity.
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Affiliation(s)
- Adam K Rowden
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908, USA.
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Abstract
PURPOSE OF REVIEW To summarize the salient reviews, studies and case reports and series that dealt with clinical, pathological, methodological, and epidemiological descriptions of drug-induced liver disease in the calendar year 2004. RECENT FINDINGS While no new causes of drug-induced liver injury were reported for 2004, several new reports of previously recognized hepatotoxins, including herbal products, were published. These include the antiretroviral drugs for HIV and agents to manage tuberculosis. Acetaminophen (APAP) retained its preeminent position as the leading cause of drug-induced acute liver failure, currently accounting for nearly 50% of cases according to the latest figures from the U.S. Acute Liver Failure Study Group. Not surprisingly, APAP also heads the list of drugs and toxins leading to liver transplantation for acute hepatic failure. Efforts to reduce the number of cases of intentional APAP poisonings by restricting the number of tablets sold at any one time in the UK are ongoing, but the success of the program may be lessening, as was pointed out this year. The use of potentially hepatotoxic medications in patients with underlying liver disease was examined with the statins, and they emerged as a safe class for use in this setting. SUMMARY Given the apparent increasing incidence of acute liver failure attributable to APAP in the US, additional efforts are still needed to better define the risks associated with its use and to further reduce the incidence of severe liver injury from this widely used agent.
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Affiliation(s)
- Susan K Lazerow
- Division of Gastroenterology, Section of Hepatology, Georgetown University Medical Center, Washington, DC 20007, USA
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Abstract
PURPOSE OF REVIEW Acetaminophen poisoning accounts for a disproportionate percentage of all toxic ingestions, and can be life-threatening. This article reviews the mechanism and presentation of acetaminophen toxicity, as well as its treatment, including current thinking and treatment recommendations. RECENT FINDINGS N-acetylcysteine acts to detoxify acetaminophen in several ways, but primarily by increasing the synthesis and availability of glutathione, which binds and inactivates the highly reactive and hepatotoxic acetaminophen metabolite N-acetyl-p-benzoquinoneimine. The US Food and Drug Administration has approved an intravenous formulation of N-acetylcysteine, thus allowing the treatment time to be decreased from the 72 hr most commonly used for the oral regimen, to only 20 hr. This comes after many years of accepted intravenous N-acetylcysteine use in Europe and Canada, and much controversy as to the superiority of both treatments. This review summarizes this controversy, and offers a framework to develop a safe treatment plan that has the optimal outcome for the patient, as well as reflecting knowledge of the potential caveats at work. It describes side effects of N-acetylcysteine treatment, as well as relative indications to choose one route of treatment over the other. SUMMARY Acetaminophen can lead to irreversible liver damage and even death in acute overdose. Outcome is related to the swiftness in which the antidote (N-acetylcysteine) is provided. In the United States, there are now available both the oral and intravenous forms of N-acetylcysteine, and pros and cons exist for each. With brisk and adequate treatment using either route, recovery can be complete, and liver function can be restored.
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Affiliation(s)
- Laurie Marzullo
- Division of Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
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