Relation of Health Literacy to Exceeding the Labeled Maximum Daily Dose of Acetaminophen

Meat tenderization using acetaminophen (paracetamol/APAP): A review on deductive biochemical mechanisms, toxicological implications and strategies for mitigation

Meats consist of edible portions originating from domestic and wild animals. Meat's palatability and sensory accessibility largely depend on its tenderness to consumers. Although many factors influence meat tenderness, the cooking method cannot be neglected. Different chemical, mechanical, and natural means of meat tenderization have been considered healthy and safe for consumers. However, many households, food vendors, and bars in developing countries engage in the unhealthy use of acetaminophen (paracetamol/APAP) in meat tenderization due to the cost reduction it offers in the overall cooking process. Acetaminophen (paracetamol/APAP) is one of the most popular, relatively cheap, and ubiquitous over-the-counter drugs that induce serious toxicity challenges when misused. It is important to note that acetaminophen during cooking is hydrolyses into a toxic compound known as 4-aminophenol, which damages the liver and kidney and results in organ failure. Despite the reports on the increase in the use of acetaminophen for meat tenderizing in many web reports, there have not been any serious scientific publications on this subject. This study adopted classical/traditional methodology to review relevant literature retrieved from Scopus, PubMed, and ScienceDirect using relevant key terms (Acetaminophen, Toxicity, Meat tenderization, APAP, paracetamol, mechanisms) and Boolean operators (AND and OR). This paper provides in-depth information on the hazard and health implications of consuming acetaminophen tenderized meat via genetic and metabolic pathways deductions. Understanding these unsafe practices will promote awareness and mitigation strategies.

The self-medication behaviors of residents and the factors related to the consideration of drug efficacy and safety-A cross-sectional study in China

Background: Over-the-counter (OTC) drugs facilitates residents self-medication. However, inappropriate self-medications have become a serious problem in China and even all over the world. Objectives: To make an investigation on the current status of Chinese residents' self-medication behaviors and important considerations, and to explore the factors related to the considerations of drug efficacy and safety. Design: A quantitative, cross-sectional study. Methods: Multi-stage sampling was used to conduct a cross-sectional investigation in China 22 provinces, 5 autonomous regions and 4 municipalities directly under the Central Government. State that an interviewer-administrated questionnaire, was used for data collection. The questionnaire that was used in the investigation included demographic sociological characteristics, health literacy scale-short form (HLS-SF), the 10-item Big Five Inventory (BFI-10), the EuroQol-5D visual analogue scale (EQ-5D VAS), self-medication status and important considerations when self-medicating. Descriptive statistics were performed, and the Chi-square test was used for univariate analysis. Log-binomial regression was used for multivariate analysis on whether residents regard drug efficacy or safety as an important consideration. Results: 9256 respondents were included in the data analysis. The self-medication rate of Chinese adults was as high as 99.1%. Paracetamol and other analgesics were the most common types of OTC medication that respondents purchased, followed by vitamins/minerals. Medical staff recommendations, drug safety and efficacy were the top three important considerations. The residents in the east, central and western regions who consider safety is 63.5%, 61.5%, and 66.8% respectively. The proportion of curative effect was 60.2%, 55.7%, and 61.4% respectively. Log-binomial regression showed that western respondents, retired people, those who mainly used ways including basic medical insurance for employees, commercial medical insurance, free medical treatment to cover their medical cost, respondents with high neuroticism, high health literacy were more likely to consider drug safety as an important factor (p < 0.05). Eastern respondents, employed, main way of medical expenses borne was Out-of-pocket Payment, those with chronic disease were more likely to consider drug efficacy as an important factor (p < 0.05). Female, respondents with high levels of agreeableness, conscientiousness, openness, and self-rated health status were more likely to regard both drug safety and efficacy as important considerations (p < 0.05). Conclusion: Self-medication is practiced by most Chinese adults. Whether Chinese adults take drug efficacy or safety as an important consideration is related to their demographic and sociological characteristics, Big Five personality characteristics, health literacy and self-assessed health status. There is a need to strengthen the management of OTC drugs and public education about self-medication.

Poison center exposures due to therapeutic misuse of nonprescription acetaminophen-containing combination products in the United States 2007-2016

BACKGROUND

Overdoses due to therapeutic misuse result when the maximum dose of a drug is exceeded while using it for its intended purpose, due to either intentionally exceeding the label dose, misunderstanding the label or use of more than one product with the same ingredient. Nonprescription acetaminophen-containing combination products have been hypothesized to be a risk for therapeutic misuse. This study assessed the contribution of nonprescription acetaminophen-containing products to Poison Center exposures and the time trend in these exposures since public attention was brought to their potential risks.

METHODS

The National Poison Data System (NPDS) was used to identify exposures involving acetaminophen-containing products in individuals 12 years or older for the period 2007-2016. Exposures due to therapeutic misuse of nonprescription acetaminophen-containing combination products were identified and demographic and clinical features of these exposures tabulated. Product sale and US population data were used to normalize the exposures.

RESULTS

Therapeutic misuse exposures involving nonprescription acetaminophen-containing combination products decreased from 8753 in 2007 to 6278 in 2016. The majority of exposures occurred in individuals 12-29 years of age. The rate of therapeutic misuse exposures was highest in the 12-19 years of age cohort with an estimated 638 exposures per million population per 10 years. More than one acetaminophen-containing product was involved in 24.8% of exposures. Individuals were hospitalized in 5.4% of exposures and 51 deaths occurred in the 10-year observation period in reported exposures.

CONCLUSIONS

NPDS exposures due to therapeutic misuse of nonprescription acetaminophen-containing combination products are infrequent and the number of exposures decreased from 2007 to 2016. Nonetheless, these exposures impact poison centers, healthcare facilities and patients. Additional initiatives to educate consumers on the safe use of these products and innovative labeling efforts to prevent concurrent use of multiple acetaminophen-containing products should be continued and are encouraged.

Exceeding the maximum daily dose of acetaminophen with use of different single-ingredient OTC formulations

OBJECTIVES

To assess whether there are differences in the likelihood of exceeding the daily limit of 4 grams of acetaminophen when using different formulations (325 mg, 500 mg, 650 mg) of OTC single-ingredient (SI) acetaminophen medications.

DESIGN AND SETTING

Multiyear observational study of acetaminophen use via daily online acetaminophen-usage diaries completed for 7 days.

PARTICIPANTS

A total of 7579 U.S. adults from online research panels who used acetaminophen in the month preceding enrollment and used an OTC SI acetaminophen medication during the study.

OUTCOME MEASURE

Exceeding the daily dose.

RESULTS

On days when 325-mg or 500-mg OTC SI formulations were taken, users were not significantly more likely to exceed 4 grams than on days when OTC SI formulations were not used. On days when 650-mg extended-release (ER) formulations were taken, exceeding 4 grams was significantly more likely (8.9% of days vs. 4.4%; P < 0.0001; median on those days was 5.2 g) than on days with 325- or 500-mg OTC SI formulations. Users of 650-mg ER formulations were significantly less likely to know their dosing interval of 8 hours (33% vs. 49%; P < 0.0001) and more likely to redose too soon (26% vs. 10%; P < 0.0001) and to use other acetaminophen medications concomitantly (14% vs. 7%; P < 0.0001). These patterns were strongest among 650-mg ER products that did not include "8-Hour" in the product name.

CONCLUSION

Usage of 500-mg OTC SI acetaminophen formulations does not contribute differently to exceeding dosage compared with other OTC SI acetaminophen formulations. Exceeding 4 grams is more likely when 650-mg ER formulations are used. Improved consumer information on the packages and counseling from pharmacists may help to reduce practices that contribute to exceeding the labeled daily limit of these medications.

Prevalence of exceeding maximum daily dose of paracetamol, and seasonal variations in cold-flu season

AIMS

To estimate prevalence of excess intake of paracetamol and investigate seasonal variations therein.

METHODS

Between 2011 and 2016, 14 481 US adults who used paracetamol in the preceding 30 days were sampled from national online panels and completed a detailed online daily diary of paracetamol medication use for 7 days. Respondents were not told that the study concerned paracetamol. Cold/flu season (CFS), identified using Google Trends data, was contrasted to off-season in symptoms, use of paracetamol medications, and consumption exceeding 4 g (the recommended daily maximum).

RESULTS

Overall, 6.3% [95% confidence interval: 5.9-6.7%] of users exceeded 4 g on at least one day; 3.7% [3.5-3.8%] of usage days exceeded 4 g. Cold/flu symptoms were more likely to be experienced and treated with paracetamol in CFS than off-season. Paracetamol users were more likely to exceed 4 g during CFS (6.5% vs. 5.3%; odds ratio = 1.24, 1.04-1.48); days exceeding 4 g also increased (3.9% vs. 2.8%; odds ratio = 1.37, 1.11-1.69). This was not due to differences in characteristics of individuals using paracetamol in CFS, but primarily to increased use of over-the-counter combination medications designed to treat upper respiratory cold/flu symptoms (33.2% of usage days in CFS vs. 24.8% in off-season; odds ratio = 1.58, 1.46-1.72). When such medications were omitted, there was no statistically significant seasonal variation in exceeding 4 g.

CONCLUSIONS

Paracetamol use and over-dosing increases in CFS, primarily due to increased use of over-the-counter combinations treating upper respiratory cold/flu symptoms. Pharmacists should warn users to follow labelled dosing directions, especially during CFS.

Consumer knowledge about over-the-counter NSAIDs: they don't know what they don't know

OBJECTIVE

To investigate consumers' knowledge about commonly purchased over-the-counter (OTC) products containing ibuprofen.

METHODS

Customers buying two popular OTC ibuprofen-containing products (Nurofen^™ or Nurofen Plus^™ ) were asked to complete a short survey assessing their knowledge about the products.

RESULTS

The survey was completed by 262 respondents, most of whom were older than 50 years of age; female; well-educated; with adequate functional health literacy. The majority correctly identified ibuprofen as an active ingredient and knew the correct intervals between doses. However, almost a third couldn't correctly identify the maximum daily dose and were unaware of some contraindications. Furthermore, fewer than half recognised potential side effects. Those who hadn't completed high school were significantly less likely to seek medical advice (when required) and significantly less likely to know when it was safe to take these products.

CONCLUSIONS

The gaps in consumer knowledge, especially about the maximum daily dose, contraindications and potential side effects may be placing consumers at risk of experiencing ibuprofen-related adverse events. Implications for public health: Improving consumer knowledge to address these gaps in their understanding about the safe use of popular OTC ibuprofen-containing products is an important public health concern.

An acetaminophen icon helps reduce medication decision errors in an experimental setting

OBJECTIVES

To assess the effect of adding an acetaminophen ingredient icon to acetaminophen medication labels on consumer decision making about concomitant use of acetaminophen medications to avoid overdose, which is associated with liver injury.

DESIGN

Parallel-group randomized study.

SETTING

Consumer research facilities in Indianapolis, Baltimore, and Los Angeles.

PARTICIPANTS

A total of 517 adults (30% with limited health literacy) recruited at 3 consumer research sites.

INTERVENTION

Participants were randomized to a non-icon condition in which medications carried current labeling or an icon condition in which all acetaminophen medications were additionally marked with an icon.

MAIN OUTCOME MEASURES

Participants were presented with a medicine cabinet containing 12 diverse prescription and non-prescription medications, one-half containing acetaminophen, and made decisions about which medications were appropriate to take after an acetaminophen medication had already been taken. Outcome measures were errors in medication decisions and response time.

RESULTS

The icon reduced the odds of participants making medication-decision errors by 53% (CI 31%-68%), with effects evident across medication categories. The icon eliminated a trend for those with lower health literacy or less education to have a greater likelihood of making errors. The icon also reduced response times, indicating reduced cognitive load for decisions.

CONCLUSION

An icon can improve decision making regarding acetaminophen-containing medications, particularly among individuals with limited health literacy or education.

Testing of Candidate Icons to Identify Acetaminophen-Containing Medicines

Adding icons on labels of acetaminophen-containing medicines could help users identify the active ingredient and avoid concomitant use of multiple medicines containing acetaminophen. We evaluated five icons for communication effectiveness. Adults (n = 300) were randomized to view a prescription container label or over-the-counter labels with either one or two icons. Participants saw two icon candidates, and reported their interpretation; experts judged whether these reflected critical confusions that might cause harm. Participants rated how effectively each icon communicated key messages. Icons based on abbreviations of “acetaminophen” (“Ac”, “Ace”, “Acm”) were rated less confusing and more effective in communicating the active ingredient than icons based on “APAP” or an abstract symbol. Icons did not result in critical confusion when seen on a readable medicine label. Icon implementation on prescription labels was more effective at communicating the warning against concomitant use than implementation on over-the-counter (OTC) labels. Adding an icon to a second location on OTC labels did not consistently enhance this communication, but reduced rated effectiveness of acetaminophen ingredient communication among participants with limited health literacy. The abbreviation-based icons seem most suitable for labeling acetaminophen-containing medications to enable users to identify acetaminophen-containing products.