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Abstract
The effect of the artificial kidney on the removal of acetaminophen was investigated in 6 chronic hemodialysis patients. Acetaminophen, 650 mg, was given orally 2 hrs prior to hemodialysis. Plasma and dialysate samples were collected periodically over 3 hours and analyzed by HPLC for acetaminophen content. Dialysis clearance was calculated by Arterial-Venous difference and simultaneous dialysate measurement. The extraction efficiency of the hollow-fiber dialyzers averaged 47.5%. The mean dialysis clearance of 112 ml/min measured with blood as the body fluid of reference was confirmed by calculation of clearance using dialysate measurement. A mean of 70.5 mg of acetaminophen or 11% of the administered dose was removed during the 3 hour dialysis period. The beta phase had a mean half-life of 1.6 hours in our patients on hemodialysis compared with 2.0 hours reported for both normal patients and uremic patients. Despite the favorable extraction ratio and dialyzer clearance, the artificial kidney is not very effective in competing with the liver for removal of the parent compound acetaminophen because of the drug's short half-life and rapid hepatic metabolism. Hence, the chronic hemodialysis patient may not need a dosage adjustment during or following hemodialysis.
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Affiliation(s)
- T.C. Marbury
- Department of Renal Medicine, College of Medicine University of Florida, Gainesville, Florida 32610, U.S.A
| | - L.H. Wang
- Department of Pharmaceutics, College of Pharmacy University of Florida, Gainesville, Florida 32610, U.S.A
| | - C.S. Lee
- Department of Pharmaceutics, College of Pharmacy University of Florida, Gainesville, Florida 32610, U.S.A
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Stewart MJ, Simpson E. Prognosis in Paracetamol Self-Poisoning: The Use of Plasma Paracetamol Concentration in a Region without a Poisoning Treatment Centre. Ann Clin Biochem 2016. [DOI: 10.1177/000456327301000161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Published criteria for prognosis following self-poisoning with paracetamol have been applied to 30 cases in a region without centralised facilities for investigation of the poisoned patient. The results show that, despite difficulties in collection and transport of specimens, useful prognostic indices can be provided by a central laboratory. The biochemical assessment of liver damage is discussed and one of two fatal cases is presented in detail.
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Affiliation(s)
- M. J. Stewart
- Department of Clinical Chemistry, University of Dundee DD1 4HN
| | - E. Simpson
- Department of Clinical Chemistry, University of Dundee DD1 4HN
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Gosselin S, Juurlink DN, Kielstein JT, Ghannoum M, Lavergne V, Nolin TD, Hoffman RS. Extracorporeal treatment for acetaminophen poisoning: recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2014; 52:856-67. [PMID: 25133498 DOI: 10.3109/15563650.2014.946994] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments (ECTR) in poisoning and the results are presented here for acetaminophen (APAP). METHODS After a systematic review of the literature, a subgroup selected and reviewed the articles and summarized clinical and toxicokinetic data in order to propose structured voting statements following a pre-determined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Following discussion, a second vote determined the final recommendations. RESULTS Twenty-four articles (1 randomized controlled trial, 1 observational study, 2 pharmacokinetic studies, and 20 case reports or case series) were identified, yielding an overall very low quality of evidence for all recommendations. Clinical data on 135 patients and toxicokinetic data on 54 patients were analyzed. Twenty-three fatalities were reviewed. The workgroup agreed that N-acetylcysteine (NAC) is the mainstay of treatment, and that ECTR is not warranted in most cases of APAP poisoning. However, given that APAP is dialyzable, the workgroup agreed that ECTR is suggested in patients with excessively large overdoses who display features of mitochondrial dysfunction. This is reflected by early development of altered mental status and severe metabolic acidosis prior to the onset of hepatic failure. Specific recommendations for ECTR include an APAP concentration over 1000 mg/L if NAC is not administered (1D), signs of mitochondrial dysfunction and an APAP concentration over 700 mg/L (4630 mmol/L) if NAC is not administered (1D) and signs of mitochondrial dysfunction and an APAP concentration over 900 mg/L (5960 mmol/L) if NAC is administered (1D). Intermittent hemodialysis (HD) is the preferred ECTR modality in APAP poisoning (1D). CONCLUSION APAP is amenable to extracorporeal removal. Due to the efficacy of NAC, ECTR is reserved for rare situations when the efficacy of NAC has not been definitively demonstrated.
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Affiliation(s)
- S Gosselin
- Department of Emergency Medicine, Medical Toxicology Service, McGill University Health Centre, McGill University , Montréal, QC , Canada
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Sivilotti MLA, Juurlink DN, Garland JS, Lenga I, Poley R, Hanly LN, Thompson M. Antidote removal during haemodialysis for massive acetaminophen overdose. Clin Toxicol (Phila) 2013; 51:855-63. [PMID: 24134534 DOI: 10.3109/15563650.2013.844824] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Haemodialysis is sometimes used for patients with massive acetaminophen overdose when signs of "mitochondrial paralysis" (lactic acidosis, altered mental status, hypothermia and hyperglycaemia) are present. The role of haemodialysis is debated, in part because the evidence base is weak and the endogenous clearance of acetaminophen is high. There is also concern because the antidote acetylcysteine is also dialyzable. We prospectively measured serum acetylcysteine concentrations during haemodialysis in three such cases. CASE DETAILS Three adults each presented comatose and acidemic 10 to ~18 h after ingesting > 1000mg/kg of acetaminophen. Two were hypothermic and hyperglycaemic. Serum lactate concentrations ranged from 7 mM to 12.5 mM. All three were intubated, and initial acetaminophen concentrations were as high as 5980 μM (900 μg/mL). An intravenous loading dose of 150 mg/kg acetylcysteine was initiated between 10.8 and ~18 h post ingestion, and additional doses were empirically administered during haemodialysis to compensate for possible antidote removal. A single run of 3-4 h of haemodialysis removed 10-20 g of acetaminophen (48-80% of remaining body burden), reduced serum acetaminophen concentrations by 56-84% (total clearance 3.4-7.8 mL/kg/min), accelerated native acetaminophen clearance (mean elimination half-life 580 min pre-dialysis, 120 min during and 340 min post-dialysis) and corrected acidemia. Extraction ratios of acetylcysteine across the dialysis circuit ranged from 73% to 87% (dialysance 3.0 to 5.3 mL/kg/min). All three patients recovered fully, and none developed coagulopathy or other signs of liver failure. DISCUSSION When massive acetaminophen ingestion is accompanied by coma and lactic acidosis, emergency haemodialysis can result in rapid biochemical improvement. As expected, haemodialysis more than doubles the clearance of both acetaminophen and acetylcysteine. Because acetylcysteine dosing is largely empirical, we recommend doubling the dose during haemodialysis, with an additional half-load when dialysis exceeds 6 h.
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Affiliation(s)
- M L A Sivilotti
- Department of Emergency Medicine, Queen's University , Kingston, ON , Canada
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Wiegand TJ, Margaretten M, Olson KR. Massive acetaminophen ingestion with early metabolic acidosis and coma: treatment with IV NAC and continuous venovenous hemodiafiltration. Clin Toxicol (Phila) 2010; 48:156-9. [PMID: 20199132 DOI: 10.3109/15563650903524142] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CONTEXT We report the extraction of acetaminophen by continuous venovenous hemodiafiltration (CVVHD) during treatment of an acute ingestion of 200 g with a peak recorded serum acetaminophen level of 1,614 mg/L (10,652 micromol/L). CASE DETAILS The patient presented with early onset of coma, metabolic acidosis, and hypotension in the absence of significant hepatic injury. In addition to N-acetylcysteine (NAC) therapy, CVVHD was performed to manage the acid-base disturbance. Flow rate, effluent volume, and serum and effluent drug concentrations were obtained at hourly intervals. During 16 h of CVVHD the acetaminophen level dropped from 1,212 to 247 mg/L. DISCUSSION The average clearance of acetaminophen by CVVHD was 2.53 L/h, with removal of 24 g of acetaminophen over 16 h. As NAC is effective in preventing hepatic injury after acute acetaminophen overdose, the role of dialysis or CVVHD is limited.
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Affiliation(s)
- Timothy J Wiegand
- Department of Medicine and Emergency Medicine, Maine Medical Center and Northern New England Poison Center, 901 Washington Avenue, Portland, ME 04102, USA.
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Thomas SH, Horner JE, Chew K, Connolly J, Dorani B, Bevan L, Bhattacharyya S, Bramble MG, Han KH, Rodgers A, Sen B, Tesfayohannes B, Wynne H, Bateman DN. Paracetamol poisoning in the north east of England: presentation, early management and outcome. Hum Exp Toxicol 1997; 16:495-500. [PMID: 9306135 DOI: 10.1177/096032719701600903] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
1. Paracetamol is increasingly involved in self-poisoning in the United Kingdom and remains a common cause of fatal poisoning. 2. To document the epidemiology and early management of paracetamol poisoning data were collected on consecutive patients with suspected paracetamol poisoning presenting to 6 hospitals in the North East of England over 12 weeks in 1994. 3. There were 400 presentations (attendance rate 1.14/10(3) population/yr) involving 343 persons (45% male). Paracetamol concentrations at 4 h correlated weakly with reported paracetamol dose (R = 0.49, P < 0.0001) and were similar comparing those treated and not treated by gastric decontamination. 4. In 38 (9%) cases paracetamol concentrations were above the appropriate nomogram treatment line, including 3% and 20% of patients who reported ingesting less than and more than 12 g respectively. In 21 patients acetylcysteine treatment was deferred until admission to the ward, the mean delay involved was 2.8 h. 5. One patient died, from arrhythmias caused by co-ingested dothiepin. 6. Paracetamol poisoning is common. Most cases do not have potentially toxic plasma paracetamol concentrations, but those who do often present late and antidotal treatment may be delayed inappropriately.
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Affiliation(s)
- S H Thomas
- Wolfson Unit of Clinical Pharmacology, University of Newcastle upon Tyne, UK
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Abstract
Paracetamol poisoning caused by intentional overdose remains a common cause of morbidity. In this article the mechanism of toxicity and the clinical effects and treatment of poisoning, including specific antidotal therapy, are reviewed. Areas for further research directed at reducing morbidity and mortality from paracetamol poisoning are considered.
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Affiliation(s)
- S H Thomas
- Wolfson Department of Clinical Pharmacology, University of Newcastle upon Tyne, U.K
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Abstract
The first cases of fulminant hepatic failure due to paracetamol poisoning were reported in 1966, and in the United Kingdom this condition is now responsible for more cases of acute hepatic failure than any other cause. Adults account for the majority of serious and fatal cases of paracetamol poisoning and it is extremely rare for young children to ingest sufficient paracetamol to cause more than minimal liver damage. A single measurement of the plasma paracetamol concentration is an accurate predictor of liver damage provided that it is taken not earlier than 4 hours after ingestion of the overdose. Peak disturbance of liver function occurs 2 to 4 days after the overdose, often accompanied by mild jaundice, after which recovery is usually rapid and complete. In a few patients, fulminant hepatic failure, manifested by increasing jaundice and encephalopathy, may develop by the third to fifth day. Acute renal failure may complicate paracetamol poisoning, often in the context of severe liver damage. Renal failure, which is often non-oliguric, typically becomes apparent 24 to 72 hours after overdosage. The treatment of paracetamol intoxication should include gastric lavage, which has been shown to be of value for up to 6 hours after ingestion of a paracetamol overdose. Further general treatment may include parenteral fluid replacement and a prophylactic infusion of dextrose (5-10%) in patients at risk of hepatic failure. Specific protective agents in those patients at risk of paracetamol-induced liver damage include N-acetylcysteine and methionine which are most effective if given within 8 to 10 hours of ingestion of the overdose. Hepatic and renal failure should be managed conventionally. In recent years in the United Kingdom there has been a gradual decline in the number of hospital admissions and the number of deaths from aspirin poisoning. Salicylates in overdose directly stimulate the respiratory centre and so cause a respiratory alkalosis. Metabolic acidosis occurs in severe poisoning because of impairment of the oxidative metabolism of energy substrates. At very high salicylate concentrations respiratory depression may occur, possibly associated with neuroglycopenia, adding respiratory acidosis to the worsening metabolic acidosis. In addition to a mixed acid-base disturbance, hypokalaemia and hypoglycaemia may be present. Nausea and vomiting increase the fluid deficit. If dehydration is sufficiently severe, decreasing cardiac output may hasten development of lactic acidosis and acute renal failure.(ABSTRACT TRUNCATED AT 400 WORDS)
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Lieh-Lai MW, Sarnaik AP, Newton JF, Miceli JN, Fleischmann LE, Hook JB, Kauffman RE. Metabolism and pharmacokinetics of acetaminophen in a severely poisoned young child. J Pediatr 1984; 105:125-8. [PMID: 6737127 DOI: 10.1016/s0022-3476(84)80376-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A 1-year-old child with severe acetaminophen (APAP) poisoning after ingestion of 10 gm APAP demonstrated central nervous system depression, shock, hypothermia, and metabolic acidosis. There was dramatic improvement during treatment with intravenously administered N-acetylcysteine (NAC) and hemodialysis, and the patient recovered without sequelae. A detailed study of APAP metabolism was carried out during the initial 72 hours after ingestion. APAP-sulfate and APAP-glucuronide accounted for 29% and 33%, respectively, of total drug in urine, whereas cysteine and NAC conjugates accounted for only 12%. The low incidence of severe toxicity in children after overdoses of APAP may be related to greater capacity to metabolize APAP via a nontoxic pathway.
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Abstract
Acetaminophen is a remarkably safe agent when used in therapeutic doses. Most reported overdoses of acetaminophen are the result of suicide attempts. The clinical course of patients with toxic blood levels follows four distinct stages. Symptoms of nausea, vomiting, diaphoresis, and anorexia usually begin within seven to 14 hours after ingestion. After 24 to 48 hours, these symptoms may diminish, but SGOT, SGPT, bilirubin, and prothrombin time begin to rise. Peak hepatotoxicity occurs at 72 to 96 hours, and SGOT levels of 20,000 I.U. are not unusual. Oral N-acetylcysteine is the drug of choice for acetaminophen overdose. Intravenous use of N-acetylcysteine is advocated in England, Europe, and elsewhere, but it is not available in the United States. Clinical studies of oral and intravenous N-acetylcysteine clearly demonstrate that the drug has a profound effect on reducing morbidity and mortality if it is administered during the first 16 hours after the overdose. In addition, data from these studies have shown that alcohol taken simultaneously with an overdose of acetaminophen is actually hepatoprotective. Therefore, patients who have consumed alcohol at the time of overdose, or those who are chronic alcoholics, should be managed in the same way as patients with no exposure to alcohol. However, study results also reveal that overdose in children under 10 to 12 years of age follows a distinctly different pattern. These children demonstrate a lesser degree of hepatotoxicity and have only minor increases in transaminase levels.
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Abstract
Acetaminophen levels were determined in 1,176 sera separated from donated blood. The analysis was performed by both a colorimetric method and by high performance liquid chromatography. 6.12% of the samples contained acetaminophen levels ranging from 18 to 58 microgram/ml. The possible clinical significance of such a high incidence of this drug among healthy blood donors is discussed.
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Lee CS, Wang LH, Marbury TC, Cade JR. Hemodialysis for acetaminophen detoxification. Clin Toxicol (Phila) 1981; 18:431-9. [PMID: 7237971 DOI: 10.3109/15563658108990267] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abstract
Paracetamol is an analgesic and antipyretic agent which was first marketed for use as a drug in the U.K. in 1956. It has since become popular with the medical profession and the general public as an alternative to aspirin.
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Takki S, Gambertoglio JG, Honda DH, Tozer TN. Pharmacokinetic evaluation of hemodialysis in acute drug overdose. JOURNAL OF PHARMACOKINETICS AND BIOPHARMACEUTICS 1978; 6:427-42. [PMID: 366103 DOI: 10.1007/bf01062724] [Citation(s) in RCA: 42] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Winchester JF, Gelfand MC, Tilstone WJ. Hemoperfusion in drug intoxication: clinical and laboratory aspects. Drug Metab Rev 1978; 8:69-104. [PMID: 363382 DOI: 10.3109/03602537808993778] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Solomon AE, Briggs JD, Knepil J, Henry DA, Winchester JF, Birrell R. Therapeutic comparison of thiol compounds in severe paracetamol poisoning. Ann Clin Biochem 1977; 14:200-2. [PMID: 900851 DOI: 10.1177/000456327701400155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Twelve patients with toxic blood concentrations of paracetamol were treated with either cysteamine or amino-acid solution. None of the patients developed severe liver damage, although transient mild biochemical abnormalities developed in three. None of the patients treated with amino-acid solution had side effects due to therapy, whereas all those treated with cysteamine did. It is recommended that amino-acid solutions be used as a temporary measure in patients suspected of massive paracetamol overdose while awaiting estimation of blood paracetamol concentration.
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Skrabanek P. Letter: Basic sciences, science, and medical education. Lancet 1976; 1:356-7. [PMID: 54757 DOI: 10.1016/s0140-6736(76)90104-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Possible ways of treating paracetamol hepatotoxicity are briefly reviewed. This toxicity appears to be due to an oxidation metabolite which is normally detoxified by conjugation with glutathione, but when in excess, as in paracetamol overdosage, binds covalently to hepatic proteins to cause liver necrosis. Depletion of hepatic glutathione may also lead to other contributory disorders of cellular metabolism. Physical methods of preventing this would appear to be of little value, and treatments are being developed which aim to lessen the production of the toxic metabolite, antagonize its attachment to hepatic tissue or to combat this toxicity via basic cellular mechanisms. At this moment the most effective substances appear to be glutathione precursors and other compounds which interfere with oxidation of paracetamol.
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Golden J, Stone RA. Letter: What is paracetamol? Lancet 1975; 1:170. [PMID: 46091 DOI: 10.1016/s0140-6736(75)91476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Winchester JF, Edwards RO, Tilstone WJ, Woodcock BG. Activated charcoal hemoperfusion and experimental acetaminophen poisoning. Toxicol Appl Pharmacol 1975; 31:120-7. [PMID: 1129779 DOI: 10.1016/0041-008x(75)90059-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Prescott LF, Newton RW, Swainson CP, Wright N, Forrest AR, Matthew H. Successful treatment of severe paracetamol overdosage with cysteamine. Lancet 1974; 1:588-92. [PMID: 4132259 DOI: 10.1016/s0140-6736(74)92649-x] [Citation(s) in RCA: 161] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Gazzard BG, Ford-Hutchinson AW, Smith MJ, Williams R. The binding of paracetamol to plasma proteins of man and pig. J Pharm Pharmacol 1973; 25:964-7. [PMID: 4150300 DOI: 10.1111/j.2042-7158.1973.tb09987.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abstract
The binding of N-acetyl-4-aminophenol (paracetamol) to human and porcine plasma at both toxic and therapeutic concentrations was investigated by ultrafiltration and equilibrium dialysis over the range 50–300 μg ml−1. Plasma protein binding occurred at paracetamol concentrations greater than 60 μg ml−1. The extent of protein binding at a plasma concentration of 280 μg ml−1 of the drug is between 15 and 21% for both pig and man. There is no appreciable binding to erythrocytes in either species over the whole concentration range studied.
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Clark R, Borirakchanyavat V, Davidson AR, Thompson RP, Widdop B, Goulding R, Williams R. Hepatic damage and death from overdose of paracetamol. Lancet 1973; 1:66-70. [PMID: 4118649 DOI: 10.1016/s0140-6736(73)90466-2] [Citation(s) in RCA: 179] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Willson RA, Thompson RP, Winch J, Williams R. Rapid removal of paracetamol by haemoperfusion through coated charcoal. In vivo and in-vitro studies in the pig. Lancet 1973; 1:77-9. [PMID: 4118653 DOI: 10.1016/s0140-6736(73)90470-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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