1
|
Prescott LF. Paracetamol (acetaminophen) poisoning: The early years. Br J Clin Pharmacol 2024; 90:127-134. [PMID: 37683599 DOI: 10.1111/bcp.15903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 09/10/2023] Open
Abstract
Paracetamol (acetaminophen) was marketed in the 1950s as a nonprescription analgesic/antipyretic without any preclinical toxicity studies. It became used increasingly for self-poisoning, particularly in the UK and was belatedly found to cause acute liver damage, which could be fatal. Management of poisoned patients was difficult as maximum abnormalities of liver function were delayed for 3 days or more after an overdose. There was no treatment and the mechanism of hepatotoxicity was not known. The paracetamol half-life was prolonged with liver damage occurring when it exceeded 4 h and the Rumack-Matthew nomogram was an important advance that allowed stratification of patients into separate zones of risk. It is used to guide prognosis and treatment and its predictive value could be increased by combining it with the paracetamol half-life. The problems of a sheep farmer in Australia in the early 1970s led to the discovery of the mechanism of paracetamol hepatotoxicity, and the first effective treatment of overdosage with intravenous (IV) cysteamine. This had unpleasant side effects and administration was difficult. N-acetylcysteine soon became the treatment of choice for paracetamol overdose and given early it was very effective when administered either IV or orally. N-acetylcysteine could cause anaphylactoid reactions, particularly early during IV administration when the concentrations were highest. Simpler and shorter regimes with slower initial rates of infusion have now been introduced with a reduced incidence of these adverse effects. In addition, there has been a move to use larger doses of N-acetylcysteine given over longer periods for patients who are more severely poisoned and those with risk factors. There has been much interest recently in the search for novel biomarkers such as microRNAs, procalcitonin and cyclophilin that promise to have greater specificity and sensitivity than transaminases. Paracetamol-protein adducts predict hepatotoxicity and are specific biomarkers of toxic paracetamol metabolite exposure. Another approach would be measurement of the plasma levels of cysteine and inorganic sulfate. It is 50 years since the first effective treatment for paracetamol poisoning and, apart from liver transplantation, there is still no effective treatment for patients who present late.
Collapse
Affiliation(s)
- Laurie F Prescott
- Emeritus Professor of Clinical Pharmacology, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
2
|
Ali K, Chiang W, Wang JJ. On the Analytic Characteristics of Commercial Acetaminophen Assays in the United States. J Appl Lab Med 2022; 7:1311-1317. [DOI: 10.1093/jalm/jfac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
The management of patients with acetaminophen (APAP) toxicity is largely informed by the blood concentration. We sought to assess the analytical characteristics of past and current commercial APAP assays in the United States.
Methods
We systematically reviewed the analytical characteristics of APAP assays cleared by the Food and Drug Administration’s (FDA) 510(k) premarket notification process by searching the Clinical Laboratory Improvement Amendments (CLIA) database. We collected the following data where available: test principle, precision near 10 mg/L, precision near 150 mg/L, limits of detection, and limits of quantitation.
Results
For all assays, absolute analytical precision decreased as analyte concentration increased. Near [APAP] = 10 mg/L, the most precise assays had a standard deviation (SD) of 0.2 mg/L or coefficient of variation (CV) of 1% and the least precise assays had a SD of 1.8 mg/L or a CV of 10%. Near [APAP] = 150 mg/L, the most precise assay had a SD of 1.4 mg/L or CV of 0.9% and the least precise assays had a SD of 7.4 mg/L or a CV of 4.9%.
Conclusions
Commercially available APAP assays had good analytical precision with improvement over time. The failure of some manufacturers to validate precision near treatment thresholds is concerning. Newer APAP assays can measure a wider range of [APAP], which likely improves the risk stratification of overdose patients but also carries a risk of overdiagnosis when minuscule quantities are detected.
Collapse
Affiliation(s)
- Khameinei Ali
- Northwell Health, Department of Emergency Medicine, Sleepy Hollow , NY , USA
| | - William Chiang
- NYU Langone Health, Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology . New York, NY , USA
| | - Josh Jiaxing Wang
- Department of Emergency Medicine, McGill University Health Centre , Montreal, QC , Canada
- Centre Anti-poison du Québec , Québec, QC , Canada
| |
Collapse
|
3
|
Tan H, Stathakis P, Varghese B, Buckley NA, Chiew AL. Delayed Acetaminophen Absorption Resulting in Acute Liver Failure. Case Rep Crit Care 2022; 2022:3672248. [PMID: 35578608 PMCID: PMC9107358 DOI: 10.1155/2022/3672248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction. Acetaminophen is a common medication involved in deliberate and accidental self-poisoning. The acetaminophen treatment nomogram is used to guide acetylcysteine treatment. It is rare to develop hepatotoxicity with an initial acetaminophen concentration below the nomogram line. We present a case of acetaminophen ingestion with an initial concentration below the nomogram line that developed hepatic failure, due to a delayed peak acetaminophen concentration secondary to coingesting medications that slow gastric emptying. Case Report. A 43-year-old (55 kg) female presented after ingesting an unknown quantity of acetaminophen, clonidine, and alcohol. Her acetaminophen level was 41 mg/L (256 μmol/L) at 4.5 h post-ingestion, well below the nomogram line, and ALT was 25 U/L. Hence, acetylcysteine was not commenced. She was intubated for decreased level of conscious. A repeat acetaminophen level 4 h later was 39 mg/L (242 μmol/L), still below the nomogram line. She was extubated 24 h later.At 38 h post-ingestion she developed abdominal pain, the repeat acetaminophen level was 85 mg/L (560 μmol/L), ALT was 489 U/L, and acetylcysteine was commenced. The patient developed hepatic failure with a peak ALT of 7009 U/L and INR of 7.5 but made a full recovery. It was discovered that she had ingested a combination acetaminophen product containing dextromethorphan and chlorphenamine. Acetaminophen metabolites were measured, including nontoxic glucuronide and sulfate conjugates and toxic cytochrome P450 (CYP) metabolites. The metabolite data demonstrated increasing CYP metabolites in occurrence with the delayed acetaminophen peak concentration. Discussion. Opioids and antimuscarinic agents are known to delay gastric emptying and clonidine may also have contributed. These coingested medications resulted in delayed acetaminophen absorption. This case highlights the issue of altered pharmacokinetics when patients coingest gut slowing agents.
Collapse
Affiliation(s)
- Huiling Tan
- Department of Critical Care Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Paul Stathakis
- NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Benoj Varghese
- Department of Critical Care Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Nicholas A. Buckley
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, NSW, Australia
| | - Angela L. Chiew
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, NSW, Australia
| |
Collapse
|
4
|
Syafira N, Graudins A, Yarema M, Wong A. Comparing development of liver injury using the two versus three bag acetylcysteine regimen despite early treatment in paracetamol overdose. Clin Toxicol (Phila) 2021; 60:478-485. [PMID: 34758680 DOI: 10.1080/15563650.2021.1998518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Some studies have reported that early administration of acetylcysteine using a 3-bag regimen may not fully prevent development of liver injury in some patients. We compared the incidence of acute liver injury (ALI) in patients receiving acetylcysteine within eight hours of ingestion between the two-bag acetylcysteine regimen (200 mg/kg over four hours, 100 mg/kg over 16 h) and the three-bag regimen (150 mg/kg over 1 h, 50 mg/kg over 4 h, 100 mg/kg over 16 h). METHOD This was a retrospective cohort study of the two-bag and three-bag acetylcysteine regimens from Monash Health, Victoria, Australia (2009-2020), compared to the three-bag acetylcysteine regimen data from the Canadian Acetaminophen Overdose Study (CAOS) database (1980-2005). The inclusion criteria included patients with an acute single ingestion of paracetamol; normal aminotransferases on presentation and acetylcysteine administered within eight hours post-overdose. The primary outcome was development of ALI (defined as: peak aminotransferase >150 IU/L). RESULTS At Monash Health, 191 patients were treated with the two-bag acetylcysteine regimen, and 180 patients with the three-bag regimen. The CAOS cohort provided 515 patients treated with the three-bag regimen. ALI developed in 1.6% (3/191) of the two-bag Monash Health group, 2.2% (4/180) of the three-bag Monash Health group (difference -0.6%, p 0.7), and 2.9% (15/515) of the three-bag CAOS group (difference compared to two-bag -1.3%, p 0.4). Hepatotoxicity (ALT >1000) developed in 0.5% (1/191) of patients treated with the two-bag regimen, 1.7% (3/180) in the Monash Health three-bag regimen and 1% (5/515) of the three-bag CAOS group. There were no statistically significant differences between groups. CONCLUSIONS ALI and hepatotoxicity were observed in a small, comparable percentage of patients despite early acetylcysteine administration using the two-bag and three-bag regimens. Repeating blood tests at the end of acetylcysteine treatment will identify these patients and indicate those requiring continuation of acetylcysteine.
Collapse
Affiliation(s)
- Naura Syafira
- Department of Medicine, School of Clinical Science at Monash Health, Monash University, Victoria, Australia.,Faculty of Medicine, Universitas Indonesia, Special Capital Region of Jakarta, Indonesia
| | - Andis Graudins
- Department of Medicine, School of Clinical Science at Monash Health, Monash University, Victoria, Australia.,Monash Toxicology Unit, Dandenong Hospital, Monash Health, Victoria, Australia
| | - Mark Yarema
- Poison and Drug Information Service, Alberta Health Services, Calgary, Canada.,Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Anselm Wong
- Department of Medicine, School of Clinical Science at Monash Health, Monash University, Victoria, Australia.,Austin Toxicology Unit, Austin Health, Victoria, Australia.,Department of Critical Care, University of Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Amer H, Archer JRH, Layne K, Dines AM, Wood DM, Greene SL, Dargan PI. Paracetamol toxicity in mild overdose in combination with opioids: A retrospective observational study. Br J Clin Pharmacol 2021; 88:1258-1267. [PMID: 34486149 DOI: 10.1111/bcp.15070] [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: 03/05/2020] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Toxicity in paracetamol overdose with opioid co-ingestion is poorly understood. We compared outcomes in both paracetamol-only and paracetamol-opioid overdoses to determine whether toxicity differed significantly between the groups, and to assess the utility of the ratio of measured plasma paracetamol concentration relative to the 4-hour nomogram-adjusted level (APAPpl /APAPt ). METHODS We conducted a retrospective observational study of all patients (n = 1159) presenting to 2 large UK hospitals between 2005 and 2013 with acute single-dose ingestion paracetamol overdose, with (n = 221) or without (n = 938) opioid co-ingestion. Adverse outcomes included biomarkers of hepatotoxicity and the need for extended treatment. Several outcomes were assessed in relation to the APAPpl /APAPt ratio. RESULTS Median ingested dose of paracetamol was low in both groups (10 g). Statistical comparison of the median APAPpl /APAPt ratios showed a significant difference (0.65 vs. 0.56 for the paracetamol-only and paracetamol-opioid groups respectively, P = .0329). Although there was a trend towards a lower risk of predefined toxic outcomes with opioid co-ingestion, statistical analysis did not show a significant difference, with outcomes for the paracetamol-only and paracetamol-opioid groups including the following: alanine transaminase >2× upper limit of normal, 7.7 vs. 5.7% (P = .6480); alanine transaminase >1000 IU/L, 2.4 vs. 0% (P = .2145); international normalised ratio > 1.3, 8.6 vs. 4.4% (P = .2774); and transfer to tertiary liver unit, 0.2 vs. 0% (P nonsignificant). CONCLUSION Our study does not support a change in current clinical practise beyond standard testing at 4 hours or longer post ingestion for mixed low dose paracetamol-opioid overdose.
Collapse
Affiliation(s)
- Halima Amer
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Department of Clinical Pharmacology, University College London, London, UK
| | - John R H Archer
- Department of 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
| | - Kerry Layne
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Alison M Dines
- Department of 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
- Department of 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
| | - Shaun L Greene
- Austin Toxicology Service and Victorian Poisons Information Centre, Austin Hospital, Victoria, Australia
| | - Paul I Dargan
- Department of 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
| |
Collapse
|
6
|
Abstract
Acetaminophen is a common medication taken in deliberate self-poisoning and unintentional overdose. It is the commonest cause of severe acute liver injury in Western countries. The optimal management of most acetaminophen poisonings is usually straightforward. Patients who present early should be offered activated charcoal and those at risk of acute liver injury should receive acetylcysteine. This approach ensures survival in most. The acetaminophen nomogram is used to assess the need for treatment in acute immediate-release overdoses with a known time of ingestion. However, scenarios that require different management pathways include modified-release, large/massive, and repeated supratherapeutic ingestions.
Collapse
Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Barker Street, Randwick, New South Wales 2031, Australia.
| | - Nicholas A Buckley
- Pharmacology and Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2050, Australia
| |
Collapse
|
7
|
Raghu G, Berk M, Campochiaro PA, Jaeschke H, Marenzi G, Richeldi L, Wen FQ, Nicoletti F, Calverley PMA. The Multifaceted Therapeutic Role of N-Acetylcysteine (NAC) in Disorders Characterized by Oxidative Stress. Curr Neuropharmacol 2021; 19:1202-1224. [PMID: 33380301 PMCID: PMC8719286 DOI: 10.2174/1570159x19666201230144109] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/27/2020] [Accepted: 12/13/2020] [Indexed: 02/08/2023] Open
Abstract
Oxidative stress, which results in the damage of diverse biological molecules, is a ubiquitous cellular process implicated in the etiology of many illnesses. The sulfhydryl-containing tripeptide glutathione (GSH), which is synthesized and maintained at high concentrations in all cells, is one of the mechanisms by which cells protect themselves from oxidative stress. N-acetylcysteine (NAC), a synthetic derivative of the endogenous amino acid L-cysteine and a precursor of GSH, has been used for several decades as a mucolytic and as an antidote to acetaminophen (paracetamol) poisoning. As a mucolytic, NAC breaks the disulfide bonds of heavily cross-linked mucins, thereby reducing mucus viscosity. In vitro, NAC has antifibrotic effects on lung fibroblasts. As an antidote to acetaminophen poisoning, NAC restores the hepatic GSH pool depleted in the drug detoxification process. More recently, improved knowledge of the mechanisms by which NAC acts has expanded its clinical applications. In particular, the discovery that NAC can modulate the homeostasis of glutamate has prompted studies of NAC in neuropsychiatric diseases characterized by impaired glutamate homeostasis. This narrative review provides an overview of the most relevant and recent evidence on the clinical application of NAC, with a focus on respiratory diseases, acetaminophen poisoning, disorders of the central nervous system (chronic neuropathic pain, depression, schizophrenia, bipolar disorder, and addiction), cardiovascular disease, contrast-induced nephropathy, and ophthalmology (retinitis pigmentosa).
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Peter M. A. Calverley
- Address correspondence to this author at Clinical Science Centre, University Hospital Aintree, Longmoor Lane, Liverpool UK L9 7AL; Tel: +44 151 529 5886, Fax: +44 151 529 5888; E-mail:
| |
Collapse
|
8
|
Daoud A, Dalhoff KP, Petersen TS. Comment on "The changing face of paracetamol toxicity and new regimens for an old antidote acetylcysteine". Br J Clin Pharmacol 2020; 87:2160-2161. [PMID: 33128254 DOI: 10.1111/bcp.14600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/02/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Alaa Daoud
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark.,Department of Clinical Pharmacology and The Danish Poisons Information Centre, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kim Peder Dalhoff
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark.,Department of Clinical Pharmacology and The Danish Poisons Information Centre, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department of Clinical Medicine, Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark.,Department of Clinical Pharmacology and The Danish Poisons Information Centre, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
9
|
Harmouche E, Bhandari M, Howland MA, Su MK. In response to: "Changing nomogram risk zone classification with serial testing after acute acetaminophen overdose: a retrospective database analysis". Clin Toxicol (Phila) 2020; 58:220-221. [DOI: 10.1080/15563650.2019.1603390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Elie Harmouche
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
| | - Misha Bhandari
- Department of Emergency Medicine, New York Presbyterian, The University Hospital of Columbia and Cornell, New York, NY, USA
| | - Mary Ann Howland
- St. John’s University College of Pharmacy and Health Sciences, Jamaica, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
| |
Collapse
|
10
|
Chrøis KM, Larsen S, Pedersen JS, Rygg MO, Boilsen AEB, Bendtsen F, Dela F. Acetaminophen toxicity induces mitochondrial complex I inhibition in human liver tissue. Basic Clin Pharmacol Toxicol 2020; 126:86-91. [PMID: 31403256 DOI: 10.1111/bcpt.13304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/25/2019] [Indexed: 01/19/2023]
Abstract
Acetaminophen (APAP) is used worldwide and is regarded as safe in therapeutic concentrations but can cause acute liver failure in higher doses. High doses of APAP have been shown to inhibit complex I and II mitochondrial respiratory capacity in mouse hepatocytes, but human studies are lacking. Here, we studied mitochondrial respiratory capacity in human hepatic tissue ex vivo with increasing doses of APAP. Hepatic biopsies were obtained from 12 obese patients who underwent a Roux-en-Y gastric bypass (RYGB) or a sleeve gastrectomy surgery. Mitochondrial respiration was measured by high-resolution respirometry. Therapeutic concentrations (≤0.13 mmol/L) of APAP did not inhibit state 3 complex I-linked respiration. APAP concentrations of ≥2.0 mmol/L in the medium significantly reduced hepatic mitochondrial respiration in a dose-dependent manner. Complex II-linked mitochondrial respiration was not inhibited by APAP. We conclude that the mitochondrial respiratory capacity is affected by a hepato-toxic effect of APAP, which involved complex I, but not complex II.
Collapse
Affiliation(s)
- Karoline Maise Chrøis
- Xlab, Centre for Healthy Aging, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Steen Larsen
- Xlab, Centre for Healthy Aging, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.,Clinical Research Centre, Medical University of Bialystok, Bialystok, Poland
| | - Julie Steen Pedersen
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Marte Opseth Rygg
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Flemming Bendtsen
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Flemming Dela
- Xlab, Centre for Healthy Aging, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Geriatrics, Bispebjerg University Hospital, Copenhagen, Denmark
| |
Collapse
|