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El-Sarnagawy GN, Elgazzar FM, Ghonem MM. Development of a risk prediction nomogram for delayed neuropsychiatric sequelae in patients with acute carbon monoxide poisoning. Inhal Toxicol 2024; 36:406-419. [PMID: 38984500 DOI: 10.1080/08958378.2024.2374394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/24/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES Delayed neuropsychiatric sequelae (DNS) are critical complications following acute carbon monoxide (CO) poisoning that can substantially affect the patient's life. Identifying high-risk patients for developing DNS may improve the quality of follow-up care. To date, the predictive DNS determinants are still controversial. Consequently, this study aimed to construct a practical nomogram for predicting DNS in acute CO-poisoned patients. METHODS This retrospective study was conducted on patients with acute CO poisoning admitted to the Tanta University Poison Control Center (TUPCC) from December 2018 to December 2022. Demographic, toxicological, and initial clinical characteristics data, as well as laboratory investigation results, were recorded for the included patients. After acute recovery, patients were followed up for six months and categorized into patients with and without DNS. RESULTS Out of 174 enrolled patients, 38 (21.8%) developed DNS. The initial Glasgow Coma Scale (GCS), carboxyhemoglobin (COHb) level, CO exposure duration, oxygen saturation, PaCO2, and pulse rate were significantly associated with DNS development by univariate analysis. However, the constructed nomogram based on the multivariable regression analysis included three parameters: duration of CO exposure, COHb level, and GCS with adjusted odd ratios of 1.453 (95% CI: 1.116-1.892), 1.262 (95% CI: 1.126-1.415), and 0.619 (95% CI: 0.486-0.787), respectively. The internal validation of the nomogram exhibited excellent discrimination (area under the curve [AUC] = 0.962), good calibration, and satisfactory decision curve analysis for predicting the DNS probability. CONCLUSIONS The proposed nomogram could be considered a simple, precise, and applicable tool to predict DNS development in acute CO-poisoned patients.
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Affiliation(s)
- Ghada N El-Sarnagawy
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Fatma M Elgazzar
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona M Ghonem
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
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2
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Martínez-Martínez LM, Rosales-Sotomayor G, Jasso-Baltazar EA, Torres-Díaz JA, Aguirre-Villarreal D, Hurtado-Díaz de León I, Páez-Zayas VM, Sánchez-Cedillo A, Martínez-Vázquez SE, Tadeo-Espinoza HN, Guerrero-Cabrera JP, García-Alanis M, García-Juárez I. Acute liver failure: Management update and prognosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:404-417. [PMID: 39033039 DOI: 10.1016/j.rgmxen.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/30/2024] [Indexed: 07/23/2024]
Abstract
Acute liver failure is a rare but serious syndrome, with an incidence of approximately 2,000 to 3,000 cases per year in North America. Its pathophysiology and clinical course vary, depending on the cause of the primary liver injury, and can lead to high morbidity and mortality or the need for liver transplantation, despite available therapies. This syndrome involves excessive activation of the immune system, with damage in other organs, contributing to its high mortality rate. The most accepted definition includes liver injury with hepatic encephalopathy and coagulopathy within the past 26 weeks in a patient with no previous liver disease. The main causes are paracetamol poisoning, viral hepatitis, and drug-induced liver injury, among others. Identifying the cause is crucial, given that it influences prognosis and treatment. Survival has improved with supportive measures, intensive therapy, complication prevention, and the use of medications, such as N-acetylcysteine. Liver transplantation is a curative option for nonresponders to medical treatment, but adequate evaluation of transplantation timing is vital for improving results. Factors such as patient age, underlying cause, and severity of organ failure influence the post-transplant outcomes and survival.
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Affiliation(s)
- L M Martínez-Martínez
- Departamento de Medicina Interna, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - G Rosales-Sotomayor
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E A Jasso-Baltazar
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J A Torres-Díaz
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - D Aguirre-Villarreal
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I Hurtado-Díaz de León
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - V M Páez-Zayas
- Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - A Sánchez-Cedillo
- Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - S E Martínez-Vázquez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - H N Tadeo-Espinoza
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J P Guerrero-Cabrera
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - M García-Alanis
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I García-Juárez
- Departamento de Gastroenterología, Clínica de Hígado y Trasplante Hepático, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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3
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Alhammad AM, Alajmi G, Alkhodair A, Mansy WH, Aljawadi MH, Aljadeed R, Alshammari R, Alshehri R, Alarifi MN, Alyahya B. Patterns of acetaminophen toxicity among patients with low-risk serum concentrations. J Int Med Res 2024; 52:3000605241260362. [PMID: 39068527 PMCID: PMC11287716 DOI: 10.1177/03000605241260362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/21/2024] [Indexed: 07/30/2024] Open
Abstract
OBJECTIVE In 2012, the Commission on Human Medicines mandated lowering the acetaminophen toxicity nomogram treatment threshold in the UK to 100 µg/ml at 4 h post-ingestion. The present study aim was to evaluate biochemical and liver toxicity patterns in patients who presented with acetaminophen overdose and had low serum acetaminophen concentrations (<150 µg/ml). METHODS Patients admitted to the emergency department with a clear history of acute acetaminophen overdose with or without other medication or ethanol were consecutively enrolled into this retrospective cohort study. Patients with serum acetaminophen concentration >150 µg/ml or an unknown ingestion time were excluded. Data were extracted from electronic medical records and are presented as mean ± SD or median (interquartile range). RESULTS A total of 103 patients were included (median age, 17 [4-21] years) and 80 (78%) were female. The median ingested acetaminophen dose was 5000 (2850-7650) mg. At baseline, the median serum acetaminophen concentration was 42 (4.5-64.8) µg/ml, and median alanine aminotransferase and aspartate aminotransferase levels were 22 (17-28) and 27 (16-45) IU/L, respectively. Twenty patients were treated with acetylcysteine, with none developing adverse reactions. No patient developed hepatotoxicity, including patients with initial multiple product ingestion or other risk factors. CONCLUSIONS Patients presenting with an acute acetaminophen overdose with acetaminophen level <150 µg/ml, including patients with other risk factors, are at low risk of hepatotoxicity.
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Affiliation(s)
- Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ghada Alajmi
- Corporate Department of Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Aljawharah Alkhodair
- Corporate Department of Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Wael H. Mansy
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad H. Aljawadi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Rania Aljadeed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Reem Alshammari
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Raghad Alshehri
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed N. Alarifi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Badr Alyahya
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
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Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
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5
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Elsaman T, Muddathir AM, Mohieldin EAM, Batubara I, Rahminiwati M, Yamauchi K, Mohamed MA, Asoka SF, Büsselberg D, Habtemariam S, Sharifi-Rad J. Ginsenoside Rg5 as an anticancer drug: a comprehensive review on mechanisms, structure-activity relationship, and prospects for clinical advancement. Pharmacol Rep 2024; 76:287-306. [PMID: 38526651 DOI: 10.1007/s43440-024-00586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
Cancer remains one of the leading causes of death in the world. Despite the considerable success of conventional treatment strategies, the incidence and mortality rates are still high, making developing new effective anticancer therapies an urgent priority. Ginsenoside Rg5 (Rg5) is a minor ginsenoside constituent obtained exclusively from ginseng species and is known for its broad spectrum of pharmacological activities. This article aimed to comprehensively review the anticancer properties of Rg5, focusing on action mechanisms, structure-activity relationship (SAR), and pharmacokinetics attributes. The in vitro and in vivo activities of Rg5 have been proven against several cancer types, such as breast, liver, lung, bone, and gastrointestinal (GI) cancers. The modulation of multiple signaling pathways critical for cancer growth and survival mediates these activities. Nevertheless, human clinical studies of Rg5 have not been addressed before, and there is still considerable ambiguity regarding its pharmacokinetics properties. In addition, a significant shortage in the structure-activity relationship (SAR) of Rg5 has been identified. Therefore, future efforts should focus on further optimization by performing extensive SAR studies to uncover the structural features essential for the potent anticancer activity of Rg5. Thus, this review highlights the value of Rg5 as a potential anticancer drug candidate and identifies the research areas requiring more investigation.
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Affiliation(s)
- Tilal Elsaman
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Sakaka, Al Jouf, Saudi Arabia
| | - Ali Mahmoud Muddathir
- Department of Horticulture, Faculty of Agriculture, University of Khartoum, Shambat, 13314, Khartoum North, Sudan
| | | | - Irmanida Batubara
- Department of Chemistry, Faculty of Mathematics and Natural Sciences, IPB University (Bogor Agricultural University), Bogor, Indonesia
- Tropical Biopharmaca Research Center, IPB University (Bogor Agricultural University), Bogor, Indonesia
| | - Min Rahminiwati
- Division of Pharmacology, School of Veterinary Medicine and Biomedical Science, IPB University, Jln Agathis Dramaga, Bogor, West Java, 16680, Indonesia
- Tropical Biopharmaca Research Center, IPB University, Jl. Taman Kencana No. 3, Bogor, West Java, 16128, Indonesia
| | - Kosei Yamauchi
- Faculty of Applied Biological Sciences, Gifu University, Gifu, Japan
| | - Magdi Awadalla Mohamed
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Sakaka, Al Jouf, Saudi Arabia
| | - Shadila Fira Asoka
- Department of Chemistry, Faculty of Mathematics and Natural Sciences, IPB University (Bogor Agricultural University), Bogor, Indonesia
- Tropical Biopharmaca Research Center, IPB University (Bogor Agricultural University), Bogor, Indonesia
| | - Dietrich Büsselberg
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar
| | - Solomon Habtemariam
- Pharmacognosy Research and Herbal Analysis Services UK, Central Avenue , Chatham, Kent, ME4 4TB, UK
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6
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Lam AH, King JD. Toxin-Induced Liver Injury and Extracorporeal Treatment of Liver Failure. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:157-165. [PMID: 38649220 DOI: 10.1053/j.akdh.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 04/25/2024]
Abstract
Poisoning with a large variety of drugs and naturally occurring toxins may result in acute liver injury and failure. Drug-induced liver injury is a major cause of liver failure nationwide, and it is likely that nephrologists will be involved in treating patients with these conditions. A number of xenobiotics resulting in liver toxicity may cause acute kidney injury or other organ injury as well. Most agents causing drug- or toxin-induced liver failure lack specific therapies, although a few xenobiotics such as acetaminophen have effective antidotal therapies if administered prior to development of hepatotoxicity. The nephrologist should be aware that extracorporeal treatment of liver failure associated with drugs and toxins may be indicated, including therapies conventionally performed by nephrologists (hemodialysis, continuous kidney replacement therapy), therapies occasionally performed by nephrologists and other specialists (plasma exchange, albumin dialysis, hemadsorption), and therapies performed by other specialists (extracorporeal membrane oxygenation). An overview of the role of these therapies in liver failure is provided, as well as a review of their limitations and potential complications.
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Affiliation(s)
- Angela H Lam
- Maryland Poison Center, Baltimore, MD; Providence St. Joseph Health, Everett, WA; Virginia Mason Franciscan Health, Seattle, WA
| | - Joshua D King
- Maryland Poison Center, Baltimore, MD; Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD.
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7
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Mercer MA, Davis JL, McKenzie HC, Byron CR, Kelleher ME, Trager L, Cecere TE, Wilson KE, Council-Troche RM, Werre SR. Pharmacokinetics, clinical efficacy and safety of acetaminophen (paracetamol) in adult horses with naturally occurring chronic lameness. Equine Vet J 2024; 56:202-214. [PMID: 37287331 DOI: 10.1111/evj.13959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 05/05/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Acetaminophen is used clinically in horses with musculoskeletal pain; however, no studies have been performed in horses with chronic lameness. OBJECTIVES To determine the pharmacokinetics, safety and efficacy of chronic dosing of acetaminophen in horses with naturally occurring chronic lameness. STUDY DESIGN Longitudinal. METHODS Twelve adult horses with chronic lameness were treated with acetaminophen (30 mg/kg PO) every 12 h for 21 days. Plasma concentrations of acetaminophen were analysed on days 7 and 21 via LC-MS/MS and noncompartmental pharmacokinetic analysis. Lameness was evaluated by body-mounted inertial sensor (BMIS) and 10-point subjective lameness score on day 21 and compared to untreated baseline evaluation on day 35. Clinicopathological analysis (n = 12), hepatic biopsy (n = 6) and gastroscopy (n = 6) were evaluated on days -1 and 22. RESULTS Maximum plasma acetaminophen concentration (Cmax ) was 20.83 ± 10.25 μg/mL at time (Tmax ) 0.40 ± 0.22 h on day 7. The Cmax on day 21 was 17.33 ± 6.91 μg/mL with a Tmax of 0.67 ± 0.26 h. Subjective lameness scores significantly improved at 2 and 4 h post-treatment; Significant percent improvement was detected in PDmax for horses with hindlimb lameness at 1, 2 and 8 h post-treatment. There were no significant differences in gastroscopy or hepatic biopsy scores between days -1 and 22. MAIN LIMITATIONS Small sample size, multi-limb lameness of varying severity and aetiology, lack of intermediary lameness evaluation. CONCLUSIONS In horses with naturally occurring chronic lameness, acetaminophen at 30 mg/kg produced a transient improvement in subjective lameness and BMIS evaluation. Acetaminophen may not be effective as a monotherapy. Acetaminophen was safe following 21 days of 30 mg/kg PO every 12 h, with no evidence of clinically significant changes in clinicopathological analysis, hepatic biopsy or gastric ulceration scores.
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Affiliation(s)
- Melissa A Mercer
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Jennifer L Davis
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Harold C McKenzie
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Christopher R Byron
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Maureen E Kelleher
- Department of Large Animal Clinical Sciences, Marion duPont Scott Equine Medical Center, Leesburg, Virginia, USA
| | - Lauren Trager
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Thomas E Cecere
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Katie E Wilson
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - R M Council-Troche
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia, USA
| | - Stephen R Werre
- Department of Population Health Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
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8
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Bateman DN, Dart RC, Dear JW, Prescott LF, Rumack BH. Fifty years of paracetamol (acetaminophen) poisoning: the development of risk assessment and treatment 1973-2023 with particular focus on contributions published from Edinburgh and Denver. Clin Toxicol (Phila) 2023; 61:1020-1031. [PMID: 38197864 DOI: 10.1080/15563650.2023.2293452] [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: 10/04/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Fifty years ago, basic scientific studies and the availability of assay methods made the assessment of risk in paracetamol (acetaminophen) poisoning possible. The use of the antidote acetylcysteine linked to new methods of risk assessment transformed the treatment of this poisoning. This review will describe the way in which risk assessment and treatments have developed over the last 50 years and highlight the remaining areas of uncertainty. METHODS A search of PubMed and its subsidiary databases revealed 1,166 references published in the period 1963-2023 using the combined terms "paracetamol", "poisoning", and "acetylcysteine". Focused searches then identified 170 papers dealing with risk assessment of paracetamol poisoning, 141 with adverse reactions to acetylcysteine and 114 describing different acetylcysteine regimens. To manage the extensive literature, we focused mainly on contributions made by the authors during their time in Edinburgh and Denver. DOSE AND CONCENTRATION RESPONSE The key relationship between paracetamol dose and toxicity risk was established in 1971 and led to the development of the Rumack-Matthew nomogram from data collected in Edinburgh. MECHANISMS OF TOXICITY A series of papers on the mechanisms of toxicity were published in 1973, and these showed that paracetamol hepatotoxicity was caused by the formation of a toxic intermediate epoxide metabolite normally detoxified by glutathione but which, in excess, was bound covalently to hepatic enzymes and proteins. An understanding of the relationship between the rate of paracetamol metabolism, paracetamol concentration, and toxic hazard in humans soon followed. ANTIDOTE DEVELOPMENT AND EFFICACY IN PATIENTS These discoveries were followed by the testing of a range of sulfhydryl-donors in animals and "at risk" patients. Acetylcysteine was developed as the lead intravenous antidote in the United Kingdom. The license holder in the United States refused to make an intravenous formulation. Thus, oral acetylcysteine became the antidote trialed in the United States National Multicenter Study. Intravenous acetylcysteine regimens used initially in the United Kingdom and subsequently in the United States used loading doses of 150 mg/kg over 15 minutes or one hour, 50 mg/kg over four hours, and 100 mg/kg over 16 hours. These regimens were associated with adverse drug reactions (nausea, vomiting and anaphylactoid reactions) and hence, treatment interruption. Newer dosing regimens now give loading doses more slowly. One, the Scottish and Newcastle Anti-emetic Pretreatment protocol, using an acetylcysteine regimen of 100 mg/kg over two hours followed by 200 mg/kg over 10 hours, has been widely adopted in the United Kingdom. A cohort comparison study suggests this regimen has comparable efficacy to standard regimens and offers opportunities for selective higher acetylcysteine dosing. RISK ASSESSMENT AT PRESENTATION No dose-ranging studies with acetylcysteine were done, and no placebo-controlled studies were performed. Thus, there is uncertainty regarding the optimal dose of acetylcysteine, particularly in patients ingesting very large overdoses of paracetamol. The choice of intervention concentration on the Rumack-Matthew nomogram has important consequences for the proportion of patients treated. The United States National Multicenter Study used a "treatment" line starting at 150 mg/L (992 µmol/L) at 4 hours post overdose, extending to 24 hours with a half-life of 4 hours, now standard there, and subsequently adopted in Australia and New Zealand. In the United Kingdom, the treatment line was initially 200 mg/L (1,323 µmol/L) at 4 hours (the Rumack-Matthew "risk" line). In 2012, the United Kingdom Medicines and Healthcare products Regulatory Agency lowered the treatment line to 100 mg/L (662 µmol/L) at 4 hours for all patients, increasing the number of patients admitted and treated at a high cost. Risk assessment is a key issue for ongoing study, particularly following the development of potential new antidotes that may act in those at greatest risk. The development of biomarkers to assess risk is ongoing but has yet to reach clinical trials. CONCLUSION Even after 50 years, there are still areas of uncertainty. These include appropriate acetylcysteine doses in patients who ingest different paracetamol doses or multiple (staggered) ingestions, early identification of at-risk patients, and optimal treatment of late presenters.
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Affiliation(s)
- D Nicholas Bateman
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Medical Toxicology, University of CO School of Medicine, Aurora, CO, USA
| | - James W Dear
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Laurie F Prescott
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Sciences, University of Edinburgh, The Queens Medical Research Institute, Edinburgh, UK
| | - Barry H Rumack
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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9
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El-Gharbawy DM, Kabbash IA, Ghonem MM. A nomogram proposal for early prediction of intensive care unit admission in patients with acute antipsychotic poisoning. Toxicol Res (Camb) 2023; 12:873-883. [PMID: 37915484 PMCID: PMC10615807 DOI: 10.1093/toxres/tfad078] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/26/2023] [Accepted: 08/30/2023] [Indexed: 11/03/2023] Open
Abstract
Background Early identification of antipsychotic poisoned patients who may have a potential risk for intensive care unit (ICU) admission is crucial especially when resources are limited. Nomograms were previously used as a practical tool to predict prognosis and planning the treatment of some diseases including some poisoning conditions. However, they were not previously investigated in antipsychotic poisoning. Aim The current study aimed to construct a nomogram to predict the need for ICU admission in acute antipsychotic poisoning. Patients and methods: This 2-year study included 140 patients acutely intoxicated with antipsychotics and admitted at Tanta University Poison Control Centre throughout July 2019 to June 2021. Personal and toxicological data, findings of clinical examination and electrocardiography, as well as, results of laboratory investigations at time of admission were recorded. According to the outcome, patients were divided into ICU-admitted and ICU-not admitted groups. Results The results of this study provided a proposed nomogram that included five significant independent predictors for ICU admission in acute antipsychotic intoxications; the presence of seizures (OR: 31132.26[108.97-Inf]), corrected QT interval (OR: 1.04[1.01-1.09]), mean arterial blood pressure (OR: 0.83[0.70-0.92]), oxygen saturation (OR: 0.62[0.40 to 0.83)], and Glasgow Coma Scale (OR: 0.25 [0.06-0.56]). Conclusion It could be concluded that the developed nomogram is a promising tool for easy and rapid decision making to predict the need for ICU admission in acute antipsychotic poisoning.
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Affiliation(s)
- Doaa M El-Gharbawy
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ibrahim Ali Kabbash
- Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona M Ghonem
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
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10
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Sridharan K, Mulubwa M, Qader AM. Population Pharmacokinetic Modeling and Dose Optimization of Acetaminophen and its Metabolites Following Intravenous Infusion in Critically ill Adults. Eur J Drug Metab Pharmacokinet 2023; 48:531-540. [PMID: 37389726 DOI: 10.1007/s13318-023-00841-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Acetaminophen (paracetamol) is a ubiquitously administered drug in critically ill patients. Considering the dearth of literature, we evaluated the population pharmacokinetics of intravenous acetaminophen and its principal metabolites (sulfate and glucuronide) in this population. METHODS Critically ill adults receiving intravenous acetaminophen were included in the study. One to three blood samples were withdrawn per patient for the estimation of acetaminophen, and its metabolites (acetaminophen glucuronide and acetaminophen sulfate). High-performance liquid chromatography was used for measuring serum concentrations. We used nonlinear mixed-effect modeling for estimating the primary pharmacokinetic parameters of acetaminophen and its metabolites. The effect of covariates was evaluated followed by dose optimization using Monte Carlo simulation. Patient factors such as demographic information, liver and renal function tests were used as covariates in population pharmacokinetic analysis. The therapeutic range for serum acetaminophen concentration was considered to be 66-132 μM, while 990 μM was considered as the threshold for toxic concentration. RESULTS Eighty-seven participants were recruited. A joint two-compartment acetaminophen pharmacokinetic model linked to glucuronide and sulfate metabolite compartments was used. The central and peripheral volume distributions were 7.87 and 8.87 L/70 kg, respectively. Estimated clearance (CL) was 0.58 L/h/70 kg, while intercompartmental clearance was 44.2 L/h/70 kg. The glucuronide and sulfate metabolite CL were 22 and 94.7 L/h/70 kg, respectively. Monte Carlo simulation showed that twice-daily administration of acetaminophen would result in a relatively higher proportion of patient population achieving and retaining serum concentrations in the therapeutic range, with reduced risk of concentrations remaining in the toxic range. CONCLUSION A joint pharmacokinetic model for intravenous acetaminophen and its principal metabolites in a critically ill patient population has been developed. Acetaminophen CL in this patient population is reduced. We propose a reduction in the frequency of administration to reduce the risk of supra-therapeutic concentrations in this population.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | - Mwila Mulubwa
- Drug Discovery and Development Centre (H3D), University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Ali Mohamed Qader
- Salmaniya medical complex, Manama, Kingdom of Bahrain
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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Chiew AL, Isbister GK. Advances in the understanding of acetaminophen toxicity mechanisms: a clinical toxicology perspective. Expert Opin Drug Metab Toxicol 2023; 19:601-616. [PMID: 37714812 DOI: 10.1080/17425255.2023.2259787] [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: 05/15/2023] [Revised: 08/02/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Acetaminophen (paracetamol) is a commonly used analgesic and antipyretic agent, which is safe in therapeutic doses. Acetaminophen poisoning due to self-harm or repeated supratherapeutic ingestion is a common cause of acute liver injury. Acetylcysteine has been a mainstay of treatment for acetaminophen poisoning for decades and is efficacious if administered early. However, treatment failures occur if administered late, in 'massive' overdoses or in high-risk patients. AREAS COVERED This review provides an overview of the mechanisms of toxicity of acetaminophen poisoning (metabolic and oxidative phase) and how this relates to the assessment and treatment of the acetaminophen poisoned patient. The review focuses on how these advances offer further insight into the utility of novel biomarkers and the role of proposed adjunct treatments. EXPERT OPINION Advances in our understanding of acetaminophen toxicity have allowed the development of novel biomarkers and a better understanding of how adjunct treatments may prevent acetaminophen toxicity. Newly proposed adjunct treatments like fomepizole are being increasingly used without robust clinical trials. Novel biomarkers (not yet clinically available) may provide better assessment of these newly proposed adjunct treatments, particularly in clinical trials. These advances in our understanding of acetaminophen toxicity and liver injury hold promise for improved diagnosis and treatment.
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Affiliation(s)
- Angela L Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, Waratah, NSW, Australia
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12
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Fontana RJ, Liou I, Reuben A, Suzuki A, Fiel MI, Lee W, Navarro V. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury. Hepatology 2023; 77:1036-1065. [PMID: 35899384 PMCID: PMC9936988 DOI: 10.1002/hep.32689] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Liou
- University of Washington, Seattle, Washington, USA
| | - Adrian Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - M. Isabel Fiel
- Department of Pathology, Mount Sinai School of Medicine, New York City, New York, USA
| | - William Lee
- Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas, USA
| | - Victor Navarro
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
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Liver Regeneration and Immunity: A Tale to Tell. Int J Mol Sci 2023; 24:ijms24021176. [PMID: 36674692 PMCID: PMC9864482 DOI: 10.3390/ijms24021176] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
The physiological importance of the liver is demonstrated by its unique and essential ability to regenerate following extensive injuries affecting its function. By regenerating, the liver reacts to hepatic damage and thus enables homeostasis to be restored. The aim of this review is to add new findings that integrate the regenerative pathway to the current knowledge. An optimal regeneration is achieved through the integration of two main pathways: IL-6/JAK/STAT3, which promotes hepatocyte proliferation, and PI3K/PDK1/Akt, which in turn enhances cell growth. Proliferation and cell growth are events that must be balanced during the three phases of the regenerative process: initiation, proliferation and termination. Achieving the correct liver/body weight ratio is ensured by several pathways as extracellular matrix signalling, apoptosis through caspase-3 activation, and molecules including transforming growth factor-beta, and cyclic adenosine monophosphate. The actors involved in the regenerative process are numerous and many of them are also pivotal players in both the immune and non-immune inflammatory process, that is observed in the early stages of hepatic regeneration. Balance of Th17/Treg is important in liver inflammatory process outcomes. Knowledge of liver regeneration will allow a more detailed characterisation of the molecular mechanisms that are crucial in the interplay between proliferation and inflammation.
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Yau CE, Chen H, Lim BPY, Ng M, Ponampalam R, Lim DYZ, Chin YH, Ho AFW. Performance of the paracetamol-aminotransferase multiplication product in risk stratification after paracetamol (acetaminophen) poisoning: a systematic review and meta-analysis. Clin Toxicol (Phila) 2023; 61:1-11. [PMID: 36444937 DOI: 10.1080/15563650.2022.2152350] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Risk stratification in paracetamol (acetaminophen) poisoning is crucial because hepatotoxicity is common and can be mitigated with treatment. However, current risk stratification tools have limitations. AIMS We evaluated the diagnostic performance of the paracetamol concentration × aminotransferase multiplication product, for predicting hepatotoxicity after paracetamol overdose. METHODS Medline, Cochrane Library and Embase were searched for eligible papers. We used random effects models to obtain pooled estimates of the likelihood ratios and diagnostic odds ratios, from which sensitivity and specificity were computed. We assessed two commonly used cut-off values of paracetamol × aminotransferase, 1500 mg/L × IU/L and 10,000 mg/L × IU/L. Using the confusion matrices of these two cut-offs, area under the summary receiver operator characteristic curve and optimal cut-off values in different clinical scenarios were established. RESULTS Six studies comprising 5036 participants were included. In 4051 patients, using the cut-off of 1500 mg/L × IU/L, a diagnostic odds ratio of 31.90 (95%CI: 9.52-106.90), sensitivity of 0.98 (95%CI: 0.94-1.00) and specificity of 0.66 (95%CI: 0.49-0.89) were obtained. In 3983 patients, using the cut-off of 10,000 mg/L × IU/L, a diagnostic odds ratio of 99.34 (95%CI: 12.26-804.87), sensitivity of 0.65 (95%CI: 0.51-0.82) and specificity of 0.97 (95%CI: 0.95-1.00) were obtained. For staggered ingestions, the 1500 mg/L × IU/L cut-off yielded a diagnostic odds ratio of 69.53 (95%CI: 4.03-1199.75), sensitivity of 1.00 (95%CI: 0.87-1.00) and specificity of 0.74 (95%CI: 0.43-1.00). Next, using the 10,000 mg/L × IU/L cut-off in this scenario yielded a diagnostic odds ratio of 254.58 (95%CI: 11.12-5827.60), sensitivity of 0.79 (95%CI: 0.59-1.00) and specificity of 0.98 (95%CI: 0.94-1.00). The overall summary receiver operator characteristic curve was 0.91 (95%CI: 0.75-0.97), and the optimal cut-off value was 3840 mg/L × IU/L. The summary receiver operator characteristic curve in patients with staggered ingestions was 0.96 (95%CI: 0.85-0.99). The summary receiver operator characteristic curve in patients with staggered ingestions and whose paracetamol concentration was below the detectable limit of 10 mg/L at presentation was 0.97 (95%CI: 0.94-0.99). CONCLUSION In this first meta-analysis, paracetamol × aminotransferase demonstrates its use in prognosticating hepatotoxicity in patients with paracetamol poisoning. It complements the Rumack-Matthew nomogram as it has shown promise in addressing two key limitations of the nomogram: it is usable after more than 24 h between overdose and acetylcysteine treatment, and it is applicable in staggered ingestions.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haoyang Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bryant Po-Yuen Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mingwei Ng
- SingHealth Toxicology Service; Singapore, Singapore
| | - R Ponampalam
- SingHealth Toxicology Service; Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
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Stampf JL, Ciotu CI, Heber S, Boehm S, Fischer MJM, Salzer I. Analgesic Action of Acetaminophen via Kv7 Channels. Int J Mol Sci 2022; 24:ijms24010650. [PMID: 36614094 PMCID: PMC9820628 DOI: 10.3390/ijms24010650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/03/2023] Open
Abstract
The mechanism of acetaminophen (APAP) analgesia is at least partially unknown. Previously, we showed that the APAP metabolite N-acetyl-p-benzoquinone imine (NAPQI) activated Kv7 channels in neurons in vitro, and this activation of Kv7 channels dampened neuronal firing. Here, the effect of the Kv7 channel blocker XE991 on APAP-induced analgesia was investigated in vivo. APAP had no effect on naive animals. Induction of inflammation with λ-carrageenan lowered mechanical and thermal thresholds. Systemic treatment with APAP reduced mechanical hyperalgesia, and co-application of XE991 reduced APAP's analgesic effect on mechanical pain. In a second experiment, the analgesic effect of systemic APAP was not antagonized by intrathecal XE991 application. Analysis of liver samples revealed APAP and glutathione-coupled APAP indicative of metabolization. However, there were no relevant levels of these metabolites in cerebrospinal fluid, suggesting no relevant APAP metabolite formation in the CNS. In summary, the results support an analgesic action of APAP by activating Kv7 channels at a peripheral site through formation of the metabolite NAPQI.
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Shariare MH, Pinky NJK, Abedin J, Kazi M, Aldughaim MS, Uddin MN. Liposomal Drug Delivery of Blumea lacera Leaf Extract: In-Vivo Hepatoprotective Effects. NANOMATERIALS 2022; 12:nano12132262. [PMID: 35808096 PMCID: PMC9268469 DOI: 10.3390/nano12132262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022]
Abstract
Background: Blumea lacera (B. lacera) is a herbaceous plant commonly found in south-east Asia. It shows significant therapeutic activities against various diseases. The objectives of this study were to evaluate hepatoprotective effects of Blumea lacera leaf extract and also to investigate the comparative effectiveness between a liposomal preparation and a suspension of B. lacera leaf extract against carbon tetrachloride (CCl4)-induced liver damage. Methods: B. lacera leaf extract was characterized using a GC-MS method. A liposomal preparation of B. lacera leaf extract was developed using an ethanol injection method and characterized using dynamic light scattering (DLS) and electronic microscopic systems. The hepatoprotective effects of B. lacera leaf extracts and its liposomal preparation were investigated using CCl4-induced liver damage in Long Evan rats. Results: GC-MS data showed the presence of different components (e.g., phytol) in the B. lacera leaf extract. DLS and microscopic data showed that a liposomal preparation of B. lacera leaf extracts was in the nano size range. In vivo study results showed that liposomal preparation and a suspension of B. lacera leaf extract normalized liver biochemical parameters, enzymes and oxidative stress markers which were elevated due to CCl4 administration. However, a liposomal formulation of B. lacera leaf extract showed significantly better hepatoprotective effects compared to a suspension of leaf extract. In addition, histopathological evaluation showed that B. lacera leaf extract and its liposomal preparation treatments decreased the extent of CCl4-induced liver inflammations. Conclusion: Results demonstrated that B. lacera leaf extract was effective against CCl4-induced liver injury possibly due to the presence of components such as phytol. A liposomal preparation exhibited significantly better activity compared to a B. lacera suspension, probably due to improved bioavailability and stability of the leaf extract.
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Affiliation(s)
- Mohammad Hossain Shariare
- Department of Pharmaceutical Sciences, North South University, Dhaka 1229, Bangladesh; (M.H.S.); (N.J.K.P.); (J.A.)
| | - Nusrat Jahan Khan Pinky
- Department of Pharmaceutical Sciences, North South University, Dhaka 1229, Bangladesh; (M.H.S.); (N.J.K.P.); (J.A.)
| | - Joynal Abedin
- Department of Pharmaceutical Sciences, North South University, Dhaka 1229, Bangladesh; (M.H.S.); (N.J.K.P.); (J.A.)
| | - Mohsin Kazi
- Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
- Correspondence: (M.K.); (M.N.U.)
| | | | - Mohammad N. Uddin
- College of Pharmacy, Mercer University, 3001 Mercer University Drive, Atlanta, GA 30341, USA
- Correspondence: (M.K.); (M.N.U.)
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Gupta R, Behnoush AH, Egeler D, Aronow WS. Effect of Acetaminophen on Blood Pressure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Eur J Prev Cardiol 2022; 29:e326-e330. [PMID: 35655390 DOI: 10.1093/eurjpc/zwac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Rahul Gupta
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Amir Hossein Behnoush
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - David Egeler
- Department of Internal Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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AlRuwaili N, Zaidan F, AlFattani A, Alenazi S. Urgent need to standardize labelling of acetaminophen-paediatric liquid drug products in Saudi Arabia. Int J Pediatr Adolesc Med 2022; 9:62-65. [PMID: 35573073 PMCID: PMC9072244 DOI: 10.1016/j.ijpam.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/12/2021] [Accepted: 09/19/2021] [Indexed: 12/01/2022]
Abstract
In this study, dosing instructions in package inserts of all 12 paediatric liquid acetaminophen products registered in pharmacies in the Kingdom of Saudi Arabia were analysed to determine the potential for administering a supratherapeutic dose of acetaminophen. Doses in millilitres were calculated as mg/kg for four age groups: three months old, one year old, six years old, and twelve years old, and based on the 3rd, 50th, and 75th weight percentiles of each age group. Acetaminophen concentrations in the products varied, and only two products included Arabic language instructions. The dosing instructions in eight products included an age overlap. The most affected age group was the 1-year-old group, with 21 supratherapeutic doses across all 12 products. The least affected age group was the 12-year-old group, with 8 supratherapeutic doses in total. The absence of strict supervision and monitoring of labels of paediatric liquid acetaminophen products increases the risk of liver toxicity in children. Therefore, we call for an immediate standardisation of all dosing instructions regarding the dose per weight and the inclusion of instructions in Arabic.
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Affiliation(s)
- Nahar AlRuwaili
- Emergency Department, King Faisal Specialist Hospital & Research Center, AlFaisal University, Saudi Arabia
| | - Faten Zaidan
- General Peadiatric Department, KFSHRC, AlMaarefa University, Saudi Arabia
| | - Areej AlFattani
- Biostatician, King Faisal Specialist Hospital & Research Center, Saudi Arabia
| | - Saud Alenazi
- Pediatric Emergency Medicine, Department of Emergency Medicine, Maternity & Children Hospital, Qassim, Saudi Arabia
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Chomchai S, Mekavuthikul P, Phuditshinnapatra J, Chomchai C. Sensitivity of dose-estimations for acute acetaminophen overdose in predicting hepatotoxicity risk using the Rumack-Matthew Nomogram. Pharmacol Res Perspect 2022; 10:e00920. [PMID: 35106928 PMCID: PMC8929339 DOI: 10.1002/prp2.920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/08/2022] Open
Abstract
Timely assessment of acetaminophen concentration in overdose situations is not always available in resource-poor settings. The 150 mg/kg dose-estimate for acetaminophen is widely considered as criterion for acetaminophen overdose. Its sensitivity and specificity when compared to the 150 mg/L treatment line on the Rumack-Matthew Nomogram (150-treatment line) has rarely been evaluated. This is a retrospective chart review of acute acetaminophen overdose patients. We evaluated the sensitivity and specificity of the 150, 200 mg/kg and 8- and 10-g dose-estimates by plotting the serum acetaminophen levels and using 150-treatment line on the Nomogram as the treatment cut-off. A comparison of medical care costs was performed. We enrolled 784 cases for analysis. Median (IQR) age was 23 (20-28) years (81.9% female). There were 545 cases (69.5%) where the estimated ingested acetaminophen dose were ≥150 mg/kg and 406 cases (51.8%) with concentrations ≥150-treatment line. Hepatotoxicity and acute liver injury (ALI) occurred in 7.3% and 23.9%, respectively. The sensitivity and specificity of 150 mg/kg dose-estimate for the 150-treatment line were 92.6% (95% CI 89.6, 94.8) and 55.3% (95% CI 50.3, 60.2). Among patients with dose-estimate below150 mg/kg, none developed hepatotoxicity and 17 (7.1%) develop ALI. The administration of activated charcoal significantly decreased the risk of being above the 150-treatment line by half. In resource-poor setings, the use of 150 mg/kg dose-estimate as a stand-alone criteria for initiation of N-acetylcysteine therapy is satisfactory, especially when combined with decontamination with activated charcoal and follow up of aminotransferase at 24 h.
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Affiliation(s)
- Summon Chomchai
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pattaraporn Mekavuthikul
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jariya Phuditshinnapatra
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chulathida Chomchai
- Division of Science, Mahidol University International College, Nakhon Pathom, Thailand.,Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Akakpo JY, Ramachandran A, Curry SC, Rumack BH, Jaeschke H. Comparing N-acetylcysteine and 4-methylpyrazole as antidotes for acetaminophen overdose. Arch Toxicol 2022; 96:453-465. [PMID: 34978586 PMCID: PMC8837711 DOI: 10.1007/s00204-021-03211-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/20/2021] [Indexed: 02/06/2023]
Abstract
Acetaminophen (APAP) overdose can cause hepatotoxicity and even liver failure. N-acetylcysteine (NAC) is still the only FDA-approved antidote against APAP overdose 40 years after its introduction. The standard oral or intravenous dosing regimen of NAC is highly effective for patients with moderate overdoses who present within 8 h of APAP ingestion. However, for late-presenting patients or after ingestion of very large overdoses, the efficacy of NAC is diminished. Thus, additional antidotes with an extended therapeutic window may be needed for these patients. Fomepizole (4-methylpyrazole), a clinically approved antidote against methanol and ethylene glycol poisoning, recently emerged as a promising candidate. In animal studies, fomepizole effectively prevented APAP-induced liver injury by inhibiting Cyp2E1 when treated early, and by inhibiting c-jun N-terminal kinase (JNK) and oxidant stress when treated after the metabolism phase. In addition, fomepizole treatment, unlike NAC, prevented APAP-induced kidney damage and promoted hepatic regeneration in mice. These mechanisms of protection (inhibition of Cyp2E1 and JNK) and an extended efficacy compared to NAC could be verified in primary human hepatocytes. Furthermore, the formation of oxidative metabolites was eliminated in healthy volunteers using the established treatment protocol for fomepizole in toxic alcohol and ethylene glycol poisoning. These mechanistic findings, together with the excellent safety profile after methanol and ethylene glycol poisoning and after an APAP overdose, suggest that fomepizole may be a promising antidote against APAP overdose that could be useful as adjunct treatment to NAC. Clinical trials to support this hypothesis are warranted.
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Affiliation(s)
- Jephte Y. Akakpo
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Anup Ramachandran
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Steven C. Curry
- Division of Clinical Data Analytics and Decision Support, and Division of Medical Toxicology and Precision Medicine, Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Barry H. Rumack
- Department of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
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OUP accepted manuscript. J Appl Lab Med 2022; 7:812-814. [DOI: 10.1093/jalm/jfac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022]
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Highly Variable Paracetamol Pharmacokinetics After Multiple Oral Dosing in Frail Older People: A Population Pharmacokinetic Analysis. Drugs Aging 2021; 39:83-95. [PMID: 34918212 DOI: 10.1007/s40266-021-00912-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Paracetamol pharmacokinetics (PK) is highly variable in older fit adults after intravenous administration. Frailty and oral administration likely result in additional variability. The aim was to determine oral paracetamol PK and variability in geriatric inpatients. METHODS A population PK analysis, using NONMEM 7.2, was performed on 245 paracetamol samples in 40 geriatric inpatients (median age 87 [range 80-95] years, bodyweight 66.4 [49.3-110] kg, 92.5% frail [Edmonton Frail Scale]). All subjects received paracetamol 1000 mg as tablet (72.5%) or granulate (27.5%) three times daily. Simulations of dosing regimens (1000 mg every 6 hours [q6h] or q8h) were performed to determine target attainment, using mean steady-state concentration (Css-mean) of 10 mg/L as target. RESULTS A one-compartment model with first order absorption and lag time best described the data. The inter-individual variability was high, with absorption rate constant containing the highest variability. The inter-individual variability could not be explained by covariates. Simulations of 1000 mg q6h and q8h resulted in a Css-mean of 10.8 [25-75th percentiles 8.2-12.7] and 8.13 [6.3-9.6] mg/L, respectively, for the average geriatric inpatient. The majority of the population remained off-target (22.2% [q6h] and 52.2% [q8h] <8 mg/L; 31.3 [q6h] and 7.6% [q8h] >12 mg/L). CONCLUSION A population of average geriatric inpatients achieved target Css-mean with paracetamol 1000 mg q6h, while q8h resulted in underexposure for the majority of them. Due to high unexplained variability, a relevant proportion remained either above or below the target concentration of 10 mg/L. Research focusing on PK, efficacy and safety is needed to recommend dosing regimens.
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Pourbagher-Shahri AM, Schimmel J, Shirazi FM, Nakhaee S, Mehrpour O. Use of fomepizole (4-methylpyrazole) for acetaminophen poisoning: A scoping review. Toxicol Lett 2021; 355:47-61. [PMID: 34785186 DOI: 10.1016/j.toxlet.2021.11.005] [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] [Received: 01/28/2021] [Revised: 08/30/2021] [Accepted: 11/11/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Acetaminophen (paracetamol, APAP) poisoning is a prominent global cause of drug-induced liver injury. While N-acetylcysteine (NAC) is an effective antidote, it has therapeutic limitations in massive overdose or delayed presentation. The objective is to comprehensively review the literature on fomepizole as a potential adjunct antidote for acetaminophen toxicity. METHODS A scoping review was performed using standardized search terms from inception through July 2021. RESULTS Reports on fomepizole as a therapeutic adjunct for APAP toxicity span heterogeneous types of evidence. Eleven preclinical studies (in vitro and animal), fourteen case reports/series, and one human volunteer study were included. Fomepizole's action is mediated by inhibition of CYP2E1 to prevent oxidant stress generation, and inhibition of c-Jun N-terminal kinase (JNK) to decrease amplification of oxidant stress signaling to mitochondria. Studies have shown a reduction in oxidative metabolites likely by shunting metabolism away from CYP2E1 and a resultant decrease in liver injury in animals, independent of CYP2E1 interactions. Fomepizole has been linked to few adverse effects. CONCLUSION Based on in vitro and animal studies, and bolstered by case reports, fomepizole likely offers benefit as an adjunct antidote for APAP toxicity, however this remains to be shown in a human trial. NAC remains the standard of care antidote, but given that fomepizole is approved and generally safe, it may be considered for APAP toxicity as off-label use by experienced clinicians, in rare circumstances associated with increased risk of hepatotoxicity despite standard NAC dosing. The marginal clinical benefit of fomepizole adjunct therapy beyond NAC monotherapy remains to be clearly defined, and routine use for APAP overdose is premature based on current evidence.
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Affiliation(s)
| | - Jonathan Schimmel
- Dept of Emergency Medicine, Division of Medical Toxicology, Mount Sinai Hospital Icahn School of Medicine, New York, NY, USA
| | - Farshad M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran; Data Science Institute, Southern Methodist University, Dallas, Texas, USA; Scientific Unlimited Horizon, Tucson, AZ, USA.
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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.
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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
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Zillen D, Movig KLL, Kant G, Masselink JB, Mian P. Impact of malnourishment on the pharmacokinetics of acetaminophen and susceptibility to acetaminophen hepatotoxicity. Clin Case Rep 2021; 9:e04611. [PMID: 34815870 PMCID: PMC8593780 DOI: 10.1002/ccr3.4611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/28/2021] [Accepted: 07/04/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Acetaminophen hepatotoxicity is thought to be primarily caused by formation of the specific reactive metabolite N-acetyl-para-benzo-quinone imine (NAPQI). Malnourished individuals are at increased risk of acetaminophen-related hepatotoxicity. We report a case of low acetaminophen clearance in a severely underweight young woman, and elaborate on the possible effects of malnutrition on the total clearance of acetaminophen as well as on the separate contributions of the different metabolic pathways. CASE REPORT An 18-year-old Caucasian woman weighing 43 kg with a history of eating disorder-related hospital admissions presented at the emergency department after having ingested 33 tablets of acetaminophen 500 mg two hours earlier. She then received intravenous N-acetylcysteine for 33 h. Nine hours after ingestion, the acetaminophen elimination half-life (t½) was estimated to be >100 h. DISCUSSION While decreased total acetaminophen clearance (twofold) due to malnutrition has been reported in literature, the extremely low clearance in this specific patient cannot be explained. Malnourished individuals generally have reduced antioxidant reserves, coinciding with a shift in metabolic routes toward oxidative metabolism. This may result in increased formation of NAPQI and reduced neutralizing capacity, thereby increasing the risk of acetaminophen-induced hepatotoxicity. Evidence for this observation can be found in animal and to a lesser extent in human studies.
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Affiliation(s)
- Daan Zillen
- Department of Clinical PharmacyMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Kris L. L. Movig
- Department of Clinical PharmacyMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Gert Kant
- Department of Internal MedicineMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Joost B. Masselink
- Department of Clinical PharmacyMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Paola Mian
- Department of Clinical PharmacyMedisch Spectrum TwenteEnschedeThe Netherlands
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Link SL, Rampon G, Osmon S, Scalzo AJ, Rumack BH. Fomepizole as an adjunct in acetylcysteine treated acetaminophen overdose patients: a case series. Clin Toxicol (Phila) 2021; 60:472-477. [PMID: 34709101 DOI: 10.1080/15563650.2021.1996591] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Acetaminophen (N-acetyl-para-aminophenol or APAP) is the leading cause of acute liver failure worldwide. Standard therapy for APAP overdose is with IV N-acetylcysteine (NAC). However, overdose patients treated with NAC can still incur hepatotoxicity in some circumstances. Fomepizole has proven safety in methanol and ethylene glycol poisoning and is a potent CYP2E1 and c-Jun-N-terminal Kinase (JNK) inhibitor that is effective even in the metabolic phase. METHODS We present a prospective case series of 14 consecutive, high-risk patients who had elevated APAP levels after overdose who were treated with fomepizole as an adjunct to standard IV-NAC. The attending toxicologist utilized clinical judgement to determine the use of fomepizole, especially if APAP levels persisted due to altered half-life or risk factors for toxicity. RESULTS There were no unfavorable outcomes in any patient, which were better than expected. CONCLUSIONS This case series has demonstrated the safety of fomepizole in high-risk APAP overdose. The efficacy of fomepizole needs to be further elucidated through controlled clinical trials on a larger scale. In massive APAP overdoses, fomepizole should be considered as an adjunct due to the known failure rate of NAC and the safety profile of fomepizole.
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Affiliation(s)
- Stephanie L Link
- Saint Louis University Pulmonary and Critical Care Medicine, St. Louis, MO, USA
| | - Garrett Rampon
- University of Kansas Pulmonary and Critical Care Medicine, Kansas City, MO, USA
| | - Stephen Osmon
- Former Saint Louis University Pulmonary and Critical Care Medicine, St. Louis, MO, USA
| | - Anthony J Scalzo
- Saint Louis University Division of Toxicology, St. Louis, MO, USA
| | - Barry H Rumack
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Minhaj FS, Leonard JB, Seung H, Anderson BD, Klein-Schwartz W, King JD. In vitro analysis of n-acetylcysteine (NAC) interference with the international normalized ratio (INR). Clin Toxicol (Phila) 2021; 60:489-492. [PMID: 34549665 DOI: 10.1080/15563650.2021.1979232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Previous literature suggests a laboratory interference of n-acetylcysteine (NAC) with prothrombin time (PT) and the international normalized ratio (INR). Early publications focused on this interaction in the setting of an acetaminophen overdose and evaluated the INR of patients receiving intravenous NAC. However, there is limited literature describing the concentration-effect relationship of NAC to INR measurement in the absence of acetaminophen-induced hepatotoxicity at therapeutic NAC concentrations. The purpose of the study is to quantify the degree of interference of NAC on INR values at therapeutic concentrations correlating to each infusion of the regimen (ex. bag 1: 550 mcg/mL, bag 2: 200 mcg/mL, bag 3: 35 mcg/mL, double bag 3: 70 mcg/mL) and at supratherapeutic concentrations in vitro. METHODS Blood samples were obtained from study volunteers. Each blood sample was transferred into vials containing 0.3 mL buffered sodium citrate 3.2% and spiked with various concentrations of NAC for final concentrations of 0, 35, 70, 200, 550, 1000, 2000, and 4000 mcg/mL. The samples were centrifuged and tested to determine PT and INR on two separate machines: Siemens CS-2500 and Stago SN1114559. We would require a sample size of 6 to achieve a power of 80% and a level of significance of 1.7% (two-sided). Differences between INRs at varying concentrations were determined by Friedman's test. For multiple comparisons, post hoc analysis was performed using Wilcoxon signed-rank test with Bonferroni adjustment. Analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC). RESULTS Participants included 11 healthy subjects: 8 males, 3 females, median age 30 years (range 25 - 58). Median and interquartile ranges (IQR) INR for the baseline samples were 1.09 (IQR 1.05, 1.16) for Siemens and 1.03 (IQR 0.99, 1.11) for Stago analyzers. There was a significant difference in INR between the therapeutic concentrations (baseline, 35, 70,200, or 550 µg/mL) (Siemens p = .0008, Stago p < .0001). The 550 µg/mL concentration with the Siemens analyzer was the only one compared separately and found to be significantly greater than the baseline (1.07 vs 1.22, p = .02). For the Stago analyzer the 200 µg/mL and 500 µg/mL were compared and found to be significantly different from baseline (1.00 vs 1.07 and 1.19, adjusted p = .02 and p = .03, respectively). The largest INR increase seen was in one subject from a baseline of 1.07-1.32 with the 550 µg/mL concentration. Increases in concentrations to supratherapeutic levels resulted in a statistically significant non-linear increase in INR for all concentrations (Siemens p < .0001, Stago p < .0001). All of these concentrations were found to be significantly different from baseline (all adjusted p < .05). CONCLUSION Although it was found that at therapeutic concentrations the in vitro presence of NAC affects INR measurements on two different machines, the change is of little clinical relevance. Supratherapeutic concentrations of NAC affect INR significantly, but the clinical utility of those results is limited by the rarity of those concentrations being measured.
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Affiliation(s)
- Faisal Syed Minhaj
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Seung
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Bruce D Anderson
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Joshua D King
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
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Modelling Tools to Characterize Acetaminophen Pharmacokinetics in the Pregnant Population. Pharmaceutics 2021; 13:pharmaceutics13081302. [PMID: 34452263 PMCID: PMC8400310 DOI: 10.3390/pharmaceutics13081302] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 11/17/2022] Open
Abstract
This review describes acetaminophen pharmacokinetics (PK) throughout pregnancy, as analyzed by three methods (non-compartmental analyses (NCA), population PK, and physiologically based PK (PBPK) modelling). Eighteen studies using NCA were reported in the scientific literature. These studies reported an increase in the volume of distribution (3.5-60.7%) and an increase in the clearance (36.8-84.4%) of acetaminophen in pregnant women compared to non-pregnant women. Only two studies using population PK modelling as a technique were available in the literature. The largest difference in acetaminophen clearance (203%) was observed in women at delivery compared to non-pregnant women. One study using the PBPK technique was found in the literature. This study focused on the formation of metabolites, and the toxic metabolite N-acetyl-p-benzoquinone imine was the highest in the first trimester, followed by the second and third trimester, compared with non-pregnant women. In conclusion, this review gave an overview on acetaminophen PK changes in pregnancy. Also, knowledge gaps, such as fetal and placenta PK parameters, have been identified, which should be explored further before dosing adjustments can be suggested on an evidence-based basis.
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Popiolek I, Hydzik P, Jagielski P, Zrodlowska M, Mystek K, Porebski G. Risk Factors for Hepatotoxicity Due to Paracetamol Overdose in Adults. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:752. [PMID: 34440958 PMCID: PMC8402128 DOI: 10.3390/medicina57080752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/26/2022]
Abstract
Background and Objectives: Over-the-counter availability and a good safety profile make paracetamol one of the most common analgesics in developed countries but also the leading cause of liver failure due to overdose. The objectives of the study were to identify modifiable risk factors for severe hepatotoxicity following paracetamol overdose in adults. Materials and Methods: A retrospective cohort study involved the consecutive adult patients hospitalized in a toxicological center over a period of seven years due to paracetamol overdose. Complete medical datasets of laboratory and anamnestic variables were analyzed and validated by means of logistic regression model. Results: A total of 185 patients entered the study, including 25 individuals who developed severe hepatotoxicity (plasma aminotransferases levels above 1000 UI/L) and 31 individuals with mild to moderate liver injury (plasma aminotransferases levels above upper normal range, but below 1000 UI/L). In the univariable analysis, significant hepatotoxicity risk factors were male gender, alcohol abuse, an ingested paracetamol dose, and a timespan from ingestion to hospital admission. The later one was the only significant risk factor in the multivariable model (adjusted odds ratio 1.08; 95% CI: 1.03-1.12). Conclusions: A delay in hospital admission, resulting in a delayed administration of disease-specific treatment outweighs any other known risk factors of paracetamol-induced hepatotoxicity.
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Affiliation(s)
- Iwona Popiolek
- Toxicology Clinical Department, University Hospital in Krakow, Jakubowskiego 2, 30-688 Krakow, Poland; (I.P.); (P.H.)
- Department of Toxicology, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Piotr Hydzik
- Toxicology Clinical Department, University Hospital in Krakow, Jakubowskiego 2, 30-688 Krakow, Poland; (I.P.); (P.H.)
- Department of Toxicology, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Pawel Jagielski
- Department of Nutrition and Drug Research, Faculty of Health Science, Jagiellonian University Medical College, Skawińska 8, 31-066 Krakow, Poland;
| | - Monika Zrodlowska
- Faculty of Medicine, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland; (M.Z.); (K.M.)
| | - Karol Mystek
- Faculty of Medicine, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland; (M.Z.); (K.M.)
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
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Burnham K, Yang T, Smith H, Knight S. A review of alternative intravenous acetylcysteine regimens for acetaminophen overdose. Expert Rev Clin Pharmacol 2021; 14:1267-1278. [PMID: 34187297 DOI: 10.1080/17512433.2021.1946392] [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: 02/05/2023]
Abstract
INTRODUCTION Acetylcysteine is the standard treatment for preventing hepatotoxicity caused by acetaminophen overdose. Several novel approaches to the management of acetaminophen overdose have been suggested to improve patient safety by reducing adverse drug reactions and dosing errors. This article reviews these alternative treatment regimens and intends to offer a detailed assessment of the available options to assist providers in managing cases of acetaminophen overdose. AREAS COVERED This review article covers observational and experimental studies that assessed the efficacy and safety of alternative intravenous acetylcysteine regimens for acetaminophen overdose. A literature search was conducted using PubMed, ProQuest, and Scopus to identify the studies, which included results through April 2021. The assessment of alternative regimens consists of a discussion on the limitations and benefits, barriers to implementation, and important considerations for each regimen. EXPERT OPINION Several alternative regimens have been studied and implemented in various institutions. Many of these dosing regimens have supporting safety data but most lack robust data. A reduction in infusion-related side effects is an important outcome, but established efficacy, local poison center familiarity with the regimen, institutional resources, and patient-specific factors should be equally considered when deciding on implementing and using an alternative dosing strategy.
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Affiliation(s)
- Kevin Burnham
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Tianrui Yang
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Haleigh Smith
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Steven Knight
- Methodist Mansfield Medical Center, Mansfield, TX, USA
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Hon KL, Hui WF, Leung AK. Antidotes for childhood toxidromes. Drugs Context 2021; 10:dic-2020-11-4. [PMID: 34122588 PMCID: PMC8177957 DOI: 10.7573/dic.2020-11-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background Poisoning causes significant morbidity and sometimes mortality in children worldwide. The clinical skill of toxidrome recognition followed by the timely administration of an antidote specific for the poison is essential for the management of children with suspected poisoning. This is a narrative review on antidotes for toxidromes in paediatric practice. Methods A literature search was conducted on PubMed with the keywords “antidote”, “poisoning”, “intoxication”, “children” and “pediatric”. The search was customized by applying the appropriate filters (species: humans; age: birth to 18 years) to obtain the most relevant articles for this review article. Results Toxidrome recognition may offer a rapid guide to possible toxicology diagnosis such that the specific antidote can be administered in a timely manner. This article summarizes toxidromes and their respective antidotes in paediatric poisoning, with an emphasis on the symptomatology and source of exposure. The antidote and specific management for each toxidrome are discussed. Antidotes are only available for a limited number of poisons responsible for intoxication. Antidotes for common poisonings include N-acetyl cysteine for paracetamol and sodium thiosulphate for poisoning by cyanide. Conclusion Poisoning is a common cause of paediatric injury. Physicians should be familiar with the recognition of common toxidromes and promptly use specific antidotes for the management of childhood toxidromes.
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Affiliation(s)
- Kam Lun Hon
- Department of a Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Department of a Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
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Physiologically Based Pharmacokinetic Modeling to Characterize Acetaminophen Pharmacokinetics and N-Acetyl-p-Benzoquinone Imine (NAPQI) Formation in Non-Pregnant and Pregnant Women. Clin Pharmacokinet 2021; 59:97-110. [PMID: 31347013 PMCID: PMC6994454 DOI: 10.1007/s40262-019-00799-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background and Objective Little is known about acetaminophen (paracetamol) pharmacokinetics during pregnancy. The aim of this study was to develop a physiologically based pharmacokinetic (PBPK) model to predict acetaminophen pharmacokinetics throughout pregnancy. Methods PBPK models for acetaminophen and its metabolites were developed in non-pregnant and pregnant women. Physiological and enzymatic changes in pregnant women expected to impact acetaminophen pharmacokinetics were considered. Models were evaluated using goodness-of-fit plots and by comparing predicted pharmacokinetic profiles with in vivo pharmacokinetic data. Predictions were performed to illustrate the average concentration at steady state (Css,avg) values, used as an indicator for efficacy, of acetaminophen achieved following administration of 1000 mg every 6 h. Furthermore, as a measurement of potential hepatotoxicity, the molar dose fraction of acetaminophen converted to N-acetyl-p-benzoquinone imine (NAPQI) was estimated. Results PBPK models successfully predicted the pharmacokinetics of acetaminophen and its metabolites in non-pregnant and pregnant women. Predictions resulted in the lowest Css,avg in the third trimester (median [interquartile range]: 4.5 [3.8–5.1] mg/L), while Css,avg was 6.7 [5.9–7.4], 5.6 [4.7–6.3], and 4.9 [4.1–5.5] mg/L in non-pregnant, first trimester, and second trimester populations, respectively. Assuming a constant raised cytochrome P450 2E1 activity throughout pregnancy, the molar dose fraction of acetaminophen converted to NAPQI was highest during the first trimester (median [interquartile range]: 11.0% [9.1–13.4%]), followed by the second (9.0% [7.5–11.0%]) and third trimester (8.2% [6.8–10.1%]), compared with non-pregnant women (7.7% [6.4–9.4%]). Conclusion Acetaminophen exposure is lower in pregnant than in non-pregnant women, and is related to pregnancy duration. Despite these findings, higher dose adjustments cannot be advised yet as it is unknown whether pregnancy affects the toxicodynamics of NAPQI. Information on glutathione abundance during pregnancy and NAPQI in vivo data are required to further refine the presented model. Electronic supplementary material The online version of this article (10.1007/s40262-019-00799-5) contains supplementary material, which is available to authorized users.
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Downs JW, Cumpston KL, Kershner EK, Troendle MM, Rose SR, Wills BK. Clinical outcome of massive acetaminophen overdose treated with standard-dose N-acetylcysteine. Clin Toxicol (Phila) 2021; 59:932-936. [PMID: 33620007 DOI: 10.1080/15563650.2021.1887493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recent recognition of "massive" acetaminophen (APAP) overdoses has led to the question of whether standard dosing of N-acetylcysteine (NAC) is adequate to prevent hepatoxicity in these patients. The primary aim of this study was to evaluate the clinical outcome for patients with massive APAP overdose who received standard intravenous NAC dosing of 300 mg/kg over 21 h. METHODS This was a single-center retrospective cohort study conducted by chart review of APAP overdoses reported to a regional poison center from 1 January 2010 to 31 December 2019. Massive APAP overdose was defined by single, acute overdose resulting in an APAP concentration exceeding 300 mcg/mL at 4 h post-ingestion. Standard univariate statistical analysis was conducted to describe the cohort, and a multivariate logistic model was utilized to calculate adjusted odds ratios for risk of hepatoxicity. RESULTS 1425 cases of APAP overdose were reviewed. 104 cases met the inclusion criteria of massive APAP overdose. Overall, 79 cases (76%) had no acute liver injury or hepatotoxicity, and 25 (24%) developed hepatoxicity. Nine percent (n = 4) of cases receiving NAC within 8 h developed hepatotoxicity. Crude odds for hepatoxicity was 5.5-fold higher for cases who received NAC after 8 h. CONCLUSIONS Standard NAC dosing received within 8 h prevented hepatoxicity in 91% (n = 40) of cases in our series of massive APAP overdoses. Additional data is needed to determine the clinical outcomes of massive APAP overdose using current intravenous NAC dosing.
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Affiliation(s)
- John W Downs
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Emily K Kershner
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Michelle M Troendle
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - S Rutherfoord Rose
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
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Application of the DILIsym® Quantitative Systems Toxicology drug-induced liver injury model to evaluate the carcinogenic hazard potential of acetaminophen. Regul Toxicol Pharmacol 2020; 118:104788. [PMID: 33153971 DOI: 10.1016/j.yrtph.2020.104788] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/11/2020] [Accepted: 10/04/2020] [Indexed: 12/12/2022]
Abstract
In 2019, the California Office of Environmental Health Hazard Assessment (OEHHA) initiated a review of the carcinogenic hazard potential of acetaminophen. The objective of the analysis herein was to inform this review by assessing whether variability in patient baseline characteristics (e.g. baseline glutathione (GSH) levels, pharmacokinetics, and capacity of hepatic antioxidants) leads to potential differences in carcinogenic hazard potential at different dosing schemes: maximum labeled doses of 4 g/day, repeated doses above the maximum labeled dose (>4-12 g/day), and acute overdoses of acetaminophen (>15 g). This was achieved by performing simulations of acetaminophen exposure in thousands of diverse virtual patients scenarios using the DILIsym® Quantitative Systems Toxicology (QST) model. Simulations included assessments of the dose and exposure response for toxicity and mode of cell death based on evaluations of the kinetics of changes of: GSH, N-acetyl-p-benzoquinone-imine (NAPQI), protein adducts, mitochondrial dysfunction, and hepatic cell death. Results support that, at therapeutic doses, cellular GSH binds to NAPQI providing sufficient buffering capacity to limit protein adduct formation and subsequent oxidative stress. Simulations evaluating repeated high-level supratherapeutic exposures or acute overdoses indicate that cell death precedes DNA damage that could result in carcinogenicity and thus acetaminophen does not present a carcinogenicity hazard to humans at any dose.
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McGill MR, Hinson JA. The development and hepatotoxicity of acetaminophen: reviewing over a century of progress. Drug Metab Rev 2020; 52:472-500. [PMID: 33103516 DOI: 10.1080/03602532.2020.1832112] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acetaminophen (APAP) was first synthesized in the 1800s, and came on the market approximately 65 years ago. Since then, it has become one of the most used drugs in the world. However, it is also a major cause of acute liver failure. Early investigations of the mechanisms of toxicity revealed that cytochrome P450 enzymes catalyze formation of a reactive metabolite in the liver that depletes glutathione and covalently binds to proteins. That work led to the introduction of N-acetylcysteine (NAC) as an antidote for APAP overdose. Subsequent studies identified the reactive metabolite N-acetyl-p-benzoquinone imine, specific P450 enzymes involved, the mechanism of P450-mediated oxidation, and major adducted proteins. Significant gaps remain in our understanding of the mechanisms downstream of metabolism, but several events appear critical. These events include development of an initial oxidative stress, reactive nitrogen formation, altered calcium flux, JNK activation and mitochondrial translocation, inhibition of mitochondrial respiration, the mitochondrial permeability transition, and nuclear DNA fragmentation. Additional research is necessary to complete our knowledge of the toxicity, such as the source of the initial oxidative stress, and to greatly improve our understanding of liver regeneration after APAP overdose. A better understanding of these mechanisms may lead to additional treatment options. Even though NAC is an excellent antidote, its effectiveness is limited to the first 16 hours following overdose.
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Affiliation(s)
- Mitchell R McGill
- Department of Environmental and Occupational Health, Fay W. Boozman College of Public Health, Little Rock, AR, USA.,Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jack A Hinson
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Amirabadizadeh A, Nakhaee S, Jahani F, Soorgi S, Hoyte CO, Mehrpour O. Prognostic indicators in critically ill poisoned patients: development of a risk-prediction nomogram. Drug Metab Pers Ther 2020; 35:dmpt-2020-0108. [PMID: 34704692 DOI: 10.1515/dmpt-2020-0108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/20/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The prognosis of acutely poisoned patients is a significant concern for clinical toxicologists. In this study, we sought to determine the clinical and laboratory findings that can contribute to predicting the medical outcomes of poisoned patients admitted to intensive care units (ICUs). METHODS This retrospective study was performed from January 2009 to January 2016 in the ICU of Vali-e-Asr Hospital in Birjand, Iran. We included all patients with the diagnosis of acute poisoning admitted to the ICU. Demographic data, laboratory results, the Sequential Organ Failure Assessment (SOFA), and acute physiology score + age points + chronic health points (APACHE) II, and the Simplified Acute Physiology Score (SAPS) II, and outcome were collected. Univariate analysis (Mann-Whitney or t-test), multiple logistic regression, receiver operating characteristics (ROC) curve analysis, and Pearson's correlation test were performed using SPSS, STATA/SE 13.0, and Nomolog software programs. RESULTS The multiple logistic regression analysis revealed that five factors were significant for predicting mortality including age (OR 95% CI: 1.1[1.05-1.12], p<0.001), Glasgow Coma Score (GCS) (OR 95% CI: 0.71[0.6-0.84], p<0.001), white blood cell (WBC) count (OR 95% CI: 1.1[1.01-1.12], p=0.04), serum sodium (Na) (OR 95% CI: 1.08[1.01-1.15], p=0.02), and creatinine levels (Cr) (OR 95% CI: 1.86 [1.23-2.81], p=0.003). We generated a five-variable risk-prediction nomogram which could both predict mortality risk and identify high-risk patients. CONCLUSIONS Age, GCS, WBC, serum creatinine, and sodium levels are the best prognostic factors for mortality in poisoned patients admitted to the ICU. The APACHE II score can discriminate between non-survivors and survivors. The nomogram developed in the current study can provide a more precise, quick, and simple analysis of risks, thereby enabling the users to predict mortality and identify high-risk patients.
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Affiliation(s)
- Alireza Amirabadizadeh
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran.,Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Firoozeh Jahani
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Sima Soorgi
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Christopher O Hoyte
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine at Anschutz Medical Center, Aurora, CO, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran.,Arizona Poison & Drug Information Center, the University of Arizona, College of Pharmacy, Tucson, AZ, USA
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Amirabadizadeh A, Nakhaee S, Jahani F, Soorgi S, Hoyte CO, Mehrpour O. Prognostic indicators in critically ill poisoned patients: development of a risk-prediction nomogram. Drug Metab Pers Ther 2020; 0:/j/dmdi.ahead-of-print/dmdi-2020-0108/dmdi-2020-0108.xml. [PMID: 32986611 DOI: 10.1515/dmdi-2020-0108] [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] [Received: 03/15/2020] [Accepted: 06/20/2020] [Indexed: 11/15/2022]
Abstract
Objectives The prognosis of acutely poisoned patients is a significant concern for clinical toxicologists. In this study, we sought to determine the clinical and laboratory findings that can contribute to predicting the medical outcomes of poisoned patients admitted to intensive care units (ICUs). Methods This retrospective study was performed from January 2009 to January 2016 in the ICU of Vali-e-Asr Hospital in Birjand, Iran. We included all patients with the diagnosis of acute poisoning admitted to the ICU. Demographic data, laboratory results, the Sequential Organ Failure Assessment (SOFA), and acute physiology score + age points + chronic health points (APACHE) II, and the Simplified Acute Physiology Score (SAPS) II, and outcome were collected. Univariate analysis (Mann-Whitney or t-test), multiple logistic regression, receiver operating characteristics (ROC) curve analysis, and Pearson's correlation test were performed using SPSS, STATA/SE 13.0, and Nomolog software programs. Results The multiple logistic regression analysis revealed that five factors were significant for predicting mortality including age (OR 95% CI: 1.1[1.05-1.12], p<0.001), Glasgow Coma Score (GCS) (OR 95% CI: 0.71[0.6-0.84], p<0.001), white blood cell (WBC) count (OR 95% CI: 1.1[1.01-1.12], p=0.04), serum sodium (Na) (OR 95% CI: 1.08[1.01-1.15], p=0.02), and creatinine levels (Cr) (OR 95% CI: 1.86 [1.23-2.81], p=0.003). We generated a five-variable risk-prediction nomogram which could both predict mortality risk and identify high-risk patients. Conclusions Age, GCS, WBC, serum creatinine, and sodium levels are the best prognostic factors for mortality in poisoned patients admitted to the ICU. The APACHE II score can discriminate between non-survivors and survivors. The nomogram developed in the current study can provide a more precise, quick, and simple analysis of risks, thereby enabling the users to predict mortality and identify high-risk patients.
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Affiliation(s)
- Alireza Amirabadizadeh
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Firoozeh Jahani
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Sima Soorgi
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
| | - Christopher O Hoyte
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado School of Medicine at Anschutz Medical Center, Aurora, CO, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Islamic Republic of Iran
- Arizona Poison & Drug Information Center, the University of Arizona, College of Pharmacy, Tucson, AZ, USA
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Wester N, Mikladal BF, Varjos I, Peltonen A, Kalso E, Lilius T, Laurila T, Koskinen J. Disposable Nafion-Coated Single-Walled Carbon Nanotube Test Strip for Electrochemical Quantitative Determination of Acetaminophen in a Finger-Prick Whole Blood Sample. Anal Chem 2020; 92:13017-13024. [PMID: 32842738 PMCID: PMC7547857 DOI: 10.1021/acs.analchem.0c01857] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
![]()
A disposable
electrochemical test strip for the quantitative point-of-care
(POC) determination of acetaminophen (paracetamol) in plasma and finger-prick
whole blood was fabricated. The industrially scalable dry transfer
process of single-walled carbon nanotubes (SWCNTs) and screen printing
of silver were combined to produce integrated electrochemical test
strips. Nafion coating stabilized the potential of the Ag reference
electrode and enabled the selective detection in spiked plasma as
well as in whole blood samples. The test strips were able to detect
acetaminophen in small 40 μL samples with a detection limit
of 0.8 μM and a wide linear range from 1 μM to 2 mM, well
within the required clinical range. After a simple 1:1 dilution of
plasma and whole blood, a quantitative detection with good recoveries
of 79% in plasma and 74% in whole blood was achieved. These results
strongly indicate that these electrodes can be used directly to determine
the unbound acetaminophen fraction without the need for any additional
steps. The developed test strip shows promise as a rapid and simple
POC quantitative acetaminophen assay.
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Affiliation(s)
- Niklas Wester
- Department of Chemistry and Materials Science, Aalto University, Kemistintie 1, 02150 Espoo, Finland
| | | | - Ilkka Varjos
- Canatu Oy, Tiilenlyöjänkuja 9, 01720 Vantaa, Finland
| | - Antti Peltonen
- Aalto-NanoFab, Micronova, Aalto University, Tietotie 3, 02150 Espoo, Finland
| | - Eija Kalso
- Department of Pharmacology, University of Helsinki, Haartmaninkatu 8, 00290 Helsinki, Finland.,Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, 00029 HUS Helsinki, Finland
| | - Tuomas Lilius
- Department of Pharmacology, University of Helsinki, Haartmaninkatu 8, 00290 Helsinki, Finland.,Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Tukholmankatu 8C, 00290 Helsinki, Finland
| | - Tomi Laurila
- Department of Electrical Engineering and Automation, Aalto University, Tietotie 3, 02150 Espoo, Finland
| | - Jari Koskinen
- Department of Chemistry and Materials Science, Aalto University, Kemistintie 1, 02150 Espoo, Finland
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Clemens MM, Vazquez JH, Kennon-McGill S, McCullough SS, James LP, McGill MR. Pre-treatment twice with liposomal clodronate protects against acetaminophen hepatotoxicity through a pre-conditioning effect. LIVER RESEARCH 2020; 4:145-152. [PMID: 33042596 PMCID: PMC7544241 DOI: 10.1016/j.livres.2020.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Acetaminophen (APAP) overdose is a major cause of acute liver injury, but the role of macrophages in propagation of the hepatotoxicity is controversial. Early research revealed that macrophage inhibitors protect against APAP injury. However, later work demonstrated that macrophage ablation by acute pre-treatment with liposomal clodronate (LC) exacerbates the toxicity. To our surprise, during other studies, we observed that pre-treatment twice with LC seemed to protect against APAP hepatotoxicity, in contrast to acute pre-treatment. The aim of this study was to confirm that observation and to explore the mechanisms. METHODS We treated mice with empty liposomes (LE) or LC twice per week for 1 week before APAP overdose and collected blood and liver tissue at 0, 2, and 6 h post-APAP. We then measured liver injury (serum ALT activity, histology), APAP bioactivation (total glutathione, APAP-protein adducts), oxidative stress (oxidized glutathione [GSSG]), glutamate cysteine-ligase subunit c (Gclc) mRNA, and nuclear factor erythroid 2-related factor (Nrf2) immunofluorescence. We also confirmed ablation of macrophages by F4/80 immunohistochemistry. RESULTS Pre-treatment twice with LC dramatically reduced F4/80 staining, protected against liver injury, and reduced oxidative stress at 6 h post-APAP, without affecting APAP bioactivation. Importantly, Gclc mRNA was higher in the LC group at 0 h and total glutathione was higher at 2 h, indicating accelerated glutathione re-synthesis after APAP overdose due to greater basal glutamate-cysteine ligase. Oxidative stress was lower in the LC groups at both time points. Finally, total Nrf2 immunofluorescence was higher in the LC group. CONCLUSIONS We conclude that multiple pre-treatments with LC protect against APAP by accelerating glutathione re-synthesis through glutamate-cysteine ligase. Investigators using two or possibly more LC pre-treatments to deplete macrophages, including peritoneal macrophages, should be aware of this possible confounder.
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Affiliation(s)
- Melissa M. Clemens
- Dept. of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, USA 72205,Interdisciplinary Graduate Program in Biomedical Sciences, Graduate School, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR USA 72205
| | - Joel H. Vazquez
- Dept. of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, USA 72205,Interdisciplinary Graduate Program in Biomedical Sciences, Graduate School, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR USA 72205
| | - Stefanie Kennon-McGill
- Dept. of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, USA 72205
| | - Sandra S. McCullough
- Dept. of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR USA 72205
| | - Laura P. James
- Dept. of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR USA 72205
| | - Mitchell R. McGill
- Dept. of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, USA 72205,Dept. of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, USA 72205,Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR, USA 72205
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40
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Zakalska K, Babiichuk O. Paracetamol as a basic component of a modern approach to adequate perioperative analgesia. PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v5i1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The problem of adequate perioperative anesthesia is one of the most pressing in the current health care system, given its medical, humanistic and socio-economic aspects. Currently, the standard of postoperative analgesia is multimodal analgesia (MMA). One of the major and required components of MMA is paracetamol, which has antipyretic and analgesic effects with limited peripheral anti-inflammatory activity. Most authors consider intravenous paracetamol as a base drug in a multimodal analgesia strategy for a variety of surgical interventions, which reduces the need for opioids and reduces the side effects of the latter, which in turn significantly affects the results of treatment and the length of hospital stay.Numerous studies in many countries have created a broad evidence base for the clinical use of this drug. Due to its pharmacokinetic and pharmacodynamic properties, it has been shown that intravenous paracetamol has several advantages over oral and rectal forms: early and more effective onset of analgesia and stable maintenance of the therapeutic dose of paracetamol are explained by the formation of a faster and higher peak in the concentration of the drug. The side effects of using paracetamol can be compared with placebo. The mechanism of action of the drug is different from the mechanism of action of NSAIDs, however, is still not fully understood. It may possibly involve inhibition of cyclooxygenase, cannabinoid, or nitric oxide pathways in the central nervous system. Intravenous paracetamol is a safe and effective first-line drug for the treatment of moderate pain in the perioperative period.
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Rotundo L, Pyrsopoulos N. Liver injury induced by paracetamol and challenges associated with intentional and unintentional use. World J Hepatol 2020; 12:125-136. [PMID: 32685105 PMCID: PMC7336293 DOI: 10.4254/wjh.v12.i4.125] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/26/2019] [Accepted: 02/18/2020] [Indexed: 02/06/2023] Open
Abstract
Drug induced liver injury (DILI) is a common cause of acute liver injury. Paracetamol, also known as acetaminophen, is a widely used anti-pyretic that has long been established to cause liver toxicity once above therapeutic levels. Hepatotoxicity from paracetamol overdose, whether intentional or non-intentional, is the most common cause of DILI in the United States and remains a global issue. Given the increased prevalence of combination medications in the form of pain relievers and antihistamines, paracetamol can be difficult to identify and remains a significant cause of acute hepatotoxicity, as evidenced by its contribution to over half of all acute liver failure cases in the United States. This is especially concerning given that, when co-ingested with other medications, the rise in serum paracetamol levels may be delayed past the 4-hour post-ingestion mark that is currently used to determine patients that require medical therapy. This review serves to describe the clinical and pathophysiologic features of hepatotoxicity secondary to paracetamol and provide an update on current available knowledge and treatment options.
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Affiliation(s)
- Laura Rotundo
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Nikolaos Pyrsopoulos
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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James LP, McGill MR, Roberts DW, Hinson JA, Lee WM. Advances in biomarker development in acetaminophen toxicity. Adv Clin Chem 2020; 98:35-50. [PMID: 32564787 DOI: 10.1016/bs.acc.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Acetaminophen liver injury is the most common cause of acute liver injury in the United States and several other countries. Diagnosis of acetaminophen-induced acute liver injury in the clinic is challenging due to the lack of validated and specific biomarkers. The following chapter provides an overview of recent advances evaluating candidate biomarkers in development for acetaminophen acute liver injury. Relationships of biomarkers to mechanisms of acetaminophen toxicity and their potential role in confirming the diagnosis and/or predicting evolving toxicity are addressed.
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Affiliation(s)
- Laura P James
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Mitchell R McGill
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Department of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Dean W Roberts
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Jack A Hinson
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - William M Lee
- Digestive and Liver Diseases Division, UT Southwestern Medical Center at Dallas, Dallas, TX, United States
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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
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Wong A, Heard K, Graudins A, Dart R, Sivilotti MLA. Adducts Post Acetaminophen Overdose Treated with a 12-Hour vs 20-Hour Acetylcysteine Infusion. J Med Toxicol 2020; 16:188-194. [PMID: 31939054 DOI: 10.1007/s13181-020-00757-9] [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] [Received: 09/12/2019] [Revised: 11/28/2019] [Accepted: 01/04/2020] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Acetaminophen protein adducts in the circulation are a specific biomarker of acetaminophen oxidation, and may be a more sensitive measure of impending hepatic injury following overdose than alanine transaminase (ALT). We performed an exploratory analytical substudy of adducts during a clinical trial (NACSTOP) of abbreviated (12-hour) versus control (20-hour) acetylcysteine to identify any signal of diminished antidotal effectiveness with shortened therapy. METHODS We measured adducts at 0, 12, and 20 hours from a convenience sample of subjects enrolled in the cluster-controlled NACSTOP trial evaluating a 12-hour ("abbreviated"; 200 mg/kg over 4 hours, 50 mg/kg over 8 hours) vs 20-hour acetylcysteine regimen ("control"; 200 mg/kg over 4 hours, 100 mg/kg over 16 hours). Adducts were assayed using high-performance liquid chromatography/mass spectrometry. RESULTS Median ALT 20 hours after the initiation of acetylcysteine was 12 U/L (IQR 8,14) in the abbreviated 12-hour regimen group (N = 8), compared with the control group 16 U/L (IQR 11,21; N = 21) (p = 0.46). Adduct concentrations were similarly low in both groups: abbreviated [(0.005 μmol/L, IQR (0,0.14)] and control [(0.005 μmol/L, IQR (0,0.05)] (p = 0.61). CONCLUSIONS There were minimal to no acetaminophen protein adducts detected. These findings further support discontinuing acetylcysteine when acetaminophen concentrations are low and liver function tests normal after 12 hours of treatment.
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Affiliation(s)
- Anselm Wong
- School of Clinical Sciences, Department of Medicine, Monash University, Melbourne, Victoria, Australia. .,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia. .,Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Victoria, 3084, Australia.
| | - Kennon Heard
- Rocky Mountain Poison and Drug Center, Denver Health and Hospitals, Denver, CO, USA.,Section of Medical Pharmacology and Toxicology, Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Andis Graudins
- School of Clinical Sciences, Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Toxicology Service, Monash Health, School of Clinical Sciences, Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Marco L A Sivilotti
- Departments of Emergency Medicine, and of Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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Li YK, Lam KF, Wong CLW, Wong A. In vitro study of pharmacobezoar formation in simulated acetaminophen overdose. Clin Toxicol (Phila) 2019; 58:900-906. [PMID: 31875726 DOI: 10.1080/15563650.2019.1705971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: There have been few studies of pharmacobezoar formation, but they can be an important contributor to overdose toxicity. Pharmacobezoars may explain the delayed peak or "double hump" pharmacokinetics, which were noted in previous case reports with delayed toxicity of acetaminophen (APAP). We validated the presence of APAP bezoar formation in a controlled modified in vitro environment simulating acute APAP overdose.Methods: This study involved the APAP and control groups (ferrous sulfate and chlorpheniramine). The APAP study group contained three subgroups of APAP with different dosage, i.e., 25 g (50 tabs)/37.5 g (75 tabs)/50 g (100 tabs). The positive control group containing ferrous sulfate, i.e., 15 g (50 tabs), has been reported previously to form pharmacobezoars in overdose. The negative control group containing chlorpheniramine, i.e., 200 mg (50 tabs), has not been reported to form pharmacobezoars in previous case studies. Tablets from each study group were placed into a separate pig stomach. Each stomach contained 28 ml USP standard simulated gastric acid. The stomach was placed in a plastic box filled with water maintaining at 37 °C. Each test group was examined for 4 h in the stomach. The primary outcome was the presence of clump formation. Positive clump formation was defined as tablets sticking together and the ability to maintain shape upon dissecting the pig stomach and lifting with fingers. Tablet clumps would then undergo dissolution testing with subsequent analysis of dissolution profiles.Results: Formation of tablets clumps was confirmed in APAP overdose in the in vitro environment. Clumps were noted to be present in the 37.5 g and 50 g APAP groups, while 25 g APAP was unlikely to form clumps. The dissolution profile of clump demonstrated slower release without reaching plateau at 60 min, as compared to corresponding individual tabs of APAP. f1 and f2 analyses showed the dissolution profile of clump was different compared to that of referenced individual tab.Conclusions: APAP clump formation was confirmed in acute overdose of 37.5 g or more. Dissolution tests revealed delayed and steady release of tablet residue from the clumps, which could explain prolonged or delayed toxicity in large APAP overdose.
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Affiliation(s)
- Yu Kwan Li
- Accident and Emergency Department, Princess Margaret Hospital, Hong Kong, Hong Kong SAR
| | - Ka Fung Lam
- Accident and Emergency Department, Princess Margaret Hospital, Hong Kong, Hong Kong SAR
| | | | - Anselm Wong
- Department of Emergency Medicine, Victorian Poisons Information Centre, Austin Toxicology Service, Austin Health, Melbourne, Australia.,Department of Medicine and Radiology, Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Chiew AL, Reith D, Pomerleau A, Wong A, Isoardi KZ, Soderstrom J, Buckley NA. Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand. Med J Aust 2019; 212:175-183. [DOI: 10.5694/mja2.50428] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Angela L Chiew
- Prince of Wales Hospital and Community Health Services Sydney NSW
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
| | | | | | - Anselm Wong
- Victorian Poisons Information CentreAustin Hospital Melbourne VIC
- Monash HealthMonash University Melbourne VIC
| | - Katherine Z Isoardi
- Princess Alexandra Hospital Brisbane QLD
- Queensland Poisons Information CentreQueensland Children's Hospital Brisbane QLD
| | - Jessamine Soderstrom
- Royal Perth Hospital Perth WA
- Western Australia Poisons Information CentreSir Charles Gairdner Hospital Perth WA
| | - Nicholas A Buckley
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
- University of Sydney Sydney NSW
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview. Biomarkers 2019; 25:9-19. [PMID: 31735069 DOI: 10.1080/1354750x.2019.1694994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute intoxications account for a significant proportion of the patient population in intensive care units and sedative medications, ethanol, illicit drugs, inhalable poisons and mixed intoxications are the most common causes. The aim of this article is to describe biomarkers for screening and diagnosis of acute intoxications in critically ill patients. For this purpose, a survey of the relevant literature was conducted, and guidelines, case reports, expert assessments, and scientific publications were reviewed. In critical care, it should always be attempted to identify and quantify the poison or toxin with the assistance of enzyme immunoassay (EIA), chromatography, and mass spectrometry techniques and this section is critically appraised in this publication. The principles for anion gap, osmol gap and lactate gap and their usage in intoxications is shown. Basic rules in test methodology and pre-analytics are reviewed. Biomarkers in general are presented in part one and biomarkers for specific intoxications including ethanol, paracetamol, cardiovascular drugs and many others are presented in part two of these publications.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Abstract
Acute liver failure is a rare and severe consequence of abrupt hepatocyte injury, and can evolve over days or weeks to a lethal outcome. A variety of insults to liver cells result in a consistent pattern of rapid-onset elevation of aminotransferases, altered mentation, and disturbed coagulation. The absence of existing liver disease distinguishes acute liver failure from decompensated cirrhosis or acute-on-chronic liver failure. Causes of acute liver failure include paracetamol toxicity, hepatic ischaemia, viral and autoimmune hepatitis, and drug-induced liver injury from prescription drugs, and herbal and dietary supplements. Diagnosis requires careful review of medications taken, and serological testing for possible viral exposure. Because of its rarity, acute liver failure has not been studied in large, randomised trials, and most treatment recommendations represent expert opinion. Improvements in management have resulted in lower mortality, although liver transplantation, used in nearly 30% of patients with acute liver failure, still provides a life-saving alternative to medical management.
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Affiliation(s)
- R Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- Digestive and Liver Diseases Division, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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Reale SC, Gray KJ, Boyer EW, Arce DY, Farber MK. Toxic Ingestion of Acetaminophen and Acetylsalicylic Acid in a Parturient at 33 Weeks Gestation: A Case Report. A A Pract 2019; 12:302-304. [PMID: 30312176 DOI: 10.1213/xaa.0000000000000915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The anesthetic management of toxic ingestion during pregnancy requires concomitant concerns for both mother and fetus. We describe the management of a parturient at 33 weeks of gestation after a suicide attempt by ingestion of acetaminophen (APAP) and acetylsalicylic acid (ASA). Timing of toxin ingestion must be determined, prompt antidote administration prioritized, and hepatotoxicity-induced hematologic impairment anticipated. Fetal exposure to toxins must also be minimized. The use of point-of-care rotational thromboelastometry in conjunction with standard coagulation testing in such cases facilitates consideration of neuraxial anesthesia and determination of risk for postpartum hemorrhage.
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Affiliation(s)
- Sharon C Reale
- Department of Anesthesiology, Perioperative and Pain Medicine
| | | | - Edward W Boyer
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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