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Tajirika S, Yamamoto M, Matsushita T, Yamada T, Shimizu M. Acetaminophen-induced liver injury at therapeutic doses in a young adult: a case report. Clin J Gastroenterol 2024; 17:130-136. [PMID: 37964179 DOI: 10.1007/s12328-023-01883-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/18/2023] [Indexed: 11/16/2023]
Abstract
Acetaminophen causes volume-dependent hepatotoxicity; however, hepatotoxicity may also occur with acetaminophen administered at normal doses. We encountered a case of allergic liver damage in a 17-year-old girl receiving acetaminophen at a regular dose. The patient was diagnosed using the Roussel Uclaf Causality Assessment Method (RUCAM) and the diagnostic scale of the Digestive Disease Week Japan 2004 workshop. She tested positive for acetaminophen on a drug-induced lymphocyte stimulation test, and liver biopsy results confirmed the diagnosis of acetaminophen-induced liver injury. Despite administering acetaminophen at normal doses, hepatotoxicity may occur, which warrants further exploration.
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Affiliation(s)
- Satoko Tajirika
- Health Administration Center, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1193, Japan.
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, 501-1194, Japan.
| | - Mayumi Yamamoto
- Health Administration Center, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1193, Japan
- United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University, Gifu, 501-1194, Japan
| | - Tomomichi Matsushita
- Department of Gastroenterology, Japanese Red Cross Gifu Hospital, Gifu, 502-8511, Japan
| | - Tetsuya Yamada
- Department of Pathology, Central Japan International Medical Center, Gifu, 505-8510, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, 501-1194, Japan
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2
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Naume MM, Zhao Q, Haslund-Krog SS, Krag T, Winter BCMD, Revsbech KL, Vissing J, Holst H, Møller MH, Hornsyld TM, Dunø M, Hoei-Hansen CE, Born AP, Bo Jensen P, Cathrine Ørngreen M. Acetaminophen treatment in children and adults with spinal muscular atrophy: a lower tolerance and higher risk of hepatotoxicity. Neuromuscul Disord 2024; 34:9-18. [PMID: 38052667 DOI: 10.1016/j.nmd.2023.11.005] [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: 09/26/2023] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 12/07/2023]
Abstract
Acute liver failure has been reported sporadically in patients with spinal muscular atrophy (SMA) and other neuromuscular disorders with low skeletal muscle mass receiving recommended dosages of acetaminophen. It is suggested that low skeletal muscle mass may add to the risk of toxicity. We aimed to describe the pharmacokinetics and safety of acetaminophen in patients with SMA. We analyzed acetaminophen metabolites and liver biomarkers in plasma from SMA patients and healthy controls (HC) every hour for six or eight hours on day 1 and day 3 of treatment with therapeutic doses of acetaminophen. Twelve patients with SMA (six adults and six children) and 11 HC participated in the study. Adult patients with SMA had significantly lower clearance of acetaminophen compared to HC (14.1 L/h vs. 21.5 L/h). Formation clearance of acetaminophen metabolites, glucuronide, sulfate, and oxidative metabolites were two-fold lower in the patients compared to HC. The liver transaminases and microRNAs increased nine-fold in one adult SMA patient after two days of treatment. The other patients and HC did not develop abnormal liver biomarkers. In this study, patients with SMA had lower clearance and slower metabolism of acetaminophen, and one patient developed liver involvement. We recommend giving 15 mg/kg/dose to SMA adults (with a maximum of 4000 mg/day) and monitoring standard liver biomarkers 48 h after first-time treatment of acetaminophen.
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Affiliation(s)
- Marie Mostue Naume
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark.
| | - Qiaolin Zhao
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands; Rotterdam Clinical Pharmacometrics Group, the Netherlands
| | | | - Thomas Krag
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands; Rotterdam Clinical Pharmacometrics Group, the Netherlands
| | - Karoline Lolk Revsbech
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John Vissing
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - Helle Holst
- Rare disease and advance therapies, Novo Nordisk, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - Tessa Munkeboe Hornsyld
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten Dunø
- Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christina Engel Hoei-Hansen
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark; Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Alfred Peter Born
- Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Bo Jensen
- Department of Clinical Biochemistry, Bispebjerg Hospital, Copenhagen, Denmark
| | - Mette Cathrine Ørngreen
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Abstract
Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.
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4
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Lao YE, Molden E, Kringen MK, Annexstad EJ, Saeverud HA, Jacobsen D, Hovda KE. Fatal liver failure after therapeutic doses of paracetamol in a patient with Duchenne muscular dystrophy and atypical pharmacogenetic profile of drug-metabolizing enzymes. Basic Clin Pharmacol Toxicol 2020; 127:47-51. [PMID: 31977139 DOI: 10.1111/bcpt.13389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 12/14/2022]
Abstract
Paracetamol has a good safety profile, but pharmacogenetic differences in drug-metabolizing enzymes may have an impact on its risk of hepatotoxicity. We present a case of fatal acute liver failure (ALF) after therapeutic doses of paracetamol in a patient with Duchenne muscular dystrophy, where pharmacogenetic screening was conducted. This 30-year-old man was electively admitted for a tracheostomy. A total of 14.5 g paracetamol was given over four days. He developed a severe ALF and died 11 days after admission. Pharmacogenetic screening showed absent CYP2D6 metabolism and increased CYP1A2 activity, which may have increased the formation of toxic intermediate metabolite, N-acetyl-p-benzo-quinone imine (NAPQI). He also had decreased function of UGT2B15, which increases the amount of paracetamol available for metabolism to NAPQI. Having a reduced muscle mass and thus a reduced glutathione levels to detoxify produced NAPQI may add to the risk of toxicity. This case may indicate that pharmacogenetic variability is of potential relevance for the risk of paracetamol-induced hepatotoxicity in patients with neuromuscular diseases. Further studies should investigate if pharmacogenetic screening could be a tool to detect potentially increased risk of hepatotoxicity in these patients at therapeutic doses of paracetamol and hence provide information for selection of analgesic treatment.
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Affiliation(s)
- Yvonne Elisabeth Lao
- Norwegian National Unit for CBRNE Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Marianne Kristiansen Kringen
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Ellen Johanne Annexstad
- Department of Neurology, Unit for Congenital and Inherited Neuromuscular Disorders, Oslo University Hospital, Oslo, Norway
| | | | - Dag Jacobsen
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Erik Hovda
- Norwegian National Unit for CBRNE Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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5
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Severe Acute Liver Injury Following Therapeutic Doses of Acetaminophen in a Patient With Spinal Muscular Atrophy. Am J Ther 2019; 26:e528-e529. [PMID: 30212380 DOI: 10.1097/mjt.0000000000000829] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Achterbergh R, Lammers LA, Kuijsten L, Klümpen HJ, Mathôt RAA, Romijn JA. Effects of nutritional status on acetaminophen measurement and exposure. Clin Toxicol (Phila) 2018; 57:42-49. [DOI: 10.1080/15563650.2018.1487563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- R. Achterbergh
- Departments of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L. A. Lammers
- Hospital Pharmacy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L. Kuijsten
- Hospital Pharmacy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - H. J. Klümpen
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - R. A. A. Mathôt
- Hospital Pharmacy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J. A. Romijn
- Departments of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
Current treatments for postsurgical pain are often inadequate and adverse effects are substantial such that residual pain and/or side effects impair recovery. The recognition of analgesic efficacy with antidepressant drugs for chronic pain suggests the potential for efficacy in acute postsurgical pain. As reviewed here, current evidence suggests that approximately half of previous trials suggest efficacy of various antidepressants for acute postoperative pain. However, most trials are older with deficiencies including: lack of designation of a primary outcome, no assessment of movement-evoked pain, small size and limited safety assessment. Only one of three trials addressing prevention of chronic postsurgical pain suggested any efficacy; however, the evidence base for this indication is limited. Thus, current evidence does not yet support routine use of any one specific antidepressant for treatment of acute, or prevention of chronic, postsurgical pain. However, limitations in available trials are such that one cannot yet rule out the possibility that one or more antidepressant drugs may provide benefit in specific populations. Therefore, future larger trials should explore optimal dosing and duration of antidepressant treatment, procedure specificity, safety evaluation, and assessment of movement-evoked pain.
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9
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Toxicity from repeated doses of acetaminophen in children: assessment of causality and dose in reported cases. Am J Ther 2014; 21:174-83. [PMID: 22407198 DOI: 10.1097/mjt.0b013e3182459c53] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Liver injury has been reported in children treated with repeated doses of acetaminophen. The objective of this study was to identify and validate reports of liver injury or death in children younger than 6 years who were administered repeated therapeutic doses of acetaminophen. We reviewed US Poison Center data, peer-reviewed literature, US Food and Drug Administration Adverse Event Reports, and US Manufacturer Safety Reports describing adverse effects after acetaminophen administration. Reports that described hepatic abnormalities (description of liver injury or abnormal laboratory testing) or death after acetaminophen administration to children younger than 6 years were included. The identified reports were double abstracted and then reviewed by an expert panel to determine if the hepatic injury was related to acetaminophen and whether the dose of acetaminophen was therapeutic (≤75 mg/kg) or supratherapeutic. Our search yielded 2531 reports of adverse events associated with acetaminophen use. From these cases, we identified 76 cases of hepatic injury and 26 deaths associated with repeated acetaminophen administration. There were 6 cases of hepatic abnormalities and no deaths associated with what our panel determined to be therapeutic doses. A large proportion of cases could not be fully evaluated due to incomplete case reporting. Although we identified numerous examples of liver injury and death after repeated doses of acetaminophen, all the deaths and all but 6 cases of hepatic abnormalities involved doses more than 75 mg/kg per day. This study suggests that the doses of less than 75 mg/kg per day of acetaminophen are safe for children younger than 6 years.
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Antidepressant drugs for prevention of acute and chronic postsurgical pain: early evidence and recommended future directions. Anesthesiology 2014; 121:591-608. [PMID: 25222675 DOI: 10.1097/aln.0000000000000307] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND This review evaluates trials of antidepressants for acute and chronic postsurgical pain. METHODS Trials were systematically identified using predefined inclusion and exclusion criteria. Extracted data included the following: pain at rest and with movement, adverse effects, and other outcomes. RESULTS Fifteen studies (985 participants) of early postoperative pain evaluated amitriptyline (three trials), bicifadine (two trials), desipramine (three trials), duloxetine (one trial), fluoxetine (one trial), fluradoline (one trial), tryptophan (four trials), and venlafaxine (one trial). Three studies (565 participants) of chronic postoperative pain prevention evaluated duloxetine (one trial), escitalopram (one trial), and venlafaxine (one trial). Heterogeneity because of differences in drug, dosing regimen, outcomes, and/or surgical procedure precluded any meta-analyses. Superiority to placebo was reported in 8 of 15 trials for early pain reduction and 1 of 3 trials for chronic pain reduction. The majority of positive trials did not report sufficient data to estimate treatment effect sizes. Many studies had inadequate size, safety evaluation/reporting, procedure specificity, and movement-evoked pain assessment. CONCLUSIONS There is currently insufficient evidence to support the clinical use of antidepressants-beyond controlled investigations-for treatment of acute, or prevention of chronic, postoperative pain. Multiple positive trials suggest the therapeutic potential of antidepressants, which need to be replicated. Other nontrial evidence suggests potential safety concerns of perioperative antidepressant use. Future studies are needed to better define the risk-benefit ratio of antidepressants in postoperative pain management. Higher-quality trials should optimize dosing, timing and duration of antidepressant treatment, trial size, patient selection, safety evaluation and reporting, procedure specificity, and assessment of movement-evoked pain relevant to postoperative functional recovery.
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11
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Shimizu D, Ishitsuka Y, Miyata K, Tomishima Y, Kondo Y, Irikura M, Iwawaki T, Oike Y, Irie T. Protection afforded by pre- or post-treatment with 4-phenylbutyrate against liver injury induced by acetaminophen overdose in mice. Pharmacol Res 2014; 87:26-41. [PMID: 24951965 DOI: 10.1016/j.phrs.2014.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/06/2014] [Accepted: 06/06/2014] [Indexed: 12/23/2022]
Abstract
Acetaminophen (paracetamol, N-acetyl-p-aminophenol; APAP) is a widely used analgesic/antipyretic drug with few adverse effects at therapeutic doses; suicidal or unintentional overdose of APAP frequently induces severe hepatotoxicity. To explore a new and effective antidote for APAP hepatotoxicity, this study examined the effects of sodium 4-phenylbutyrate (4-PBA) on liver injury induced by APAP overdose in mice. Liver injury was induced in C57BL/6 male mice by intraperitoneal injection of APAP (400mg/kg). The effects of 4-PBA (100-200mg/kg) treatment at 1h before the APAP injection were evaluated with serum alanine aminotransferase (ALT) and blood ammonia levels, hepatic pathological changes, including histopathology, DNA damage, nitrotyrosine formation, and mRNA or protein expression involved in the development of hepatotoxicity, such as X-box binding protein-1 (XBP1), c-Jun N-terminal kinase (JNK), C/EBP homologous protein (CHOP) and B-cell lymphoma 2 interacting mediator of cell death (Bim). In addition, glutathione depletion and CYP2E1 protein expression, which are measures of the metabolic conversion of APAP to a toxic metabolite, were examined. Furthermore, we examined the effects of post-treatment with 4-PBA against APAP-induced hepatotoxicity in mice. When administered at 1h before APAP injection, 4-PBA significantly prevented the increase in serum ALT and blood ammonia levels, centrilobular necrosis of hepatocytes, DNA fragmentation, and nitrotyrosine formation induced by APAP in mice. 4-PBA also inhibited hepatic Xbp1 mRNA splicing and JNK phosphorylation induced by APAP, but did not suppress CHOP and Bim mRNA and protein expression. In addition, 4-PBA had little effect on hepatic glutathione depletion and CYP2E1 expression, parameters of toxic APAP metabolite production. Post-treatment with 4-PBA administration at 1 or 2h after APAP injection also attenuated the increase in serum ALT and blood ammonia levels and hepatic pathological changes in APAP-induced hepatotoxicity in mice. Although post-treatment with 4-PBA did not show any effects on hepatic Xbp1 mRNA splicing and JNK phosphorylation, it drastically attenuated the DNA fragmentation induced by APAP. The precise molecular mechanisms of the protection afforded by 4-PBA against APAP hepatotoxicity in mice are unclear, but they seem to involve inhibition of hepatocellular DNA fragmentation. We suggest that 4-PBA is a promising candidate as an antidote against APAP-induced liver injury.
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Affiliation(s)
- Daisuke Shimizu
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan.
| | - Keishi Miyata
- Department of Molecular Genetics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Yoshiro Tomishima
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
| | - Mitsuru Irikura
- Laboratory of Evidence-Based Pharmacotherapy, College of Pharmaceutical Sciences, Daiichi University, 22-1 Tamagawa-Cho, Minami-Ku, Fukuoka 815-8511, Japan
| | - Takao Iwawaki
- Iwawaki Lab, Advanced Scientific Research Leaders Development Unit, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuichi Oike
- Department of Molecular Genetics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Tetsumi Irie
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan; Center for Clinical Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto 862-0973, Japan
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12
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Abstract
Pediatric patients often undergo anesthesia for ambulatory procedures. This article discusses several common preoperative dilemmas, including whether to postpone anesthesia when a child has an upper respiratory infection, whether to test young women for pregnancy, which children require overnight admission for apnea monitoring, and the effectiveness of nonpharmacological techniques for reducing anxiety. Medication issues covered include the risks of anesthetic agents in children with undiagnosed weakness, the use of remifentanil for tracheal intubation, and perioperative dosing of rectal acetaminophen. The relative merits of caudal and dorsal penile nerve block for pain after circumcision are also discussed.
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Affiliation(s)
- David A August
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB-444, Boston, MA 02114, USA.
| | - Lucinda L Everett
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB-415, Boston, MA 02114, USA
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13
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Marzuillo P, Guarino S, Barbi E. Paracetamol: a focus for the general pediatrician. Eur J Pediatr 2014; 173:415-25. [PMID: 24374658 DOI: 10.1007/s00431-013-2239-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/05/2013] [Indexed: 02/02/2023]
Abstract
UNLABELLED Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever in children. This drug has multiple mechanisms of action, but its pharmacodynamic is still not well known. The central nervous system is the main site of action and it mirrors the paracetamol effect compartment. The recommended dosages and routes of administration should be different whether paracetamol is used for the treatment of pain or fever. For example, the rectal route, while being efficacious for the treatment of fever, should be avoided in pain management. Paracetamol is a safe drug, but some clinical conditions and concomitant drugs, which are frequent in clinical practice, may increase the risk of paracetamol toxicity. Therefore, it is important to optimize its administration to avoid overdoses and maximize its effect. The principal mediator of the paracetamol toxicity is the N-acetyl-p-benzo-quinone imine (NAPQI), a toxic product of the paracetamol metabolism, which could bind cysteine groups on proteins forming paracetamol-protein adduct in the liver. CONCLUSION Although frequently prescribed, the concept of "effect compartment concentration" and the possible co-factors that could cause toxicity at recommended doses are not familiar to all pediatricians and general practitioners. We reviewed the literature concerning paracetamol mechanisms of action, we highlighted some relevant pharmacodynamic concepts for clinical practice, and we summarized the possible risk factors for toxicity at therapeutic dosages.
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Affiliation(s)
- Pierluigi Marzuillo
- Department of Women and Children and General and Specialized Surgery, Seconda Università degli Studi di Napoli, Via L. De Crecchio 2, 80138, Naples, Italy,
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14
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Abstract
Paracetamol has become a focus of attention as being unsafe due to hepatic toxicity and market withdrawal or prescription status is presently under discussion in Germany. This drug is, however, effective and safe if notes of caution are applied. In Germany 38 fatal cases of analgesic poisoning were observed in 2010, only 4 of which were due to paracetamol and 16 were caused by diclofenac and ibuprofen. Alternative pain medications are obviously much less safe, in particular given the additional risk of sometimes fatal gastrointestinal bleeding and cardiovascular side effects. This review extensively analyzes the safety record of paracetamol and applies these findings to the treatment of elderly people. Even very elderly patients may be safely treated with this compound, although a dose limit of 3 g/day should be instituted. This renewed discussion was triggered by the uncontrolled availability of paracetamol in the USA but observations from this country should not be generalized and applied to the German situation and objective reasoning should be re-installed.
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Affiliation(s)
- M Wehling
- Klinische Pharmakologie Mannheim, Zentrum für Gerontopharmakologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Maybachstr. 14, 68169, Mannheim, Deutschland.
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15
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Kalsi SS, Dargan PI, Waring WS, Wood DM. A review of the evidence concerning hepatic glutathione depletion and susceptibility to hepatotoxicity after paracetamol overdose. Open Access Emerg Med 2011; 3:87-96. [PMID: 27147856 PMCID: PMC4753970 DOI: 10.2147/oaem.s24963] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Indexed: 01/10/2023] Open
Abstract
Paracetamol (acetaminophen) poisoning is common throughout the world. The management of nonstaggered (acute) paracetamol overdose is based on the plasma paracetamol concentration plotted on a treatment nomogram. In the UK there are two treatment lines on this nomogram, with the lower treatment line used for individuals felt to be at ‘high risk’ of paracetamol-related hepatotoxicity either as a result of induction of cytochrome P450 isoenzymes or reduction of intrahepatic glutathione. In this article we review the risk factors that, in current guidelines, are felt to increase risk due to a reduction in intrahepatic glutathione concentrations. Based on our review of the published literature, we feel that cystic fibrosis, acute viral illness, malnutrition, and eating disorders such as anorexia nervosa are likely to be associated with reduction in intrahepatic glutathione concentrations, and that this risk is likely to be related to malnutrition secondary to the disease. Chronic hepatitis C infection is also associated with reduced glutathione concentrations, although this appears to be independent of any associated malnutrition. Ageing and acute fasting are not associated with an increased risk of paracetamol-related hepatotoxicity due to reductions in glutathione concentrations. Finally, the evidence for HIV infection is inconclusive, particularly as the majority of studies were conducted in the pre-anti-viral treatment (HAART) era; however it is likely that patients with symptomatic HIV/AIDS have reduced glutathione concentrations due to associated malnutrition. Although there have been few studies which have specifically investigated whether there is an association between reduced intrahepatic glutathione concentrations and increased risk of paracetamol-related hepatotoxicity, in our opinion, it is likely that the above conditions that are associated with reduced glutathione concentrations, will be associated with an increased risk of paracetamol-related hepatotoxicity.
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Affiliation(s)
- Sarbjeet S Kalsi
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK;; Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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