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Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 2021; 59:1196-1227. [PMID: 34424785 DOI: 10.1080/15563650.2021.1961144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations. OBJECTIVES The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal? Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal. METHODS A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations. One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study. RESULTS From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals. CONCLUSIONS This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death. Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.
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Affiliation(s)
- Lotte C G Hoegberg
- Department of Anesthesiology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Silas W Smith
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, California
| | - Sophie Gosselin
- Emergency Department CISSS Montérégie Centre, Greenfield Park, Canada.,Centre antipoison du Québec, Québec, Canada.,Department of Emergency Medicine, McGill Faculty of Medicine, Montreal, Canada
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de Souza JB, Okomo U, Alexander ND, Aziz N, Owens BMJ, Kaur H, Jasseh M, Muangnoicharoen S, Sumariwalla PF, Warhurst DC, Ward SA, Conway DJ, Ulloa L, Tracey KJ, Foxwell BMJ, Kaye PM, Walther M. Oral activated charcoal prevents experimental cerebral malaria in mice and in a randomized controlled clinical trial in man did not interfere with the pharmacokinetics of parenteral artesunate. PLoS One 2010; 5:e9867. [PMID: 20419161 PMCID: PMC2855344 DOI: 10.1371/journal.pone.0009867] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 02/17/2010] [Indexed: 11/18/2022] Open
Abstract
Background Safe, cheap and effective adjunct therapies preventing the development of, or reducing the mortality from, severe malaria could have considerable and rapid public health impact. Oral activated charcoal (oAC) is a safe and well tolerated treatment for acute poisoning, more recently shown to have significant immunomodulatory effects in man. In preparation for possible efficacy trials in human malaria, we sought to determine whether oAC would i) reduce mortality due to experimental cerebral malaria (ECM) in mice, ii) modulate immune and inflammatory responses associated with ECM, and iii) affect the pharmacokinetics of parenteral artesunate in human volunteers. Methods/Principal Findings We found that oAC provided significant protection against P. berghei ANKA-induced ECM, increasing overall survival time compared to untreated mice (p<0.0001; hazard ratio 16.4; 95% CI 6.73 to 40.1). Protection from ECM by oAC was associated with reduced numbers of splenic TNF+ CD4+ T cells and multifunctional IFNγ+TNF+ CD4+ and CD8+ T cells. Furthermore, we identified a whole blood gene expression signature (68 genes) associated with protection from ECM. To evaluate whether oAC might affect current best available anti-malarial treatment, we conducted a randomized controlled open label trial in 52 human volunteers (ISRCTN NR. 64793756), administering artesunate (AS) in the presence or absence of oAC. We demonstrated that co-administration of oAC was safe and well-tolerated. In the 26 subjects further analyzed, we found no interference with the pharmacokinetics of parenteral AS or its pharmacologically active metabolite dihydroartemisinin. Conclusions/Significance oAC protects against ECM in mice, and does not interfere with the pharmacokinetics of parenteral artesunate. If future studies succeed in establishing the efficacy of oAC in human malaria, then the characteristics of being inexpensive, well-tolerated at high doses and requiring no sophisticated storage would make oAC a relevant candidate for adjunct therapy to reduce mortality from severe malaria, or for immediate treatment of suspected severe malaria in a rural setting. Trial Registration Controlled-Trials.com ISRCTN64793756
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Affiliation(s)
- J. Brian de Souza
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Division of Infection and Immunity, Department of Immunology, University College London, London, United Kingdom
| | - Uduak Okomo
- Medical Research Council Laboratories, Fajara, Banjul, The Gambia
| | - Neal D. Alexander
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Naveed Aziz
- The Technology Facility, Department of Biology, University of York, York, United Kingdom
| | - Benjamin M. J. Owens
- Centre for Immunology and Infection, Hull York Medical School and Department of Biology, University of York, York, United Kingdom
| | - Harparkash Kaur
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Momodou Jasseh
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Percy F. Sumariwalla
- Kennedy Institute of Rheumatology, Imperial College of Science, London, United Kingdom
| | - David C. Warhurst
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen A. Ward
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - David J. Conway
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Medical Research Council Laboratories, Fajara, Banjul, The Gambia
| | - Luis Ulloa
- Center of Immunology and Inflammation, North Shore-LIJ Research Institute, New York, New York, United States of America
| | - Kevin J. Tracey
- Center of Immunology and Inflammation, North Shore-LIJ Research Institute, New York, New York, United States of America
| | - Brian M. J. Foxwell
- Kennedy Institute of Rheumatology, Imperial College of Science, London, United Kingdom
| | - Paul M. Kaye
- Centre for Immunology and Infection, Hull York Medical School and Department of Biology, University of York, York, United Kingdom
- * E-mail: (PMK); (MW)
| | - Michael Walther
- Medical Research Council Laboratories, Fajara, Banjul, The Gambia
- * E-mail: (PMK); (MW)
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Walton K, Dorne JLCM, Renwick AG. Species-specific uncertainty factors for compounds eliminated principally by renal excretion in humans. Food Chem Toxicol 2004; 42:261-74. [PMID: 14667472 DOI: 10.1016/j.fct.2003.09.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An uncertainty factor of 100 is used to derive health-based guidance values for human intakes of chemicals based on data from studies in animals. The 100-fold factor comprises 10-fold factors for species differences and for interindividual differences in response. Each 10-fold factor can be subdivided into toxicokinetic and toxicodynamic aspects with a 4.0-fold factor to allow for kinetic differences between test species and humans. The current work determined the extent of interspecies differences in the internal dose (toxicokinetics) of compounds which are eliminated primarily by renal excretion in humans. An analysis of the published data showed that renal excretion was also the main route of elimination in the test species for most of the identified probe substrates. Interspecies differences were apparent for both the mechanism of renal excretion (glomerular filtration, tubular secretion and/or reabsorption) and the extent of plasma protein binding, both of which may affect renal clearance and therefore the magnitude of species differences in the internal dose. For compounds which are eliminated unchanged by both humans and the test species, the average differences in the internal doses between humans and animals were 1.6 for dogs, 3.3 for rabbits, 5.2 for rats and 13 for mice. This suggests that for renal excretion, the differences between humans and the rat and especially the mouse may exceed the 4.0-fold default factor for toxicokinetics.
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Affiliation(s)
- K Walton
- Clinical Pharmacology Group, University of Southampton, Biomedical Sciences Building, Bassett Crescent East, SO16 7PX Southampton, UK
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Chyka PA, Holley JE, Mandrell TD, Sugathan P. Correlation of drug pharmacokinetics and effectiveness of multiple-dose activated charcoal therapy. Ann Emerg Med 1995; 25:356-62. [PMID: 7864477 DOI: 10.1016/s0196-0644(95)70295-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVE To evaluate an animal model of multiple-dose activated charcoal (MDAC) therapy and correlate the pharmacokinetic properties of four drugs with the efficacy of MDAC. DESIGN Prospective, randomized, controlled, crossover design. SETTING A university animal research facility. PARTICIPANTS Seven female pigs (15 to 22 kg) with an indwelling central venous line and gastrostomy tube. INTERVENTIONS Acetaminophen (30 mg/kg), digoxin (30 micrograms/kg), theophylline (8.9 mg/kg), and valproic acid (18 mg/kg) were simultaneously administered intravenously over 12 minutes. In the experimental arm, 25 g activated charcoal was administered at 0, 2, 4, 6, 12, 18, 24, and 30 hours through the gastric tube. In the control arm, an equal volume of water was given at the same times. Blood specimens were obtained over 36 hours to measure serum drug concentrations. RESULTS Each drug exhibited enhanced elimination (P < .01) in the MDAC group except valproic acid. Lower intrinsic clearance was correlated (P < .05) with increased systemic elimination during the charcoal arm. Volume of distribution, half-life, and protein binding were not significantly correlated with charcoal-enhanced systemic drug elimination. CONCLUSION The response of a drug to MDAC may be affected by its intrinsic clearance. The restrictive nature of the protein binding of valproic acid may be responsible for its lack of response. Results with the porcine model are consistent with the effects observed in human beings.
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Affiliation(s)
- P A Chyka
- Department of Clinical Pharmacy, University of Tennessee, Memphis
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Chyka PA. Multiple-dose activated charcoal and enhancement of systemic drug clearance: summary of studies in animals and human volunteers. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1995; 33:399-405. [PMID: 7650764 DOI: 10.3109/15563659509013748] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Multiple-dose activated charcoal therapy can enhance the systemic elimination of many drugs. Studies in animals and human volunteers provide a framework for understanding the indications and limitations of multiple-dose activated charcoal therapy. Enterocapillary exsorption creates a compartment for diffusion drugs out of the bloodstream and activated charcoal can augment this process to enhance drug clearance. Once charcoal reaches the intestine, there is a rapid onset of action. Clearance at exsorption sites is limited by blood flow; moreover, the rate of exsorption is related to the dose of charcoal up to a ceiling dose. Drug absorption, distribution, metabolism and elimination dynamically interact with multiple-dose activated charcoal therapy making it difficult to identify a single variable that may predict the success or failure with this therapy. Drug characteristics associated with enhanced systemic clearance with multiple-dose activated charcoal include a low intrinsic clearance, presence in the body for a sufficient time period for charcoal to act, a prolonged distributive phase, non-restrictive protein binding, and a small volume of distribution. Drugs that are unaffected at low doses may respond to multiple doses of activated charcoal when nonlinear kinetics are apparent due to overdose or disease. Although our current understanding is incomplete, multiple-dose activated charcoal therapy will play a role in the future therapy of poisoning patients.
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Affiliation(s)
- P A Chyka
- University of Tennessee, Memphis, USA
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Rawashdeh NM, al-Hadidi HF, Irshaid YM, Battah AK. Gastrointestinal dialysis of digoxin using cholestyramine. PHARMACOLOGY & TOXICOLOGY 1993; 72:245-8. [PMID: 8372041 DOI: 10.1111/j.1600-0773.1993.tb01644.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The pharmacokinetic parameters of digoxin given intravenously (0.075 mg/kg) alone and following treatment with oral cholestyramine (8 gm in 50 ml water) were studied in rabbits. Pretreatment with cholestyramine produced a significant decrease in the serum concentration of digoxin and significantly enhances its systemic clearance as indicated by a statistically significant decrease in the area under the concentration-time curve (AUC), half time of elimination (t 1/2), and mean residence time (MRT). These findings indicate that the idea of gastrointestinal dialysis, known with activated charcoal, could be extended to ion-exchange resins that could be a potentially useful adjunctive measure in the management of drug overdose especially with commonly used drugs with a low therapeutic index like digoxin.
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Affiliation(s)
- N M Rawashdeh
- Department of Pharmacology, Faculty of Medicine, University of Science & Technology, Irbid, Jordan
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al-Meshal MA, el-Sayed YM, al-Angary AA, al-Dardiri MM. Effect of oral activated charcoal on propranolol pharmacokinetics following intravenous administration to rabbits. J Clin Pharm Ther 1993; 18:39-44. [PMID: 8473358 DOI: 10.1111/j.1365-2710.1993.tb00564.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The pharmacokinetics of propranolol following intravenous administration (1 mg/kg), with and without treatment with oral activated charcoal, was investigated in rabbits. In charcoal-treated rabbits a significant reduction in propranolol serum concentrations was observed compared to control animals. Charcoal treatment significantly reduced the half-life of elimination (16.6%) and the mean residence time (19%) of propranolol. A 17% increase in the systemic clearance and a 14% decrease in AUC were also noted. Charcoal administration did not significantly alter the volume of distribution (Vc' V(area) and Vss) or the apparent distribution half-life. A two-compartment model adequately described propranolol in control and treated rabbits. The results indicate that administration of oral activated charcoal enhances the systemic elimination of propranolol. This is presumably mediated by interruption of the enterohepatic circulation of propranolol by activated charcoal.
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Affiliation(s)
- M A al-Meshal
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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el-Sayed YM, Hasan MM. Enhancement of morphine clearance following intravenous administration by oral activated charcoal in rabbits. J Pharm Pharmacol 1990; 42:538-41. [PMID: 1981579 DOI: 10.1111/j.2042-7158.1990.tb07054.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A single dose of activated charcoal (10 g) significantly reduced the half-life of elimination (1.02 +/- 0.10 and 0.70 +/- 0.04 h for the control and treated groups, respectively) and mean residence time (1.01 +/- 0.12 and 0.76 +/- 0.05 h for the control and treated groups, respectively) of morphine in rabbits. A 40% increase in the systemic clearance (85.73 +/- 7.72 and 122.64 +/- 16.32 mL min-1 kg-1 for the control and treated groups, respectively) and a 30% decrease in AUC (204.38 +/- 22.20 and 140.03 +/- 19.32 micrograms h L-1 in the control and treated groups, respectively) were also noted. Charcoal administration did not significantly alter the volume of distribution (Varea and Vss) or the apparent distribution half-life. A two-compartment model adequately described morphine kinetics in control and treated rabbits; charcoal administration produced a significant increase in the tissue compartment rate constant (K21). This finding indicates that activated charcoal not only enhances the systemic elimination of morphine, but also accelerates the rate of transfer of morphine from the tissue compartment to the central compartment.
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Affiliation(s)
- Y M el-Sayed
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid
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Hasan MM, Hassan MA, Rawashdeh NM. Effect of oral activated charcoal on the pharmacokinetics of quinidine and quinine administered intravenously to rabbits. PHARMACOLOGY & TOXICOLOGY 1990; 67:73-6. [PMID: 2395819 DOI: 10.1111/j.1600-0773.1990.tb00785.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The pharmacokinetics of quinidine and quinine following intravenous administration (10 mg/kg) with and without concurrent treatment with oral activated charcoal was studied in the rabbit. Marked differences were observed in the pharmacokinetic parameters. Compared to quinidine, quinine was characterized by larger volume of distribution (Vd), systemic clearance (Cl) and elimination rate constant (Kel), and smaller half-life of elimination (t1/2), mean residence time (MRT) and area under the curve (AUC). Activated charcoal administered orally (15 g) significantly decreased the serum concentrations of quinidine but not quinine. Furthermore, charcoal treatment significantly enhanced the systemic elimination of quinidine as indicated by the significant increase in Cl and decrease in t1/2, MRT and AUC. By contrast, activated charcoal had no significant effect on the pharmacokinetic parameters of quinine. Differences between quinidine and quinine in respect to the effect of activated charcoal on the systemic elimination of these drugs seem at least, in part, dependent on dispositional factors. The high Cl and Vd of quinine in the rabbit are probably factors that mask the effect of charcoal on the elimination of this drug.
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Affiliation(s)
- M M Hasan
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid
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