Consumer concerns about paracetamol: a retrospective analysis of a medicines call centre

Exploring public knowledge and perceptions regarding per os OTC pain-relieving medications: the case of paracetamol (acetaminophen)

BACKGROUND

Over-the-counter medications (OTC) are safe and effective when patients follow the patient's information leaflet (PIL) instructions and/or the instructions given by healthcare professionals (HCPs). However, OTC medications could be harmful and unsafe when individuals do not follow the given instructions and/or when their understanding about the proper use of OTC medications is incorrect. This study aimed to investigate the knowledge and perceptions of people regarding paracetamol use in the Republic of Cyprus.

METHODS

This cross-sectional study, which belongs to quantitative research methods, included participants visiting community pharmacies in the following three cities of the Republic of Cyprus: Nicosia, Limassol and Larnaca. Participation in the study was voluntary and anonymous. Participants responded to the survey-based questionnaire, which concerned their knowledge and views on paracetamol use. After the data collection, responses were tabulated and analysed statistically.

RESULTS

The original compound was shown to be more well-known compared to generics. A notable percentage of respondents-ranging between 13.0% (N = 49) and 29.8% (N = 112)-answered incorrectly that broadly used non-steroidal anti-inflammatory drugs (NSAIDs) contain paracetamol. Furthermore, a remarkable percentage of respondents (71.5%, N = 269 and 50.3%, N = 189, respectively) falsely believed that two widely used combination products in the market of Cyprus (Paracetamol and Hyoscine-N-butylbromide; Paracetamol and Codeine and Caffeine) did not contain paracetamol. A notable percentage of participants (27.6%, N = 100) believed that paracetamol causes low toxicity. More than a third of the respondents (40.2%, N = 149) drink alcohol together with or slightly after consuming paracetamol products. This viewpoint was linked with the participants' attitude towards consuming paracetamol medications after drinking alcohol (OR for consuming alcohol versus not consuming alcohol 0.100, 95% CI 0.044-0.225, p = 0.000).

CONCLUSIONS

To the best of our knowledge, this is the first study conducted in the Republic of Cyprus on this topic. Paracetamol is frequently consumed by individuals, both in its generic and original forms. However, the study showed that respondents often misperceive NSAIDs and paracetamol-containing medications. In addition, it is identified that there is a lack of education among people about the safe and effective use of paracetamol, namely, indications, potential side effects, maximum daily dose, alcohol consumption, and the potential risks of hepatotoxicity. The study contributed to the current published literature as it showed that there is a significant public health issue, for which appropriate measures can be established by the respective Authorities of Cyprus.

Exposure to acetaminophen impairs gametogenesis and fertility in zebrafish (Danio rerio)

Acetaminophen (ACE; paracetamol) is one of the most widely used nonsteroidal anti-inflammatory drugs worldwide and is often found in aquatic systems, where it can act on nontarget species and impair fish reproduction. This study aimed to investigate the effects of chronic exposure to environmentally relevant ACE concentrations (0.5, 5 and 50 µg/L) on multiple reproductive parameters in zebrafish (Danio rerio). Gametogenesis was analyzed using histology, morphometry, cell proliferation, and apoptosis. This study also evaluated sex steroids, and prostaglandin E₂ (PGE₂) levels, gene expression for sex steroids and PGE₂ receptors, fertilization rate, and semen quality. In females, exposure to 5 and 50 µg/L ACE induced larger and more abundant vitellogenic follicles and increased follicular atresia. In these treatments, males showed a lower proportion and proliferation of undifferentiated spermatogonia and a higher proportion of TUNEL-positive differentiated spermatogonia, spermatids, and spermatozoa, resulting in lower sperm production. ACE increased 17β-estradiol (E₂) and reduced 11-ketotestosterone levels in the testis, whereas only E₂ increased in the ovaries. In both sexes, gonadal PGE₂ levels were reduced. ACE at 50 µg/L induced an increase in the gene expression of androgen, estrogen, and PGE₂ receptors in the ovaries, and reduced expression in the testes. Results also showed lower egg production and fertilization rate from 28 days of exposure with reduced sperm quality. These results demonstrated that ACE impairs the reproductive performance of zebrafish, affecting multiple reproductive parameters, which may be caused by the synergistic action of the imbalance of sex steroids, with a reduction of PGE₂ and its receptors.

Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older

Acute pain is among the most common reasons that people consult primary care physicians, who must weigh benefits versus risks of analgesics use for each patient. Paracetamol (acetaminophen) is a first-choice analgesic for many adults with mild to moderate acute pain, is generally well tolerated at recommended doses (≤4 g/day) in healthy adults and may be preferable to non-steroidal anti-inflammatory drugs that are associated with undesirable gastrointestinal, renal, and cardiovascular effects. Although paracetamol is widely used, many patients and physicians still have questions about its suitability and dosing, especially for older people or adults with underlying comorbidities, for whom there are limited clinical data or evidence-based guidelines. Inappropriate use may increase the risks of both overdosing and inadequate analgesia. To address knowledge deficits and augment existing guidance in salient areas of uncertainty, we have researched, reviewed, and collated published evidence and expert opinion relevant to the acute use of paracetamol by adults with liver, kidney, or cardiovascular diseases, gastrointestinal disorders, asthma, or/and who are older. A concern is hepatotoxicity, but this is rare among adults who use paracetamol as directed, including people with cirrhotic liver disease. Putative epidemiologic associations of paracetamol use with kidney or cardiovascular disease, hypertension, gastrointestinal disorders, and asthma largely reflect confounding biases and are of doubtful relevance to short-term use (<14 days). Paracetamol is a suitable first-line analgesic for mild to moderate acute pain in many adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, and/or who are older. No evidence supports routine dose reduction for older people. Rather, dosing for adults who are older and/or have decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma that is known to be cross-sensitive to paracetamol, should be individualized in consultation with their physician, who may recommend a lower effective dose appropriate to the circumstances.

Assessment of Paracetamol Toxic Effects under Varying Seawater pH Conditions on the Marine Polychaete Hediste diversicolor Using Biochemical Endpoints

Simple Summary

Context of climate change is being widely studied, nevertheless its effects in the toxicity of other contaminants have been poorly study. Particularly, the effects of ocean acidification on the modulation of pharmaceutical absorption and consequent effects, have not been extensively addressed before. In this study, we aimed to assess the effects of ocean acidification (specifically pH values of 8.2, 7.9, and 7.6) combined with paracetamol exposure (0, 30, 60, and 120 µg/L) on the polychaeta Hediste diversicolor. To do so, specific biomarkers were measured namely (CAT), glutathione S-transferases (GSTs), acetylcholinesterase (AChE), and cyclooxygenase (COX) activities, as well as thiobarbituric acid reactive substance (TBARS), were quantified to serve as ecotoxicological endpoints. Alterations of CAT, and GSTs activities, and TBARS levels indicate an alteration in redox balances. Differences in exposed pH levels indicate the possible modulation of the absorption of this pharmaceutical in ocean acidifications scenarios. Alterations in AChE were only observed following paracetamol exposure, not being altered by media pH. Hereby obtained results suggest that seawater acidification is detrimental to marine wildlife, since it may enhance toxic effects caused by environmental realistic concentrations of pharmaceuticals. This work is crucial to understand the potential effects of pharmaceuticals in a climate change scenario.

Abstract

Increasing atmospheric carbon dioxide (CO₂) levels are likely to lower ocean pH values, after its dissolution in seawater. Additionally, pharmaceuticals drugs are environmental stressors due to their intrinsic properties and worldwide occurrence. It is thus of the utmost importance to assess the combined effects of pH decreases and pharmaceutical contamination, considering that their absorption (and effects) are likely to be strongly affected by changes in oceanic pH. To attain this goal, individuals of the marine polychaete Hediste diversicolor were exposed to distinct pH levels (8.2, 7.9, and 7.6) and environmentally relevant concentrations of the acidic drug paracetamol (PAR: 0, 30, 60, and 120 µg/L). Biomarkers such as catalase (CAT), glutathione S-transferases (GSTs), acetylcholinesterase (AChE), and cyclooxygenase (COX) activities, as well as peroxidative damage (through thiobarbituric acid reactive substance (TBARS) quantification), were quantified to serve as ecotoxicological endpoints. Data showed a general increase in CAT and a decrease in GST activities (with significant fluctuations according to the tested conditions of PAR and pH). These changes are likely to be associated with alterations of the redox cycle driven by PAR exposure. In addition, pH levels seemed to condition the toxicity caused by PAR, suggesting that the toxic effects of this drug were in some cases enhanced by more acidic conditions. An inhibition of AChE was observed in animals exposed to the highest concentration of PAR, regardless of the pH value. Moreover, no lipid peroxidation was observed in most individuals, although a significant increase in TBARS levels was observed for polychaetes exposed to the lowest pH. Finally, no alterations of COX activities were recorded on polychaetes exposed to PAR, regardless of the pH level. The obtained results suggest that seawater acidification is detrimental to marine wildlife, since it may enhance toxic effects caused by environmental realistic concentrations of acidic drugs, such as PAR. This work was crucial to evidence that ocean acidification, in the context of a global change scenario of increased levels of both atmospheric and oceanic CO₂, is a key factor in understanding the putative enhanced toxicity of most pharmaceutical drugs that are of an acidic nature.

An Initial Approach to the Presence of Pharmaceuticals in Wastewater from Hospitals in Colombia and Their Environmental Risk

Hospital wastewater (HWW) from three different cities in Colombia was characterized. Wastewater quality indicators and 38 relevant pharmaceuticals were examined. The HWW had pH from 6.82 to 8.06, chemical oxygen demand was between 235.5 and 1203 mg L−1, and conductivity ranged from 276.5 to 717.5 µS cm−1. Additionally, most of the target pharmaceuticals (20 of 38) had 100% occurrence frequency in the samples due to their high and continuous consumption in the hospitals. Indeed, acetaminophen, diclofenac, azithromycin, ciprofloxacin, sulfamethoxazole, losartan, metoprolol, and omeprazole were present in all samples at concentrations from one up to some hundreds of μg L−1. Once pharmaceuticals are discharged into local sewage systems or rivers, because of the high dilution of HWW, the individual environmental hazards are low (i.e., risk quotients, RQ < 0.1 were determined). The action of conventional treatments on HWW also decreased the individual environmental risks of pharmaceuticals (RQ values < 0.1). However, the mixture of pharmaceuticals in the HWW had potential environmental risks (as RQ > 0.1 were found), remarking the need for efficient processes to eliminate pharmaceuticals from HWW. This work provides an initial view on the characterization of diverse Colombian HWW, which could be useful for the understanding of the current situation of pollution by pharmaceuticals in Latin America.

Teratogenic effects induced by paracetamol, ciprofloxacin, and their mixture on Danio rerio embryos: Oxidative stress implications

Even though the toxic effects of paracetamol (PCM) and ciprofloxacin (CPX) have been deeply studied in the last decades, the impact of the PCM-CPX mixture may induce in aquatic organisms is poorly known. Thus, the objective of this work was to investigate the teratogenic effects and oxidative stress that PCM, CPX, and their mixture induce in Danio rerio embryos. Moreover, we aimed to determine whether the PCM-CPX mixture induces more severe effects on the embryos than the individual drugs. For this purpose, zebrafish embryos (4 hpf) were exposed to environmentally relevant concentrations of PCM, CPX, and their mixture until 96 hpf. In addition, at 72 hpf and 96 hpf, we also evaluated the oxidative stress biomarkers (superoxide dismutase, catalase, glutathione peroxidase, lipid peroxidation, and hydroperoxides and carbonyl content) in the embryos. Our results demonstrated that PCM, CPX, and their mixture reduced the survival rate of embryos by up to 75%. In addition, both drugs, induced morphological alterations in the embryos, causing their death. The most observed malformations were: scoliosis, craniofacial malformations, hypopigmentation, growth retardation, pericardial edema. Concerning oxidative stress, our integrated biomarkers response (IBR) analysis demonstrated that PCM, CPX, and their mixture induce oxidative damage on the embryos. In conclusion, PCM, CPX, and their mixture can alter zebrafish embryonic development via an oxidative stress response.

An assessment of parents' knowledge and awareness regarding paracetamol use in children: a cross-sectional study from Palestine

BACKGROUND

Paracetamol, also known as acetaminophen, is one of the most common antipyretic and analgesic over-the-counter (OTC) medicines administered to children due to its efficacy, safety, and availability in many pharmaceutical forms, including suppositories, syrup, and drops. Parents frequently administer the wrong dose of paracetamol by mistake for their children, as reported by many previous studies. We aimed in this study to assess parents' knowledge, attitudes, and practice regarding paracetamol dosing and toxicity, as well as their awareness regarding paracetamol-containing products.

METHODS

This was a cross-sectional study that targeted parents of children seeking healthcare services at primary health care centers in the Nablus area in the West Bank, Palestine. We used questionnaire-based interviews with parents for data collection.

RESULTS

A total of 300 parents were included in the study. Most of the caregivers surveyed were (87%) females (mothers). About half the parents (50.9%) reported previously using paracetamol as an antipyretic in children under the age of six. A quarter (25.4%) preferred the syrup forms, while 33.8% preferred the suppository dosage form. Medical personnel was the primary source of information for half the caregivers (51.2%). The mean knowledge score about paracetamol was 2.1 (SD = 1.4) out of 6, and the median was 2.0 with an interquartile range of 1.0-3.0. Two hundred seventy-four (95.5%) of the participants scored less than 80% and were considered to have insufficient knowledge. Only 50.9% of parents recognized that paracetamol overdose could result in serious harm.

CONCLUSIONS

We found a serious lack of knowledge regarding paracetamol dosing, administration, and potential toxicity among Palestinian parents. We recommend raising awareness regarding this problem among healthcare providers and authorities and working on plans that aim to provide caregivers with accurate and adequate information on dosing, formulation, side effects, and other aspects of paracetamol use, as well as developing effective educational plans targeting healthcare providers, as well as the public.

Health-care providers' concern regarding smoking cessation pharmacotherapies during pregnancy: Calls to a teratology information service

INTRODUCTION AND AIMS

Few smokers use smoking cessation pharmacotherapies during pregnancy. It is hypothesised that health-care providers' reluctance due to safety concerns contributes to their low use. This study examined the extent of providers' concern regarding smoking cessation pharmacotherapies, relative to other medications in the same and other pregnancy risk categories. Calls made to a teratology information service (MotherSafe, Australia) were taken as a proxy indicator of concern regarding safety during pregnancy.

DESIGN AND METHODS

The primary exposure discussed in 66 687 calls made to MotherSafe between 2001 and 2016 was categorised as nicotine replacement therapy (NRT), bupropion, varenicline or category A (low risk), B1, B2, B3, C, D or X (teratogenic). Separate logistic regression models estimated the odds that calls regarding pharmacotherapies were from providers, relative to medications in the same and other risk categories. Models adjusted for caller remoteness and socio-economic status.

RESULTS

Calls regarding bupropion were more likely to be made by providers than calls regarding other medications in its corresponding risk category [B2, adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 1.17, 6.59]. Calls about varenicline were also more likely to be from providers than calls regarding other category B3 medications (aOR 95% CI 2.33:1.30, 4.17). Calls regarding NRT were not more or less likely to be from providers than calls regarding other category D medications.

DISCUSSION AND CONCLUSIONS

Providers were more concerned about bupropion and varenicline than other medications within the same pregnancy risk categories. As this overestimation of risk may limit cessation pharmacotherapy use during pregnancy, research investigating strategies for correcting this imbalance is warranted.

Withdrawal and Misuse Concerns of Consumers regarding Opioid Analgesic and Anxiolytic, Hypnotic and Sedative Medicines

Opioid analgesic (OA) and anxiolytic, hypnotic and sedative (AHS) medicines use raise community concerns about risks of dependence: dose escalation, unintentional misuse. Objectives: We aimed to identify common consumer OA and AHS information gaps and concerns that led to information seeking from a hotline. Methods: We conducted a retrospective, mixed-method observational study of consumers' OA and AHS-related calls to an Australian national medicines call center (September 2002-30 June 2010). We analyzed these medicines' call characteristics compared to their respective rest of calls (ROC) and thematically explored narratives concerning withdrawal and misuse. Results: Of 123,217 calls, 7,395 (6.0%) involved OA and 7,789 (6.2%) AHS, with consistency between call characteristics. While female middle-aged callers predominated, more males called for these medicines than their complementary ROC. Uncertainty about unresolved OA and AHS concerns led to help-seeking that was consistent over eight years. Main motivations were inadequate information (OA 44.5%; AHS 41.2%), seeking a second opinion (OA 24.2%; AHS 24.2%), worrying symptoms (OA 21.6%; AHS 23.1%), and conflicting information (OA 4.9%; AHS 5.1%). Callers focused on withdrawal and issues related to inadvertent overuse or deliberate misuse (OA 9.2% vs. non-OA ROC 2.9%; AHS 12.6% vs. non-AHS ROC 2.7%). Primary themes were similar for both cohorts: concern about harm or aiming to minimize harm by information seeking, requesting a strategy, or reassurance. Conclusions: Consumers have under-recognized perceptions of harm from OA and AHS use, particularly withdrawal and misuse. Resources based on real world consumer concerns can encourage open dialogue between patients and their prescribers.

Operating a patient medicines helpline: a survey study exploring current practice in England using the RE-AIM evaluation framework

BACKGROUND

Patient medicines helplines provide a means of accessing medicines-related support following hospital discharge. However, it is unknown how many National Health Service (NHS) Trusts currently provide a helpline, nor how they are operated. Using the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance), we sought to obtain key data concerning the provision and use of patient medicines helplines in NHS Trusts in England. This included the extent to which the delivery of helplines meet with national standards that are endorsed by the Royal Pharmaceutical Society (standards pertaining to helpline access, availability, and promotion).

METHODS

An online survey was sent to Medicines Information Pharmacists and Chief Pharmacists at all 226 acute, mental health, specialist, and community NHS Trusts in England in 2017.

RESULTS

Adoption: Fifty-two percent of Trusts reported providing a patient medicines helpline (acute: 67%; specialist: 41%; mental health: 29%; community: 18%). Reach: Helplines were predominantly available for discharged inpatients, outpatients, and carers (98%, 95% and 93% of Trusts, respectively), and to a lesser extent, the local public (22% of Trusts). The median number of enquiries received per week was five.

IMPLEMENTATION

For helpline access, 54% of Trusts reported complying with all 'satisfactory' standards, and 26% reported complying with all 'commendable' standards. For helpline availability, the percentages were 86% and 5%, respectively. For helpline promotion, these percentages were 3% and 40%. One Trust reported complying with all standards. Maintenance: The median number of years that helplines had been operating was six. Effectiveness: main perceived benefits included patients avoiding harm, and improving patients' medication adherence.

CONCLUSIONS

Patient medicines helplines are provided by just over half of NHS Trusts in England. However, the proportion of mental health and community Trusts that operate a helpline is less than half of that of the acute Trusts, and there are regional variations in helpline provision. Adherence to the national standards could generally be improved, although the lowest adherence was regarding helpline promotion. Recommendations to increase the use of helplines include increasing the number of promotional methods used, the number of ways to contact the service, and the number of hours that the service is available.

Paracetamol causes endocrine disruption and hepatotoxicity in male fish Rhamdia quelen after subchronic exposure

Paracetamol is one of the most widely sold non-prescription drugs. This study aimed to evaluate the effects of the paracetamol on reproductive, biochemical, genetic, histopathological and hematogical biomarkers by waterborne exposure. Male fish of Rhamdia quelen were exposed to environmental concentrations of paracetamol (0, 0.25, 2.5μg/L) in a semi-static bioassay for 21days. Hemoglobin and hematocrit were reduced upon exposure to 0.25μg/L of paracetamol. Leukocytes and thrombocytes increased after paracetamol exposure. Paracetamol reduced testosterone levels in all exposed groups and increased estradiol levels at higher concentration. Serotonin and dopamine levels increased at exposure to 0.25μg/L. Paracetamol also caused protein carbonyls and increased SOD activity in fish exposed to 2.5μg/L and in addition led to an inhibition of EROD and GST activities in both concentrations. Hepatic genotoxicity occurred at the 0.25μg/L concentration. Hepatic tissues of exposed fish showed mild blood congestion and leucocytes infiltration. The results showed that paracetamol disrupted the hypothalamic-pituitary-gonadal axis, changed hematological parameters and caused hepatotoxicity in Rhamdia quelen. The findings suggest that this drug merits attention relative to its potential endocrine disrupter effect and hepatotoxicity, even at concentrations found in the aquatic environment.