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Saad M, Flament J. Paracetamol overdose causing acute kidney injury without hepatotoxicity: a case report. Int J Emerg Med 2024; 17:81. [PMID: 38956487 PMCID: PMC11220941 DOI: 10.1186/s12245-024-00662-w] [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: 04/17/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Paracetamol is a widely used analgesic and antipyretic. Paracetamol-induced hepatotoxicity is well known, but nephrotoxicity without hepatotoxicity is rarely seen. CASE PRESENTATION We present a case of acute kidney injury without hepatotoxicity in paracetamol overdose. A 15-year-old girl was admitted 48 h after she had taken 10 g of paracetamol. She was complaining of abdominal pain and vomiting. Her blood level of creatinine was 1.20 mg/dL on admission, with a peak at 3.67 mg/dL 3 days later. The liver blood tests and blood paracetamol level were negative. She did not receive N-acetyl cysteine and was treated with intravenous fluid (crystalloid). The ultrasonography of the kidneys was normal. Her renal function returned almost to baseline 7 days after admission. It was concluded that the diagnosis was an acute kidney injury caused by acute tubular necrosis due to paracetamol overdose. CONCLUSION This case shows that nephrotoxicity can occur without hepatotoxicity in paracetamol overdose.
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Affiliation(s)
- Micha Saad
- Faculty of Medicine, Université Catholique de Louvain, Avenue Mounier 50, boîte B1.50.04, Brussels, 1200, Belgium.
| | - Julien Flament
- Emergency Department, CHU UCL Namur, 1, rue Dr G. Therasse, Mont-Godinne, Yvoir, 5530, Belgium
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2
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Chidiac AS, Buckley NA, Noghrehchi F, Cairns R. Paracetamol (acetaminophen) overdose and hepatotoxicity: mechanism, treatment, prevention measures, and estimates of burden of disease. Expert Opin Drug Metab Toxicol 2023; 19:297-317. [PMID: 37436926 DOI: 10.1080/17425255.2023.2223959] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Paracetamol is one of the most used medicines worldwide and is the most common important poisoning in high-income countries. In overdose, paracetamol causes dose-dependent hepatotoxicity. Acetylcysteine is an effective antidote, however despite its use hepatotoxicity and many deaths still occur. AREAS COVERED This review summarizes paracetamol overdose and toxicity (including mechanisms, risk factors, risk assessment, and treatment). In addition, we summarize the epidemiology of paracetamol overdose worldwide. A literature search on PubMed for poisoning epidemiology and mortality from 1 January 2017 to 26 October 2022 was performed to estimate rates of paracetamol overdose, liver injury, and deaths worldwide. EXPERT OPINION Paracetamol is widely available and yet is substantially more toxic than other analgesics available without prescription. Where data were available, we estimate that paracetamol is involved in 6% of poisonings, 56% of severe acute liver injury and acute liver failure, and 7% of drug-induced liver injury. These estimates are limited by lack of available data from many countries, particularly in Asia, South America, and Africa. Harm reduction from paracetamol is possible through better identification of high-risk overdoses, and better treatment regimens. Large overdoses and those involving modified-release paracetamol are high-risk and can be targeted through legislative change.
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Affiliation(s)
- Annabelle S Chidiac
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, Australia
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
- Faculty of Medicine and Health, School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Firouzeh Noghrehchi
- Faculty of Medicine and Health, School of Medical Sciences, Discipline of Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Rose Cairns
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, Australia
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
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3
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Osman W, Mostafa-He G, Osman A, Rashed L, Labib D. Effect of Arabic Gum (Acacia senegal) on Paracetamol-Induced Chronic Nephrotoxicity in Albino Rats. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.1593.1604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Mehrpour O, Hoyte C, Goss F, Shirazi FM, Nakhaee S. Decision tree algorithm can determine the outcome of repeated supratherapeutic ingestion (RSTI) exposure to acetaminophen: review of 4500 national poison data system cases. Drug Chem Toxicol 2022:1-7. [DOI: 10.1080/01480545.2022.2083149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Omid Mehrpour
- Data Science Institute, Southern Methodist University, Dallas, TX, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | - Christopher Hoyte
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, Colorado
| | - Foster Goss
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, Colorado
| | - Farshad M. Shirazi
- Arizona Poison & Drug Information Center, University of Arizona, College of Pharmacy and University of Arizona, College of Medicine, Tucson, AZ, USA
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
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Shao QH, Yin XD, Liu HX, Zhao B, Huang JQ, Li ZL. Kidney Injury Following Ibuprofen and Acetaminophen: A Real-World Analysis of Post-Marketing Surveillance Data. Front Pharmacol 2022; 12:750108. [PMID: 35002695 PMCID: PMC8727534 DOI: 10.3389/fphar.2021.750108] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Although kidney injury has been reported as a serious adverse effect in patients treated with ibuprofen or acetaminophen (APAP), there are still few real-world studies to compare the specific differences in the adverse effects of nephrotoxicity. Methods: Disproportionality analysis and Bayesian analysis were devoted to data-mining of the suspected kidney injury after using ibuprofen and APAP based on the FDA’s Adverse Event Reporting System (FAERS) from January 2004 to March 2021. The times to onset, fatality, and hospitalization rates of ibuprofen-associated kidney injury and APAP-associated kidney injury were also investigated. Results: 2,453 reports of ibuprofen-associated kidney injury and 1,288 reports of APAP-associated kidney injury were identified. Ibuprofen appeared to affected more middle-aged patients than elderly ones (27.76 vs 16.53%) while APAP appeared to affected more young patients than middle-aged patients (45.24 vs 29.10%) and elderly patients were fewer (13.99%). Compared to ibuprofen, APAP had the higher association with renal injury based on the higher reporting odds ratio (ROR = 2.45, 95% two-sided CI = 2.36–2.56), proportional reporting ratio (PRR = 2.39, χ2 = 2002.94) and empirical Bayes geometric mean (EBGM = 2.38, 95% one-sided CI = 2.3). In addition, APAP-associated kidney injury had earlier onset (32.74 vs 115.82 days, p < 0.0001) and a higher fatality rate (44.43 vs 7.36%, p < 0.001) than those of ibuprofen-associated kidney injury. Conclusion: The analysis of FAERS data provides a more accurate profile on the incidence and prognosis of kidney injury after ibuprofen and acetaminophen treatment, enabling continued surveillance and timely intervention in patients at risk of kidney injury using these drugs.
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Affiliation(s)
- Qi-Hui Shao
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue-Dong Yin
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong-Xia Liu
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Zhao
- Pharmacy Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jian-Quan Huang
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Ling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Khan Z, Abumedian M, Ibekwe M, Musa K, Mlawa G. Acute Renal Impairment in Patients Due to Paracetamol Overdose in the Absence of Hepatic Impairment. Cureus 2021; 13:e20727. [PMID: 35111421 PMCID: PMC8790541 DOI: 10.7759/cureus.20727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/25/2022] Open
Abstract
In general, paracetamol poisoning is associated with hepatotoxicity and very rarely with renal impairment in the absence of significant hepatic impairment. Paracetamol poisoning associated with renal impairment is rare, and it is mostly associated with hepatotoxicity. Most patients with acute renal impairment show a pattern of acute tubular necrosis or injury based on their blood, clinical presentation, and imaging. The level of injury was found to be associated with the dose of paracetamol taken. We describe a case of a 22-year-old patient presenting to the hospital with abdominal pain, back pain, and two episodes of vomiting after 36 hours of an intentional paracetamol overdose of 60 tablets. His lab results showed raised creatinine levels and C-reactive protein (CRP) despite normal liver function tests. His paracetamol and salicylate levels were not checked on his initial presentation. He was given N-acetyl cysteine (NAC) treatment for paracetamol overdose and had computed tomography of kidneys, ureters, and bladder (CT KUB) the following day, which showed mild, uncomplicated sigmoid diverticula. He was discharged the next day, but was readmitted two days later with severe abdominal pain and worsening renal function. He had an magnetic resonance imaging (MRI) abdomen that showed coronal/axial wedge like areas of relative hypo-intense change in the T2 acquisition. He received intravenous fluids and antibiotics, and his renal function improved. He was discharged home with outpatient follow-up and appeared to be fully recovered.
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Mehrpour O, Saeedi F, Hoyte C. Decision tree outcome prediction of acute acetaminophen exposure in the United States: A study of 30,000 cases from the National Poison Data System. Basic Clin Pharmacol Toxicol 2021; 130:191-199. [PMID: 34649297 DOI: 10.1111/bcpt.13674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022]
Abstract
Acetaminophen is one of the most commonly used analgesic drugs in the United States. However, the outcomes of acute acetaminophen overdose might be very serious in some cases. Therefore, prediction of the outcomes of acute acetaminophen exposure is crucial. This study is a 6-year retrospective cohort study using National Poison Data System (NPDS) data. A decision tree algorithm was used to determine the risk predictors of acetaminophen exposure. The decision tree model had an accuracy of 0.839, an accuracy of 0.836, a recall of 0.72, a specificity of 0.86 and an F1_score of 0.76 for the test group and an accuracy of 0.848, a recall of 0.85, a recall of 0.74, a specificity of 0.87 and an F1_score of 0.78 for the training group. Our results showed that elevated serum levels of liver enzymes, other liver function test abnormality, anorexia, acidosis, electrolyte abnormality, increased bilirubin, coagulopathy, abdominal pain, coma, increased anion gap, tachycardia and hypotension were the most important factors in determining the outcome of acute acetaminophen exposure. Therefore, the decision tree model is a reliable approach in determining the prognosis of acetaminophen exposure cases and can be used in an emergency room or during hospitalization.
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Affiliation(s)
- Omid Mehrpour
- Data Science Institute, Southern Methodist University, Dallas, Texas, USA.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Farhad Saeedi
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran.,Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,University of Colorado Hospital, Aurora, Colorado, USA
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8
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Akgun E, Boyacioglu M, Kum S. The potential protective role of folic acid against acetaminophen-induced hepatotoxicity and nephrotoxicity in rats. Exp Anim 2021; 70:54-62. [PMID: 32963203 PMCID: PMC7887621 DOI: 10.1538/expanim.20-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Folic acid (FA), is a group B vitamin, has high reactive oxygen radicals quenching ability, resulting in protection against oxidative damage in aerobic cell. Acetaminophen (N-acetyl-p-aminophenol, APAP) is a nonsteroidal anti-inflammatory drug, and can promote oxidative damage in liver and kidney tissues. The aim of this study was to investigate whether folic acid has protective effects on oxidative liver and kidney injury caused by experimental APAP toxication. Forty female Sprague dawley rats were divided into 5 groups; control, APAP, FA, APAP+FA, and APAP+N-acetylcysteine (NAC) groups. APAP toxication was induced by oral gavage (3 g/kg bodyweight). FA (20 mg/kg bodyweight) and NAC (150 mg/kg bodyweight) were given by oral gavage to the specified groups. Oxidant and antioxidant parameter were determined in liver and kidney tissues. In addition, the liver and kidney tissues were histological evaluated. When compared with APAP group, superoxide dismutase (SOD) and catalase activities and glutathione levels were statistically higher, malondialdehyde (MDA) level and myeloperoxidase activity (except liver tissue) were statistically lower in both APAP+FA and APAP+NAC. Liver and kidney MDA level and kidney SOD activity were significantly lower in APAP+NAC group compared with APAP+FA group. Co-administration of NAC with APAP was found to provide protection, but hepatic cords were defective in some places and some glomerular tubules also had dilatation. Necrotic areas was reduced in the liver and the glomerular structure was in good condition in the APAP+FA group. As a result, FA might have a protective effect against APAP-induced hepato-nephrotoxicity and oxidative stress in rat.
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Affiliation(s)
- Emrah Akgun
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Aydin Adnan Menderes University, Isikli, 09016, Aydin, Turkey
| | - Murat Boyacioglu
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Aydin Adnan Menderes University, Isikli, 09016, Aydin, Turkey
| | - Sadiye Kum
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Aydin Adnan Menderes University, Isikli, 09016, Aydin, Turkey
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9
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Kanchanasurakit S, Arsu A, Siriplabpla W, Duangjai A, Saokaew S. Acetaminophen use and risk of renal impairment: A systematic review and meta-analysis. Kidney Res Clin Pract 2020; 39:81-92. [PMID: 32172553 PMCID: PMC7105620 DOI: 10.23876/j.krcp.19.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acetaminophen is commonly used for the relief of pain and fever. Advocacy organizations recommend acetaminophen as the drug of choice in patients with kidney disease. Although some studies have suggested a risk of renal impairment after the use of acetaminophen, the effect of acetaminophen on the risk of renal impairment is unclear. The purpose of this research was to demonstrate any correlation linking acetaminophen treatment and renal impairment. METHODS We performed a systematic review and meta-analysis of the association between acetaminophen and renal impairment in adults by searching Cochrane Library, PubMed, and Embase databases from initiation to June 16, 2019. RESULTS Of 13,097 articles identified, 5 studies (2 cohort studies and 3 case-control studies) with a total of 13,114 participants were included. In the random-effects meta-analysis of the cohort study, acetaminophen use was shown to have statistically significant effects on the increased risk of renal impairment (adjusted odds ratio 1.23; 95% confidence interval, 1.07-1.40). The results of sensitivity and subgroup analyses also suggested that acetaminophen use increases the risk of renal impairment. The Egger's test (P = 0.607) and Begg's test (P = 0.732) revealed no apparent publication bias. CONCLUSION Acetaminophen is associated with a significantly increased risk of newly developing renal impairment in adults. Physicians who prescribe acetaminophen should be aware of potential adverse renal effects. A longitudinal study that further explores this association is warranted.
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Affiliation(s)
- Sukrit Kanchanasurakit
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Department of Pharmacy, Phrae Hospital, Phrae, Thailand
| | - Aimusa Arsu
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | | | - Acharaporn Duangjai
- School of Medical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Surasak Saokaew
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia
- Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
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10
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Abstract
Acute kidney injury (AKI) occurs frequently in patients with liver disease and increases morbidity and mortality. Hepatorenal syndrome is a common cause of AKI in patients with decompensated cirrhosis and is due to alterations in systemic and renal hemodynamics. Serum creatinine-based estimation of kidney function is a key component of the Model for End-stage Liver Disease score in liver transplant candidates. Continuous renal replacement therapy is used in critically ill patients with liver failure and AKI. Simultaneous liver-kidney transplantation (SLK) may be required in patients with liver failure and prolonged AKI. Identification of appropriate candidates for SLK remains controversial.
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Affiliation(s)
- Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Kai Singbartl
- Department of Anesthesiology, Milton S. Hershey Medical Center, Penn State College of Medicine, PO Box 850, H187, Hershey, PA 17033, USA.
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11
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Castillo-Guzman S, González-Santiago O, Delgado-Leal IA, Lozano-Luévano GE, Reyes-Rodríguez MJ, Elizondo-Solis CV, Nava-Obregón TA, Palacios-Ríos D. Perception of the risk of adverse reactions to analgesics: differences between medical students and residents. PeerJ 2016; 4:e2255. [PMID: 27547561 PMCID: PMC4974922 DOI: 10.7717/peerj.2255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 06/23/2016] [Indexed: 12/05/2022] Open
Abstract
Background. Medications are not exempt from adverse drug reactions (ADR) and how the physician perceives the risk of prescription drugs could influence their availability to report ADR and their prescription behavior. Methods. We assess the perception of risk and the perception of ADR associated with COX2-Inbitors, paracetamol, NSAIDs, and morphine in medical students and residents of northeast of Mexico. Results. The analgesic with the highest risk perception in both group of students was morphine, while the drug with the least risk perceived was paracetamol. Addiction and gastrointestinal bleeding were the ADR with the highest score for morphine and NSAIDs respectively. Discussion. Our findings show that medical students give higher risk scores than residents toward risk due to analgesics. Continuing training and informing physicians about ADRs is necessary since the lack of training is known to induce inadequate use of drugs.
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Affiliation(s)
- Sandra Castillo-Guzman
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - Omar González-Santiago
- Posgraduate Division of the Faculty of Chemical Science, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - Ismael A Delgado-Leal
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - Gerardo E Lozano-Luévano
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - Misael J Reyes-Rodríguez
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - César V Elizondo-Solis
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - Teresa A Nava-Obregón
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
| | - Dionicio Palacios-Ríos
- Pain and Palliative Care Clinic, Anesthesiology Service, University Hospital Dr Jose E Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey , Nuevo León , Mexico
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Saengcharoen W, Buasri N, Khantapokha B, Lerkiatbundit S. Public knowledge and factors associated with inappropriate analgesic use: a survey in Thailand. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2015; 24:22-9. [DOI: 10.1111/ijpp.12201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 05/26/2015] [Indexed: 11/28/2022]
Abstract
Abstract
Objective
This study aims to evaluate knowledge of analgesics and factors associated with inappropriate analgesic use among the public.
Methods
The cross-sectional study was carried out in one large city in the south of Thailand. The survey was conducted using interview of people of age 16 or older. The questionnaire elicited information regarding knowledge, attitudes and behaviours on analgesic use including prevalence of taking paracetamol >4 g/day (overdosage) and not taking non-steroidal anti-inflammatory drugs (NSAIDs) with meals (inappropriate taking).
Key findings
Of 1982 participants, paracetamol overdose (n = 595) and inappropriate NSAID users (n = 751) were less likely to give correct answers about analgesics compared with appropriate users. The overdose use was inversely associated with knowledge on paracetamol (odds ratio (OR) 0.90; 95% confidence interval (CI), 0.83, 0.98) but directly associated with positive attitudes towards high dose taking (OR 2.15; 95% CI, 1.49, 3.11), and high frequency of analgesic use (OR 1.78; 95% CI, 1.24, 2.54). Inappropriate NSAID ingestion was inversely associated with knowledge on NSAIDs and directly associated with more commonly obtaining analgesics from community pharmacies (OR 0.87; 95% CI, 0.82, 0.92 and OR 1.27; 95% CI, 1.01, 1.61, respectively).
Conclusions
Poor knowledge, positive attitudes towards high dose or high frequency of analgesic consumption and the patterns of using drugs were associated with inappropriate analgesic use especially that of paracetamol.
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Affiliation(s)
- Woranuch Saengcharoen
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Nutdaporn Buasri
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Boonyisa Khantapokha
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Sanguan Lerkiatbundit
- Department of Pharmacy Administration, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
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13
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Cazacu I, Mogosan C, Loghin F. Safety issues of current analgesics: an update. ACTA ACUST UNITED AC 2015; 88:128-36. [PMID: 26528060 PMCID: PMC4576793 DOI: 10.15386/cjmed-413] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/17/2015] [Indexed: 12/18/2022]
Abstract
Pain represents a complex experience which can be approached by various medicines. Non-opioid and opioid analgesics are the most common drugs used to manage different types of pain. The increased attention nowadays to pain management entailed concomitantly more frequent adverse drug reactions (ADRs) related to analgesic use. Drug-drug interactions can be sometimes responsible for the adverse effects. However, a significant proportion of analgesic ADRs are preventable, which would avoid patient suffering. In order to draw the attention to analgesics risks and to minimize the negative consequences related to their use, the present review comprises a synthesis of the most important safety issues described in the scientific literature. It highlights the potential risks of the most frequently used analgesic medicines: non-opioid (paracetamol, metamizole, non-steroidal anti-inflammatory drugs) and opioid analgesics. Even if there is a wide experience in their use, they continue to capture attention with safety concerns and with potential risks recently revealed. Acknowledging potential safety problems represents the first step for health professionals in assuring a safe and efficient analgesic treatment with minimum risks to patients. Taking into consideration all medical and environmental factors and carefully monitoring the patients are also essential in preventing and early detecting analgesic ADRs.
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Affiliation(s)
- Irina Cazacu
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Mogosan
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Felicia Loghin
- Department of Toxicology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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14
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Tujios SR, Hynan LS, Vazquez MA, Larson AM, Seremba E, Sanders CM, Lee WM. Risk factors and outcomes of acute kidney injury in patients with acute liver failure. Clin Gastroenterol Hepatol 2015; 13:352-9. [PMID: 25019700 PMCID: PMC4937794 DOI: 10.1016/j.cgh.2014.07.011] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with acute liver failure (ALF) frequently develop renal dysfunction, yet its overall incidence and outcomes have not been fully assessed. We investigated the incidence of acute kidney injury (AKI) among patients with ALF, using defined criteria to identify risk factors and to evaluate its effect on overall outcomes. METHODS We performed a retrospective review of data from 1604 patients enrolled in the Acute Liver Failure Study Group, from 1998 through 2010. Patients were classified by the Acute Kidney Injury Network criteria, as well as for etiology of liver failure (acetaminophen-based, ischemic, and all others). RESULTS Seventy percent of patients with ALF developed AKI, and 30% received renal replacement therapy (RRT). Patients with severe AKI had higher international normalized ratio values than those without renal dysfunction (P < .001), and a higher proportion had advanced-grade coma (coma grades 3 or 4; P < .001) or presented with hypotension requiring vasopressor therapy (P < .001). A greater proportion of patients with acetaminophen-induced ALF had severe kidney injury than of patients with other etiologies of ALF; 34% required RRT, compared with 25% of patients with ALF not associated with acetaminophen or ischemia (P < .002). Of the patients with ALF who were alive at 3 weeks after study entry, significantly fewer with AKI survived for 1 year. Although AKI reduced the overall survival time, more than 50% of patients with acetaminophen-associated or ischemic ALF survived without liver transplantation (even with RRT), compared with 19% of patients with ALF attribute to other causes (P < .001). Only 4% of patients requiring RRT became dependent on dialysis. CONCLUSIONS Based on a retrospective analysis of data from more than 1600 patients, AKI is common in patients with ALF and affects short- and long-term outcomes, but rarely results in chronic kidney disease. Acetaminophen-induced kidney injury is frequent, but patients have better outcomes than those with other forms of ALF.
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Affiliation(s)
- Shannan R. Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Linda S. Hynan
- Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Miguel A. Vazquez
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Corron M. Sanders
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas,Division of Gastroenterology, Hepatology and Nutrition, The Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Zyoud SH, Al-Jabi SW, Sweileh WM. Worldwide research productivity of paracetamol (acetaminophen) poisoning: a bibliometric analysis (2003-2012). Hum Exp Toxicol 2015; 34:12-23. [PMID: 24758786 DOI: 10.1177/0960327114531993] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE There is a lack of data concerning the evaluation of scientific research productivity in paracetamol poisoning from the world. The purposes of this study were to analyse the worldwide research output related to paracetamol poisoning and to examine the authorship pattern and the citations retrieved from the Scopus database for over a decade. METHODS Data were searched for documents with specific words regarding paracetamol poisoning as 'keywords' in the title or/and abstract. Scientific output was evaluated based on a methodology developed and used in other bibliometric studies. Research productivity was adjusted to the national population and nominal gross domestic product (GDP) per capita. RESULTS There were 1721 publications that met the criteria during study period from the world. All retrieved documents were published from 72 countries. The largest number of articles related to paracetamol poisoning was from the United States (US; 30.39%), followed by India (10.75%) and the United Kingdom (UK; 9.36%). The total number of citations at the time of data analysis was 21,109, with an average of 12.3 citations per each documents and median (interquartile range) of 4 (1-14). The h-index of the retrieved documents was 57. After adjusting for economy and population power, India (124.2), Nigeria (18.6) and the US (10.5) had the highest research productivity. Countries with large economies, such as the UK, Australia, Japan, China and France, tended to rank relatively low after adjustment for GDP over the entire study period. CONCLUSION Our study demonstrates evidence that research productivity related to paracetamol poisoning has increased rapidly during the recent years. The US obviously dominated in research productivity. However, certain smaller country such as Nigeria has high scientific output relative to their population size and GDP. A highly noticeable increase in the contributions of Asia-Pacific and Middle East regions to scientific literature related to paracetamol poisoning was also observed.
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Affiliation(s)
- S H Zyoud
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia
| | - S W Al-Jabi
- Department of Clinical Pharmacy and Pharmacotherapy, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - W M Sweileh
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Ściskalska M, Śliwińska-Mossoń M, Podawacz M, Sajewicz W, Milnerowicz H. Mechanisms of interaction of the N-acetyl-p-aminophenol metabolites in terms of nephrotoxicity. Drug Chem Toxicol 2014; 38:121-5. [DOI: 10.3109/01480545.2014.928722] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Waring WS. Criteria for acetylcysteine treatment and clinical outcomes after paracetamol poisoning. Expert Rev Clin Pharmacol 2014; 5:311-8. [DOI: 10.1586/ecp.12.15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Emmett M. Acetaminophen toxicity and 5-oxoproline (pyroglutamic acid): a tale of two cycles, one an ATP-depleting futile cycle and the other a useful cycle. Clin J Am Soc Nephrol 2013; 9:191-200. [PMID: 24235282 DOI: 10.2215/cjn.07730713] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The acquired form of 5-oxoproline (pyroglutamic acid) metabolic acidosis was first described in 1989 and its relationship to chronic acetaminophen ingestion was proposed the next year. Since then, this cause of chronic anion gap metabolic acidosis has been increasingly recognized. Many cases go unrecognized because an assay for 5-oxoproline is not widely available. Most cases occur in malnourished, chronically ill women with a history of chronic acetaminophen ingestion. Acetaminophen levels are very rarely in the toxic range; rather, they are usually therapeutic or low. The disorder generally resolves with cessation of acetaminophen and administration of intravenous fluids. Methionine or N-acetyl cysteine may accelerate resolution and methionine is protective in a rodent model. The disorder has been attributed to glutathione depletion and activation of a key enzyme in the γ-glutamyl cycle. However, the specific metabolic derangements that cause the 5-oxoproline accumulation remain unclear. An ATP-depleting futile 5-oxoproline cycle can explain the accumulation of 5-oxoproline after chronic acetaminophen ingestion. This cycle is activated by the depletion of both glutathione and cysteine. This explanation contributes to our understanding of acetaminophen-induced 5-oxoproline metabolic acidosis and the beneficial role of N-acetyl cysteine therapy. The ATP-depleting futile 5-oxoproline cycle may also play a role in the energy depletions that occur in other acetaminophen-related toxic syndromes.
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Affiliation(s)
- Michael Emmett
- Division of Nephrology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
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Le Vaillant J, Pellerin L, Brouard J, Eckart P. [Acetaminophen (paracetamol) causing renal failure: report on 3 pediatric cases]. Arch Pediatr 2013; 20:650-3. [PMID: 23628119 DOI: 10.1016/j.arcped.2013.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 02/12/2013] [Accepted: 03/20/2013] [Indexed: 11/28/2022]
Abstract
Renal failure secondary to acetaminophen poisoning is rare and occurs in approximately 1-2 % of patients with acetaminophen overdose. The pathophysiology is still being debated, and renal acetaminophen toxicity consists of acute tubular necrosis, without complication if treated promptly. Renal involvement can sometimes occur without prior liver disease, and early renal manifestations usually occur between the 2nd and 7th day after the acute acetaminophen poisoning. While therapy is exclusively symptomatic, sometimes serious metabolic complications can be observed. The monitoring of renal function should therefore be considered as an integral part of the management of children with acute, severe acetaminophen intoxication. We report 3 cases of adolescents who presented with acute renal failure as a result of voluntary drug intoxication with acetaminophen. One of these 3 girls developed severe renal injury without elevated hepatic transaminases. None of the 3 girls' renal function required hemodialysis, but one of the 3 patients had metabolic complications after her acetaminophen poisoning.
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Affiliation(s)
- J Le Vaillant
- Service de pédiatrie médicale, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen, France.
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Sun B, Utleg AG, Hu Z, Qin S, Keller A, Lorang C, Gray L, Brightman A, Lee D, Alexander VM, Ranish JA, Moritz RL, Hood L. Glycocapture-assisted global quantitative proteomics (gagQP) reveals multiorgan responses in serum toxicoproteome. J Proteome Res 2013; 12:2034-44. [PMID: 23540550 DOI: 10.1021/pr301178a] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Blood is an ideal window for viewing our health and disease status. Because blood circulates throughout the entire body and carries secreted, shed, and excreted signature proteins from every organ and tissue type, it is thus possible to use the blood proteome to achieve a comprehensive assessment of multiple-organ physiology and pathology. To date, the blood proteome has been frequently examined for diseases of individual organs; studies on compound insults impacting multiple organs are, however, elusive. We believe that a characterization of peripheral blood for organ-specific proteins affords a powerful strategy to allow early detection, staging, and monitoring of diseases and their treatments at a whole-body level. In this paper we test this hypothesis by examining a mouse model of acetaminophen (APAP)-induced hepatic and extra-hepatic toxicity. We used a glycocapture-assisted global quantitative proteomics (gagQP) approach to study serum proteins and validated our results using Western blot. We discovered in mouse sera both hepatic and extra-hepatic organ-specific proteins. From our validation, it was determined that selected organ-specific proteins had changed their blood concentration during the course of toxicity development and recovery. Interestingly, the peak responding time of proteins specific to different organs varied in a time-course study. The collected molecular information shed light on a complex, dynamic, yet interweaving, multiorgan-enrolled APAP toxicity. The developed technique as well as the identified protein markers is translational to human studies. We hope our work can broaden the utility of blood proteomics in diagnosis and research of the whole-body response to pathogenic cues.
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Affiliation(s)
- Bingyun Sun
- Institute for Systems Biology , 401 N. Terry Ave., Seattle, Washington 98109, USA.
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Abstract
Acetaminophen poisoning remains one of the more common drugs taken in overdose with potentially fatal consequences. Early recognition and prompt treatment with N-acetylcysteine can prevent hepatic injury. With acute overdose, the Rumack-Matthew nomogram is a useful tool to assess risk and guide management. Equally common to acute overdose is the repeated use of excessive amounts of acetaminophen. Simultaneous ingestion of several different acetaminophen-containing products may result in excessive dosage. These patients also benefit from N-acetylcysteine. Standard courses of N-acetylcysteine may need to be extended in patients with persistently elevated plasma concentrations of acetaminophen or with signs of hepatic injury.
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Affiliation(s)
- Michael J Hodgman
- Department of Emergency Medicine, Upstate New York Poison Center, SUNY Upstate Medical University, Suite 202, 250 Harrison Street, Syracuse, NY 13202, USA.
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Vilay AM, Wong CS, Schrader RM, Mercier RC, Seifert SA. Indicators for serious kidney complications associated with toxic exposures: an analysis of the National Poison Data System. Clin Toxicol (Phila) 2013; 51:96-105. [PMID: 23331216 DOI: 10.3109/15563650.2012.762456] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Over two million poisoning exposures are reported to U.S. poison control centers annually. A broad population-based survey of toxic exposures and the correlated patterns of reported kidney injury (acute or chronic) have not been systematically characterized. OBJECTIVE Our objective was to study the demographic and exposure patterns associated with indicators for serious kidney complications (ISKC), as defined by the variables in the NPDS. MATERIALS AND METHODS This was a retrospective, case-control study using the data elements available in the NPDS. We assessed data related to patient characteristics, substance exposure, and management. Cases and controls were derived from adult and pediatric exposures documented in NPDS (2001-2007) as having "renal effects." For substance-specific analyses, cases were restricted to those involving single substances or single entity pharmaceutical preparations. ISKC cases presented with one or more of the following NPDS codes: increased creatinine, and/or oliguria/anuria, and/or renal failure. Controls were subjects with "renal effects" but did not have increased creatinine, nor anuria/oliguria, nor renal failure. Univariate and multivariate logistic regression analyses identified factors associated with ISKC and determined the relationship between these factors. RESULTS From the approximate 16.8 million exposures reported to the NPDS within the study timeframe, there were 16,444 single substance exposures with renal effects of which 9,074 cases experienced ISKC (55.2%) compared to 7,370 controls without ISKC. Cases with ISKC tended to be males, adults, and reported to involve intentional exposures. Cases with ISKC had higher rates of reported hemodialysis/hemofiltration (27.7%; N = 2,517) and death (10.9%; N = 990) compared to controls, respectively, (2.1%; N = 155) and (0.8%; N = 60), p < 0.001. Substances considered a priori to be nephrotoxic were associated with a higher risk of ISKC. DISCUSSION AND CONCLUSION The NPDS provided insight into the subjects and types of exposures that associate with ISKC. Subjects with ISKC experienced higher rates of morbidity and mortality compared to subjects without ISKC. We identified subject characteristics and classes of compounds associated with ISKC. We hope that the hypotheses generated from this study of the NPDS will raise awareness of the possible risk factors and complications associated with ISKC.
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Affiliation(s)
- A M Vilay
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, Albuquerque, NM, USA.
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Kelkar M, Cleves MA, Foster HR, Hogan WR, James LP, Martin BC. Acute and chronic acetaminophen use and renal disease: a case-control study using pharmacy and medical claims. JOURNAL OF MANAGED CARE PHARMACY : JMCP 2012; 18:234-46. [PMID: 22468732 PMCID: PMC4000171 DOI: 10.18553/jmcp.2012.18.3.234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Studies have examined the association between acetaminophen (APAP) use and renal disease; however, their interpretation is limited by a number of methodological issues. OBJECTIVE To study the association between acute and chronic prescription-acquired APAP use and renal disease. METHODS This was a retrospective case-control study of medical and pharmacy claims of a 10% random sample of the enrollees from the IMS LifeLink Health Plans commercial claims dataset for dates of service from January 1, 1997, through December 31, 2009. Subjects were continuously enrolled and aged 18 years or older. Cases had at least 1 incident claim of renal disease defined by ICD-9-CM codes in the primary diagnosis field. Controls were randomly selected from individuals without evidence of renal disease, liver disease, or asthma in medical claims and matched to cases in a 3-to-1 ratio based on 3 variables (age, gender, and geographic region). APAP exposure, dosage, and duration of use were measured in the 7 and 30 days (acute) and in the 1-year (chronic) look-back periods. Multivariable conditional logistic regression was used to estimate the risk of APAP exposure adjusted for comorbidities, use of other nephrotoxic drugs, and health system factors. RESULTS There were 4,724 cases and 14,172 controls with a mean (SD) age of 60.8 (17.8) years, and 52.6% were males; 10.9% of cases and 4.2% of controls had APAP exposure in the 30 days pre-index with mean potential maximum daily dosages of 3,846.5 mg and 3,190.8 mg, respectively. Acute APAP exposure was significantly associated with renal disease, and the risk decreased with longer look-back periods (7 days: adjusted odds ratio [OR] = 1.93, 95% CI = 1.61-2.30); 30 days: OR = 1.71, 95% CI = 1.48-1.97). Cumulative APAP dosage greater than 1 kg and APAP use for longer than 30 days in the pre-index year were not significantly associated with an increased risk of renal disease (both P values = 0.900). CONCLUSIONS Acute prescription-acquired APAP use was associated with renal disease, while chronic use was not. Because this study assessed APAP use in pharmacy claims, further research accounting for over-the-counter APAP use is warranted before the safety of chronic APAP consumption can be firmly established.
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Affiliation(s)
- Mugdha Kelkar
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
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Zyoud SH, Awang R, Sulaiman SAS. Reliability of the reported ingested dose of acetaminophen for predicting the risk of toxicity in acetaminophen overdose patients. Pharmacoepidemiol Drug Saf 2012; 21:207-13. [PMID: 21812068 DOI: 10.1002/pds.2218] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 06/16/2011] [Accepted: 06/16/2011] [Indexed: 02/05/2023]
Abstract
PURPOSE The present study examines the relationship between the dose of acetaminophen reported to have been ingested by patients and the occurrence of serum acetaminophen levels above the 'possible toxicity' line in patients presenting at the hospital after acetaminophen overdose. The prognostic value of patient-reported dosage cut-offs of 8, 10 and 12 g was determined. METHODS This retrospective cohort study included patients admitted to the emergency department or hospital within 24 hours of acetaminophen ingestion. Serum acetaminophen concentrations were considered to be the gold standard, and specificity, sensitivity and positive/negative predictive values were calculated from the reported ingested dose, to predict toxicity using the Rumack-Matthew nomogram (i.e. the 'possible toxicity' treatment line) and standard equations. RESULTS Of 305 patients identified, 291 met the study inclusion criteria, and 121 (41.6%) had serum acetaminophen concentrations above the 'possible toxicity' treatment line. The range of patient-reported acetaminophen ingested was 1-75 g, with 185 patients (63.6%) reporting ≥8 g. One hundred eighteen patients (97.5%) who reported ingesting ≥8 g had serum acetaminophen concentrations above the '150-line', compared with only three patients (2.5%) who reported ingesting <8 g (p < 0.001). The positive predictive value of a patient-reported dose ≥8 g for predicting serum acetaminophen concentrations above the 'possible toxicity' treatment line was 63.78%, with a negative predictive value of 97.17%. The sensitivity of patient-reported doses ≥8 g was high (97.52%) but with low specificity (60.59%). The sensitivity of patient-reported doses ≥10 g also was high (89.26%) with low specificity (65.29%), whereas the sensitivity of ≥12 g dose was low (61.16%) with high specificity (86.47%). CONCLUSIONS Patient-reported doses of acetaminophen are good risk indicators for acetaminophen overdose patients in Malaysia. Patient-reported ingestion of ≥8 g (as a cut-off dose) had a higher sensitivity than ≥10 g or ≥12 g. The results of this study have important implications for toxicity risk evaluations in areas with poor serum acetaminophen assay availability.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia, Penang, Malaysia.
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Waring WS, Moonie A. Earlier recognition of nephrotoxicity using novel biomarkers of acute kidney injury. Clin Toxicol (Phila) 2011; 49:720-8. [PMID: 21970770 DOI: 10.3109/15563650.2011.615319] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
CONTEXT A broad range of drugs and chemicals are capable of evoking acute kidney injury, which is conventionally determined by rising serum creatinine concentrations. However there are important limitations to this approach, and there has been interest in alternative biomarkers that might provide a more sensitive and rapid means of detecting acute kidney injury. Most of the available clinical data have thus far been ascertained in patients requiring critical care or with acute sepsis. However, if a sensitive indicator of acute kidney injury were developed, then this could provide a significantly improved means of detecting the effects of acute drug or toxin exposure. OBJECTIVE To review the available data concerning potential biomarkers of acute kidney injury and to assess their relative strengths and weaknesses in comparison to existing methods based on serum creatinine concentrations. A large number of possible biomarkers have been proposed. Evidence for individual biomarkers is reviewed with a particular emphasis on those with potential application in clinical toxicology. Where available, comparative data are presented. METHODS There were 236 papers identified using Medline, Embase, and Google Scholar databases, of which 52 were considered directly relevant. CREATININE: Creatinine is subject to glomerular filtration and, to a lesser extent tubular secretion. Serum concentrations are an insensitive marker of acute kidney injury, and the speed of an increase from baseline depends on the magnitude of the acute injury and pre-existing kidney functional reserve. A wide range of inter-individual concentrations means that single time-point determinations are difficult to interpret, and acute kidney injury may not manifest as a detectable increase in serum creatinine concentrations until at least 24-48 h after the primary insult. KIDNEY ENZYMES: Enzymes are often localised to specific anatomical locations, and acute injury may cause a detectable increase in urinary activity due to up-regulated activity or leakage due to cell membrane disruption. Key examples include gamma-glutamyl transpeptidase (GGT), glutathione-S-transferase (GST), and N-acetyl-glucosaminidase (NAG), which are found predominantly in the proximal tubule and urinary enzyme activity increases after acute exposure to heavy metals and other nephrotoxins. NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN: Neutrophil gelatinase-associated lipocalin (NGAL) is expressed by renal tubular epithelium, and a rise in urinary concentrations may provide an indicator of acute renal injury caused by any one of a broad range of provoking factors that is detectable before a rise in serum creatinine concentrations. CYSTATIN C: Serum and urinary cystatin C concentrations are closely related to kidney function and, for example, in acute tubular necrosis allow better prediction of the need for renal replacement therapy than serum creatinine concentrations. KIDNEY INJURY MOLECULE 1: Kidney injury molecule 1 (KIM-1) is expressed in the proximal tubule in the setting of acute ischaemia. For example, urinary KIM-1 concentrations becomes detectable within 24 h of acute tubular necrosis. Urinary KIM-1 expression may be detected after exposure to a variety of nephrotoxic agents, even when serum creatinine concentrations do not increase, and this has been accepted by regulatory authorities as a sensitive biomarker of acute kidney injury during early drug development. CONCLUSIONS Novel biomarkers appear capable of offering a more sensitive means of detecting acute kidney injury than existing approaches. Certain of these allow discrimination between the various mechanisms and anatomical site of acute injury. Ultimately, clinical assessment might incorporate a panel of different biomarkers, each informing on the integrated aspects of glomerular, tubular and interstitial function. Presence of biomarkers may in some cases detect mild or transient renal dysfunction that is presently undetected, and the clinical relevance needs further exploration. Whilst many potentially useful biomarkers have been proposed, comparatively few clinical data exist to support their validity in routine practice. Further prospective clinical studies are required to examine the validity of biomarkers after acute drug or toxin exposure, and to establish whether they might offer improved clinical outcomes in the setting of clinical toxicology.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. An analysis of the length of hospital stay after acetaminophen overdose. Hum Exp Toxicol 2011; 30:550-9. [PMID: 20630911 DOI: 10.1177/0960327110377647] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acetaminophen is one of the most commonly encountered medications in self-poisoning, with a high rate of morbidity. The prevalence and characteristics of acetaminophen intoxication associated with long hospital stay in patients are not well defined. OBJECTIVES This study aims to identify the clinical and demographic factors associated with the length of in-hospital stay (LOS), and to evaluate the effect of early treatment of acetaminophen overdose patients (≤8 hours) by intravenous N-acetylcysteine (IV-NAC) on hospital stay. METHODS This is a retrospective cohort study of hospital admissions for acetaminophen overdose conducted over a period of 5 years from 1 January 2004 to 31 December 2008. Patients were divided into two groups: LS group patients had a long hospital stay (> median hours stay in hospital) and SS group patients had a short hospital stay (≤ median hours stay in hospital). Variables were abstracted from medical records for comparison between the two groups. A total of 20 variables were identified for comparison. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. RESULTS Of the 305 patients, 11 factors were identified in the univariate analysis as associated with LS. Three independent factors were found to be significant predictors of LS in the multivariate analysis. The factors associated with LS were seen among patients with a history of abdominal pain after ingestion of acetaminophen (p = 0.04), who were on IV-NAC administration (p < 0.001) and had an acutely depressed mood (p = 0.003). Late time to NAC infusion of more than 8 hours was associated with LS rather than SS (96 patients [57%] and 6 [24%], respectively; p = 0.003). CONCLUSION Patients with long hospital stay have different clinical characteristics compared to patients with short hospital stay. We identified time to IV-NAC administration is a potentially modifiable factor that may lead to prolonged hospital stay. When risk assessment indicates that NAC is required, it is highly recommended that NAC be started in the first hours of admission to reduce the LOS.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia, Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. N-acetylcysteine-induced headache in hospitalized patients with acute acetaminophen overdose. Fundam Clin Pharmacol 2011; 25:405-10. [PMID: 20584210 DOI: 10.1111/j.1472-8206.2010.00831.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Intravenous N-acetylcysteine (IV-NAC) is usually regarded as a safe antidote to acetaminophen overdose. However, during infusion of the loading dose, adverse drug reactions such as a headache may occur. The objectives of this study were to investigate the prevalence of headache in patients presenting to hospital after acetaminophen overdose and to determine which clinical findings are most predictive of headache among these patients. This is a retrospective cohort study of hospital admissions for acute acetaminophen overdose that was conducted over a period of 4 years from January 1, 2005 to December 31, 2008. Demographic data, clinical characteristics, and predictors of headache were analyzed. spss 15 was used for data analysis. Two-hundred and fifty-five patients were studied; their mean age was 23.1 ± 1.6; 83.9% of them were women and 14.9% had a headache during hospitalization. Headache among patients was significantly associated with IV-NAC administration (P = 0.001), intentional ingestion of drug (P = 0.04), acetaminophen concentration above 'possible toxicity' treatment line (P = 0.04), a high acetaminophen concentration (P = 0.04), and a long hospital stay (P = 0.03). Multiple logistic regression showed a significant risk factor for headache in patients administered IV-NAC (P = 0.04). We recorded a high frequency of headache in patients with acute acetaminophen overdose in our geographical area. This study suggests that among those patients, the use of IV-NAC is associated with an increased risk of headache.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Hassan Y, Al-Jabi SW, Aziz NA, Looi I, Zyoud SH. Statin use prior to ischemic stroke onset is associated with decreased in-hospital mortality. Fundam Clin Pharmacol 2011; 25:388-94. [PMID: 20608996 DOI: 10.1111/j.1472-8206.2010.00846.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Statins can reduce the risk of stroke in at-risk populations and improve survival after acute ischemic stroke (AIS) among patients with previous statin use. This study aimed to investigate the impact of statin use before AIS onset on in-hospital mortality and identify the factors related to in-hospital mortality among patients with and without previous statin use. A retrospective cohort study of all patients with AIS attending hospital from June 1, 2008 to December 31, 2008. Data were collected from medical records including demographic information, diagnostic information, risk factors, previous statin use, and vital discharge status. Chi-square, Fisher's exact tests, student's t-test, and Mann-Whitney U test, whatever appropriate, were used to test the significance between the variables, and multiple logistic regression was used to identify factors associated with in-hospital mortality. Altogether, 386 patients with AIS were studied, of which 113 (29.3%) had a documented previous statin use. A total of 62 (16.1%) patients with AIS died in hospital. In-hospital mortality was significantly lower among previous statin users (P = 0.013). The presence of atrial fibrillation (AF) increased in-hospital mortality among patients with or without previous statin use. The independent predictors for in-hospital mortality among AIS patients without previous statin use were the presence of diabetes mellitus (P = 0.047), AF (P = 0.045), and renal impairment (P < 0.001). The prophylactic administration of statins significantly reduces post-AIS in-hospital mortality. Furthermore, the identification of predictors of in-hospital mortality might reduce death rates and enhance the application of specific therapeutic and management strategies to patients at a high risk of dying.
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Affiliation(s)
- Yahaya Hassan
- Clinical Pharmacy Program, School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. Impact of serum acetaminophen concentration on changes in serum potassium, creatinine and urea concentrations among patients with acetaminophen overdose. Pharmacoepidemiol Drug Saf 2011; 20:203-8. [PMID: 21254292 DOI: 10.1002/pds.2060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 08/10/2010] [Accepted: 09/06/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acetaminophen overdose may be accompanied by electrolyte disturbances. The basis for electrolyte change appears to be due to increased fractional urinary electrolyte excretion. PURPOSE This study investigated the impact of serum acetaminophen concentration on changes in serum potassium, creatinine and urea concentrations in patients with acetaminophen overdose. METHODS This was a retrospective cohort study which included patients admitted to the emergency department and hospital within 24 h of acetaminophen ingestion. The study was conducted over a period of 5 years from 1 January 2004 to 31 December 2008. Data are presented as mean ± SD and as medians (interquartile range) and groups were compared using independent two-tailed Student t-test. Statistical Package for Social Sciences (SPSS) 15 was used for data analysis. RESULTS Two hundred and eighty-three patients were studied (44 males and 239 females), mean age 23 ± 7.5 years. Patients who had a serum acetaminophen concentration above a 'possible toxicity' treatment line were associated with an elevation in serum creatinine concentration (p=0.044) and a reduction in the serum potassium concentration (p<0.001) but were not associated with a reduction in serum urea concentration (p>0.99). During the study period, 63.3% (179 patients) had serum potassium concentrations less than the normal concentration (3.5 mmol/l) and 31.4% (89 patients) had serum urea concentrations less than the normal concentration (2.5 mmol/l). The serum creatinine concentration in all patients was within the normal range. CONCLUSIONS Acetaminophen appears to cause a concentration-dependent reduction of potassium concentrations and an elevation of creatinine concentrations of short duration (<24 h) after overdose.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. Assessing the impact of vomiting episodes on outcome after acetaminophen poisoning. Basic Clin Pharmacol Toxicol 2010; 107:887-92. [PMID: 20456332 DOI: 10.1111/j.1742-7843.2010.00594.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Identifying indices of poor prognosis at first presentation after acetaminophen poisoning is the key to both improving clinical care and determining targets for intervention. This study intended to document the prevalence, clinical characteristics and predictors of vomiting and to investigate the relationship between episodes of vomiting at first hospital presentation and outcome in acetaminophen poisoning. This retrospective cohort study included patients who attended the emergency department and were admitted within 24 hr of acetaminophen ingestion. The study was conducted over a period of 5 years from 1 January 2004 to 31 December 2008. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. Data from 291 patients were included. Vomiting was present in 65.3% of patients with acetaminophen poisoning at the time of first presentation. Multiple logistic regression showed that significant risk factors for vomiting were present among patients who reported an ingested dose of acetaminophen ≥10 g (p < 0.001) and a latency time of more than 8 hr (p = 0.030). Overall, an increasing trend in prothrombin time (p = 0.03), serum bilirubin (p < 0.001), serum creatinine (p = 0.005), serum potassium (p < 0.001), length of hospital stay (p < 0.001) and the prevalence of patients who had a serum acetaminophen level above a 'possible toxicity' treatment line (p = 0.001) were associated with an increased number of episodes of vomiting. In conclusion, vomiting was common among patients with acetaminophen poisoning. This study suggests that an increase in episodes of vomiting at first presentation appears to be an important risk marker of subsequent nephrotoxicity and hepatotoxicity.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. Effects of delay in infusion of N-acetylcysteine on appearance of adverse drug reactions after acetaminophen overdose: a retrospective study. Pharmacoepidemiol Drug Saf 2010; 19:1064-70. [PMID: 20712021 DOI: 10.1002/pds.1955] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the relationship between different types of adverse drug reaction (ADR) and late time to N-acetylcysteine (NAC) infusion in patients presenting to the hospital with acetaminophen overdose. METHODS This is a retrospective study of patients admitted to the hospital for acute acetaminophen overdose over a period of 5 years (1 January 2004 to 31 December 2008). The primary outcome of interest was the relationship between ADR, if any, and late time to NAC infusion. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. RESULTS Of 305 patients with acetaminophen overdose, 146 (47.9%) were treated with intravenous NAC and 139 (45.6%) were included in this study. Different types of ADR were observed in 94 (67.6%) patients. Late time to NAC infusion was significantly associated with cutaneous anaphylactoid reactions when compared to patients without this type of ADR (p < 0.001). However, there were no significant differences in time to NAC infusion between patients with and without the following ADR: gastrointestinal reactions (p = 0.11), respiratory reactions (p = 0.77), central nervous reactions (p = 0.64), and cardiovascular reactions (p = 0.63). CONCLUSION Late time to NAC infusion is a risk factor for developing cutaneous anaphylactoid reactions, suggesting, rather than proving, that early NAC infusion (≤ 8 hours) may be protective against this type of ADR.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Hassan Y, Aziz NA, Al-Jabi SW, Looi I, Zyoud SH. Impact of angiotensin-converting enzyme inhibitors administration prior to acute ischemic stroke onset on in-hospital mortality. J Cardiovasc Pharmacol Ther 2010; 15:274-81. [PMID: 20624923 DOI: 10.1177/1074248410373751] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitors (ACEIs) have shown promising results in decreasing the incidence and the severity of ischemic stroke in populations at risk and in improving ischemic stroke outcomes. OBJECTIVES The objectives of this study were to investigate the impact of ACEI use before ischemic stroke onset on in-hospital mortality and to identify the independent predictors of in-hospital mortality among patients with ischemic stroke. METHODS AND MATERIALS A retrospective cohort study of all patients with acute ischemic stroke attending the hospital from June 1, 2008 to November 30, 2008 was performed. Data were collected from medical records and included demographic information, diagnostic information, risk factors, previous ACEI use, and vital discharge status. Statistical Package for Social Sciences (SPSS) version 15 was used for data analysis. RESULTS A total of 327 patients with acute ischemic stroke were studied, of which 119 (36.4%) had documented previous ACEI use. During the study period, 52 (15.9%) of the patients with acute ischemic stroke died in hospital. In-hospital mortality was significantly lower among patients who were on ACEI before the attack (P = 0.002). The independent predictors for in-hospital mortality among patients with ischemic stroke were age >or=65 years (P < .001), the presence of diabetes mellitus (P = .012), renal impairment (P = .002), and heart failure (P = .001). Moreover, prior use of ACEI was an independent predictor for survival after ischemic stroke attack (P < .001). CONCLUSION This study provides evidence that the prophylactic administration of ACEI before ischemic stroke may be a potential life-saving strategy. Furthermore, knowledge of in-hospital mortality predictors is necessary to improve survival rate after acute stroke.
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Affiliation(s)
- Yahaya Hassan
- Clinical Pharmacy Program, School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. A cross-sectional observation of the factors associated with deliberate self-poisoning with acetaminophen: impact of gender differences and psychiatric intervention. Hum Psychopharmacol 2010; 25:500-8. [PMID: 20737523 DOI: 10.1002/hup.1140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The objectives of this study were to determine the risk factors and life stressors that are prevalent among the acetaminophen deliberate self-poisoning (DSP) cases, to identify gender differences in the associated factors, and to determine the prevalence of psychiatric diagnosis and the patterns and types of psychotherapeutic interventions provided by psychiatrists. METHODS This is a cross-sectional study, a retrospective descriptive case review of hospital admissions for acetaminophen DSP. RESULTS There were 177 incidences of DSP during the study period. The mean age of the cases was 23.1 +/- 7.3 years and 84.1% of them were females. The risk factors were more significantly associated with males: chronic ethanol intake (p = 0.04), higher reported dose ingested (p = 0.01), higher latency time (p = 0.04) and longer hospital stay (p = 0.03). The most commonly reported psychotherapeutic interventions used by psychiatrists were psychoeducation of the patient, followed by referral to a psychiatric clinic, family psychoeducation and psychotropic medication. Sertraline (SSRI) was the most frequently prescribed antidepressant. CONCLUSIONS Males have been shown to use more toxic doses and to delay treatment due to high latency time. Most DSP patients have different life stressors and psychiatric diagnoses that may be associated with varying degrees of suicidal intent. All patients presenting following DSP need to be carefully screened for psychiatric illness. Randomized controlled studies need to be conducted on DSP patients with psychiatric illness to determine which treatments are effective.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Zyoud SH, Awang R, Sulaiman SAS, Al-Jabi SW. Association between gastrointestinal manifestations following acetaminophen poisoning and outcome in 291 acetaminophen poisoning patients. Pharmacoepidemiol Drug Saf 2010; 19:511-7. [PMID: 20333776 DOI: 10.1002/pds.1940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acetaminophen poisoning is a common clinical problem, and early identification of patients with more severe poisoning is key to improving outcomes. PURPOSES This study intends to document prevalence, clinical characteristics, and predictors of gastrointestinal (GI) manifestations and to assess the impact of these manifestations on outcome in patients with acetaminophen poisoning. METHODS This is a retrospective cohort study of hospital admissions for acute acetaminophen poisoning conducted over a period of 5 years from 1 January 2004 to 31 December 2008. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. Statistical Package for Social Sciences (SPSS) 15 was used for data analysis. RESULTS Two hundred and ninety-one patients were studied; their mean age was 23.01 +/- 7.4 years and 76.6% had GI manifestations. Multiple logistic regression showed that significant risk factors for GI manifestations were present among patients who reported acetaminophen dose ingested >or=10 g (p < 0.001), and latency time more than 8 hours (p = 0.030). GI manifestations at first admission predicted poorer outcomes in terms of estimated acetaminophen levels to be a possible toxic (p < 0.001), elevated bilirubin levels (p = 0.002), prolonged prothrombin time (PT; p = 0.002), elevated creatinine level (p = 0.028), declination of potassium level (p < 0.001), and prolonged hospital stay (p < 0.001). CONCLUSIONS GI manifestations were common among patients with acetaminophen poisoning. This study suggests that the presence of GI manifestations at first presentation appears to be an important risk marker of subsequent hepatotoxicity and nephrotoxicity.
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Affiliation(s)
- Sa'ed H Zyoud
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia.
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Benhalim S, Leggett GE, Jamie H, Waring WS. Proteinuria is unrelated to the extent of acute acetaminophen overdose: a prospective clinical study. J Med Toxicol 2009; 4:232-7. [PMID: 19031374 DOI: 10.1007/bf03161206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Acute renal failure is a recognized complication of acute acetaminophen overdose. Its detection depends on rising creatinine concentrations, which is an insensitive method. The present study examined whether proteinuria might correspond with the extent of acute acetaminophen exposure as a possible early marker of renal effects. METHODS A prospective case-control study included patients attending the emergency department within 24 hours of acetaminophen ingestion. A urine specimen was collected within 12 hours of hospital attendance for creatinine, albumin, and protein determination. Equivalent 4-hour acetaminophen concentrations were used to indicate drug exposure: mild if >100 g/L (>662 mmol/L), moderate if 100-200 g/L (662-1323 mmol/L), or severe if <200 g/L (<1323 mmol/L). Data are presented as median (interquartile range) and groups compared using Mann Whitney and chi-square tests. RESULTS Seventy patients were studied (17 men, 53 women), age 37 years (23-45 years). The stated acetaminophen dose was 15 g (8-20 g), and interval between ingestion and presentation was 4.6 hours (4.1-7.9 hours). Urinary albumin concentrations were 8 mg/L (0-12 mg/L) in the mild group, 12 mg/L (5-25 mg/L) in the moderate group, and 11 mg/L (6-22 mg/L) in the severe group. Total protein concentrations were 90 mg/L (50-183 mg/L), 70 mg/L (40 to 130 mg/L), and 110 mg/L (75-205 mg/L), respectively. The proportions of patients who had urine albumin:creatinine ratio >3 mg/mmol were 20.8%, 23.5%, and 21.2%, respectively. None of the patients developed acute renal failure. CONCLUSIONS No relationship was found between the extent of acute acetaminophen exposure and proteinuria. Further work is required to examine whether urinary protein excretion is altered in patients who subsequently develop acute renal failure following acetaminophen overdose.
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Affiliation(s)
- Suzanne Benhalim
- Scottish Poisons Information Bureau, Royal Infirmary of Edinburgh, UK
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Waring WS. Onset and recovery of hepatic and renal injury after deliberate acute paracetamol overdose. BMJ Case Rep 2009; 2009:bcr08.2008.0806. [PMID: 21886662 DOI: 10.1136/bcr.08.2008.0806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 54-year-old woman presented to hospital after deliberate acute ingestion of paracetamol 20 g. Despite early administration of a standardised acetylcysteine regimen, the patient developed acute liver impairment and acute renal impairment. Prolonged acetylcysteine administration and supportive measures allowed restoration of normal liver and renal function. Early presentation to hospital and prolonged duration of follow-up gave an unusual opportunity to examine the onset and duration of paracetamol-induced hepatic and renal impairment.
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Affiliation(s)
- William Stephen Waring
- The Royal Infirmary of Edinburgh, Scottish Poisons Information Bureau, 51 Little France Crescent, Edinburgh, Edinburgh, EH16 4SA, UK
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