Does Mixing Activated Charcoal With Cola Improve Tolerability Without Affecting Pharmacokinetics? A Randomized Controlled Crossover Trial

INTRODUCTION

Activated charcoal is the most common form of gastrointestinal decontamination used for the poisoned patient. One limitation to its use is patient tolerability due to palatability. Some recommend mixing activated charcoal with cola to improve palatability. An important question is whether mixing activated charcoal with cola affects the ability of the activated charcoal to adsorb xenobiotic.

METHODS

This was a prospective randomized controlled crossover trial. Five healthy adults aged 18 to 40 years were recruited. Participants received 45 mg/kg acetaminophen rounded down to the nearest whole tablet. One hour later, they were randomized to receive 50 g of an activated charcoal-water premixture alone or mixed with cola. Acetaminophen levels were collected. The area under the curve of acetaminophen concentrations over time was measured as a marker for degree of absorption. Participants also completed an appeal questionnaire in which they rated the activated charcoal preparations. Participants would then return after at least 7 days to repeat the study with the other activated charcoal preparation.

RESULTS

Four male participants and 1 female participant were recruited. There was no statistical difference in preference score for activated charcoal alone versus the cola-activated charcoal mixture. There was no statistical difference in the area under the curve of acetaminophen concentrations over time between activated charcoal alone and the cola-activated charcoal mixture. Of note, the study is limited by the small sample size, limiting its statistical power.

DISCUSSION

The absorption of acetaminophen in an overdose model is no different when participants received activated charcoal alone or a cola-activated charcoal mixture as suggested by area under the curve. In this small study, there was no difference in preference for activated charcoal alone or a cola-activated charcoal mixture across a range of palatability questions. On an individual level, some participants preferred the activated charcoal-cola mixture, and some preferred the activated charcoal alone.

Effect of Taste Additives on the Palatability of Activated Charcoal: a Systematic Review

INTRODUCTION

Activated charcoal is a decontaminating agent used for acute intoxication. It can be mixed with taste additives to overcome its poor palatability. Our purpose was to evaluate the taste additives used to improve activated charcoal's palatability.

METHODS

We conducted a systematic review of comparative studies on taste additives used to improve activated charcoal's palatability. We searched PubMed, Embase, Web of Science, Cochrane, and CINAHL. We included controlled trials and observational studies that evaluate the effect of at least one taste additive, compared with activated charcoal alone. Our primary outcome was palatability. Our secondary outcomes included treatment adherence, adsorption efficacy, and adverse events. The risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Among 38 eligible articles, seven observational studies and three crossover clinical trials met our inclusion criteria. The risk of bias was found to be high for seven studies and intermediate for three others. The preferred flavoring agents were cola and chocolate milk for children, and sweetening agents for adults. All taste additives studied seemed to improve activated charcoal's palatability, except for yogurt (n = 1). The addition of bentonite, sorbitol, carboxymethylcellulose, or yogurt showed no impact on the in-vivo adsorption capacity of activated charcoal, whereas the results were inconclusive for chocolate. No meta-analysis was performed due to insufficient data.

CONCLUSION

Strategies to improve activated charcoal's palatability seem to enhance the taste. Descriptive data are in favor of a limited impact on activated charcoal's adsorption capacity when adding binding agents or sweeteners.

TRIAL REGISTRATION ON PROSPERO

This review is registered as PROSPERO CRD42019135092.

Dispensing of minitablets - Has the problem been resolved?

Recently, minitablets have been given extensive coverage in literature, as they are perfectly matched to the current therapy individualization trend. Within this scope, special attention is paid to minitablets that enable convenient drug intake for patients with swallowing problem. However, the packaging system, dispensing the necessary amount of drug units and safe administration still remain unsolved problems or are partially overlooked. Although there are many different approaches towards dosing tablets, only a few seem to be tailored to particularly small tablets. Moreover, none of these approaches meets all the user's expectations. This paper comprehensively elaborates and critically discusses the available dosing options like sachets, blisters, home electronic dispensing systems and minitablets manual dispensers. Additional tests have been also conducted to simulate the handling and dosing procedure with 2 mm diameter placebo minitablets. Despite many advantageous inventions, it has been revealed that further efforts are necessary to identify the optimal design that would allow to eliminate the shaking procedure, adjust cavities diameter or provide better protection against humidity. Nevertheless, the current trend may lead to individual therapy becoming more convenient, safe and reliable, especially in pediatric and geriatric patients.

The effect of administration media on palatability and ease of swallowing of multiparticulate formulations

Multiparticulate formulations based on pellets, granules or beads, could be advantageous for paediatrics, geriatrics and patients with swallowing difficulties. However, these formulations may require suitable administration media to facilitate administration. The aim of this work was to investigate the effect of administration media properties on palatability and ease of swallowing of multiparticulates. A range of vehicles were developed using xanthan gum (XG) and carboxymethyl cellulose (CMC) as model hydrocolloids. Such vehicles were prepared at three consistency levels (Level 1 - 'syrup', Level 2 - 'custard' and Level 3 - 'pudding') to investigate the effect of viscosity on their performance as administration media. A randomised, single-blind sensory evaluation study was carried out in thirty healthy adult volunteers using microcrystalline cellulose pellets as model multiparticulates, dispersed in the hydrogels (and water as control) at a concentration of 250 mg in 5 ml. Samples were evaluated using 5-point scales. The use of hydrogels as administration media improved a range of sample attributes compared to water formulations, including appearance, taste, mouthfeel, ease of swallowing and residue in the mouth (all improved by ca. 0,5 points) and oral grittiness perception (improved by ca. 1 point). Polymeric hydrogels thickened to medium consistency (Level 2, XG 0.5% and CMC 1.0% w/v) demonstrated the best performance.

Application properties of oral gels as media for administration of minitablets and pellets to paediatric patients

Modern solid multiparticulate drug forms (minitablets, pellets, granules) can provide the possibility of precise dosing or modified drug release or taste masking for medicines used in children. However, these solid particles require an adequate medium to ease swallowing. The aim of the research was to design a universal semisolid dispersing medium for administration of minitablets and pellets. High viscosity sodium carmellose and carbomer were considered as gelling agents. The hydrogels were prepared with sucrose, glycerol, and potassium sorbate or parabens. Preliminary studies were undertaken to estimate the application properties of the gels under conditions where a medicine is administered to a child. Besides standard tests (viscosity, sedimentation) the following measurements were conducted: gel ductility, mass of the gel removed from a spoon under shaking, ability of the gels to disperse solid particles, and disintegration of minitablets in the gels. The oral hydrogels prepared either with 1.0% and 1.5% carmellose or 0.25% and 0.5% (w/w) carbomer were suitable for dispersing and delivery of minitablets or pellets. Not only viscosity but also ductility was an essential criterion in selecting the best vehicle. The in vivo perceptibility test for pellets and minitablets did not confirm that gels are more advantageous than syrups.

Evaluation of the odour of Aminoleban® EN, taste-masked with flavoured powders, by human and electronic noses

OBJECTIVES

Aminoleban® EN is a bitter total enteral nutrient product with an unpleasant odour. The purpose of this study was to evaluate the odour of Aminoleban® EN, taste-masked with various flavoured powders, by human testing and by using an electronic nose system (Alpha M.O.S.).

METHODS

Initially, the odour of Aminoleban® EN alone at various concentrations was evaluated. Secondly, the odour of Aminoleban® EN with the addition of various flavoured powders was evaluated; the evaluation included data on odour intensity, preference levels and evoked taste image.

KEY FINDINGS

With the human nose, a concentration of 0.43 g/100 ml seemed to be the taste threshold for Aminoleban® EN. In the electronic nose system, principal component analysis revealed that concentrations over 0.39 g/100 ml Aminoleban® EN could be distinguished from water. It was clear from both human testing and using the electronic nose system that the unpleasant odour of Aminoleban® EN could be masked by pineapple- and plum-flavoured powders, both of which contain not only sweet but also sour components.

CONCLUSIONS

The electronic nose system may be useful for detecting odours at or below the level detectable by the human olfactory system and for classifying the quality of different odours, thus reducing the amount of human testing required.