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Chiew AL, Isbister GK. Advances in the understanding of acetaminophen toxicity mechanisms: a clinical toxicology perspective. Expert Opin Drug Metab Toxicol 2023; 19:601-616. [PMID: 37714812 DOI: 10.1080/17425255.2023.2259787] [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: 05/15/2023] [Revised: 08/02/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Acetaminophen (paracetamol) is a commonly used analgesic and antipyretic agent, which is safe in therapeutic doses. Acetaminophen poisoning due to self-harm or repeated supratherapeutic ingestion is a common cause of acute liver injury. Acetylcysteine has been a mainstay of treatment for acetaminophen poisoning for decades and is efficacious if administered early. However, treatment failures occur if administered late, in 'massive' overdoses or in high-risk patients. AREAS COVERED This review provides an overview of the mechanisms of toxicity of acetaminophen poisoning (metabolic and oxidative phase) and how this relates to the assessment and treatment of the acetaminophen poisoned patient. The review focuses on how these advances offer further insight into the utility of novel biomarkers and the role of proposed adjunct treatments. EXPERT OPINION Advances in our understanding of acetaminophen toxicity have allowed the development of novel biomarkers and a better understanding of how adjunct treatments may prevent acetaminophen toxicity. Newly proposed adjunct treatments like fomepizole are being increasingly used without robust clinical trials. Novel biomarkers (not yet clinically available) may provide better assessment of these newly proposed adjunct treatments, particularly in clinical trials. These advances in our understanding of acetaminophen toxicity and liver injury hold promise for improved diagnosis and treatment.
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Affiliation(s)
- Angela L Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, Waratah, NSW, Australia
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2
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Filip AB, Mullins ME. Fomepizole should be used more liberally in paracetamol overdose. Br J Clin Pharmacol 2023; 89:594-598. [PMID: 36471569 DOI: 10.1111/bcp.15594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
Growing clinical and basic science data support the use of fomepizole as an adjunct to N-acetylcysteine in paracetamol poisoning. This safe antidote may be helpful in severely poisoned patients.
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Affiliation(s)
- Ari B Filip
- Arkansas Poison and Drug Information Center, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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3
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Yau CE, Chen H, Lim BPY, Ng M, Ponampalam R, Lim DYZ, Chin YH, Ho AFW. Performance of the paracetamol-aminotransferase multiplication product in risk stratification after paracetamol (acetaminophen) poisoning: a systematic review and meta-analysis. Clin Toxicol (Phila) 2023; 61:1-11. [PMID: 36444937 DOI: 10.1080/15563650.2022.2152350] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Risk stratification in paracetamol (acetaminophen) poisoning is crucial because hepatotoxicity is common and can be mitigated with treatment. However, current risk stratification tools have limitations. AIMS We evaluated the diagnostic performance of the paracetamol concentration × aminotransferase multiplication product, for predicting hepatotoxicity after paracetamol overdose. METHODS Medline, Cochrane Library and Embase were searched for eligible papers. We used random effects models to obtain pooled estimates of the likelihood ratios and diagnostic odds ratios, from which sensitivity and specificity were computed. We assessed two commonly used cut-off values of paracetamol × aminotransferase, 1500 mg/L × IU/L and 10,000 mg/L × IU/L. Using the confusion matrices of these two cut-offs, area under the summary receiver operator characteristic curve and optimal cut-off values in different clinical scenarios were established. RESULTS Six studies comprising 5036 participants were included. In 4051 patients, using the cut-off of 1500 mg/L × IU/L, a diagnostic odds ratio of 31.90 (95%CI: 9.52-106.90), sensitivity of 0.98 (95%CI: 0.94-1.00) and specificity of 0.66 (95%CI: 0.49-0.89) were obtained. In 3983 patients, using the cut-off of 10,000 mg/L × IU/L, a diagnostic odds ratio of 99.34 (95%CI: 12.26-804.87), sensitivity of 0.65 (95%CI: 0.51-0.82) and specificity of 0.97 (95%CI: 0.95-1.00) were obtained. For staggered ingestions, the 1500 mg/L × IU/L cut-off yielded a diagnostic odds ratio of 69.53 (95%CI: 4.03-1199.75), sensitivity of 1.00 (95%CI: 0.87-1.00) and specificity of 0.74 (95%CI: 0.43-1.00). Next, using the 10,000 mg/L × IU/L cut-off in this scenario yielded a diagnostic odds ratio of 254.58 (95%CI: 11.12-5827.60), sensitivity of 0.79 (95%CI: 0.59-1.00) and specificity of 0.98 (95%CI: 0.94-1.00). The overall summary receiver operator characteristic curve was 0.91 (95%CI: 0.75-0.97), and the optimal cut-off value was 3840 mg/L × IU/L. The summary receiver operator characteristic curve in patients with staggered ingestions was 0.96 (95%CI: 0.85-0.99). The summary receiver operator characteristic curve in patients with staggered ingestions and whose paracetamol concentration was below the detectable limit of 10 mg/L at presentation was 0.97 (95%CI: 0.94-0.99). CONCLUSION In this first meta-analysis, paracetamol × aminotransferase demonstrates its use in prognosticating hepatotoxicity in patients with paracetamol poisoning. It complements the Rumack-Matthew nomogram as it has shown promise in addressing two key limitations of the nomogram: it is usable after more than 24 h between overdose and acetylcysteine treatment, and it is applicable in staggered ingestions.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haoyang Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bryant Po-Yuen Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mingwei Ng
- SingHealth Toxicology Service; Singapore, Singapore
| | - R Ponampalam
- SingHealth Toxicology Service; Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
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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: 6] [Impact Index Per Article: 6.0] [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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Filip AB, Berg SE, Mullins ME, Schwarz ES. Fomepizole as an adjunctive therapy for acetaminophen poisoning: cases reported to the toxicology investigators consortium (ToxIC) database 2015-2020. Clin Toxicol (Phila) 2022; 60:1006-1011. [PMID: 35510880 DOI: 10.1080/15563650.2022.2070071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Fomepizole inhibits formation of toxic acetaminophen (APAP) metabolites and may prevent or reverse mitochondrial toxicity. Given these mechanisms, it may be beneficial in patients with severe APAP toxicity. Current patterns of use for this indication are not well-studied. METHODS This is a secondary analysis of patients enrolled in the Toxicology Investigators Consortium (ToxIC) database from January 2015 to July 2020. We queried cases in which APAP was listed as an ingested agent and fomepizole was also administered. We excluded cases in which APAP was not the primary agent, N-acetylcysteine (NAC) was not administered, or fomepizole was explicitly administered for another indication. Additionally, we sent a survey to each ToxIC site that administered fomepizole for APAP toxicity to better understand when, why, and how they were using it for this indication. RESULTS Twenty-five cases of fomepizole administration following an APAP ingestion met our inclusion criteria. There were one to four cases per year between 2015 and 2019 and eight cases in 2020. Seventeen of 25 (68%) cases were for a known acute ingestion. Eighteen of 25 (72%) patients developed hepatotoxicity (AST or ALT > 1000 IU/L) and 10 of 25 (40%) developed coagulopathy (PT > 15s). This was an ill patient population, with 18 of 25 (72%) developing metabolic acidosis (pH <7.20), 12 of 25 (48%) were intubated, 9 of 25 (36%) receiving vasopressors, and 6 of 25 (24%) receiving continuous renal replacement therapy. Overall, mortality was 24%. CONCLUSION The use of fomepizole is increasing in frequency in a small subset of critically ill and acutely APAP-poisoned patients.
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Affiliation(s)
- Ari B Filip
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sarah E Berg
- The Toxikon Consortium, Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan S Schwarz
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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- American College of Medical Toxicology, Phoenix, AZ, USA
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Lebin JA, Mudan A. Comment on Fomepizole as an adjunct in acetylcysteine treated acetaminophen overdose patients: a case series. Clin Toxicol (Phila) 2021; 60:665. [PMID: 34871121 DOI: 10.1080/15563650.2021.2009847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jacob A Lebin
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anita Mudan
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY, USA
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7
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Pourbagher-Shahri AM, Schimmel J, Shirazi FM, Nakhaee S, Mehrpour O. Use of fomepizole (4-methylpyrazole) for acetaminophen poisoning: A scoping review. Toxicol Lett 2021; 355:47-61. [PMID: 34785186 DOI: 10.1016/j.toxlet.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/30/2021] [Accepted: 11/11/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Acetaminophen (paracetamol, APAP) poisoning is a prominent global cause of drug-induced liver injury. While N-acetylcysteine (NAC) is an effective antidote, it has therapeutic limitations in massive overdose or delayed presentation. The objective is to comprehensively review the literature on fomepizole as a potential adjunct antidote for acetaminophen toxicity. METHODS A scoping review was performed using standardized search terms from inception through July 2021. RESULTS Reports on fomepizole as a therapeutic adjunct for APAP toxicity span heterogeneous types of evidence. Eleven preclinical studies (in vitro and animal), fourteen case reports/series, and one human volunteer study were included. Fomepizole's action is mediated by inhibition of CYP2E1 to prevent oxidant stress generation, and inhibition of c-Jun N-terminal kinase (JNK) to decrease amplification of oxidant stress signaling to mitochondria. Studies have shown a reduction in oxidative metabolites likely by shunting metabolism away from CYP2E1 and a resultant decrease in liver injury in animals, independent of CYP2E1 interactions. Fomepizole has been linked to few adverse effects. CONCLUSION Based on in vitro and animal studies, and bolstered by case reports, fomepizole likely offers benefit as an adjunct antidote for APAP toxicity, however this remains to be shown in a human trial. NAC remains the standard of care antidote, but given that fomepizole is approved and generally safe, it may be considered for APAP toxicity as off-label use by experienced clinicians, in rare circumstances associated with increased risk of hepatotoxicity despite standard NAC dosing. The marginal clinical benefit of fomepizole adjunct therapy beyond NAC monotherapy remains to be clearly defined, and routine use for APAP overdose is premature based on current evidence.
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Affiliation(s)
| | - Jonathan Schimmel
- Dept of Emergency Medicine, Division of Medical Toxicology, Mount Sinai Hospital Icahn School of Medicine, New York, NY, USA
| | - Farshad M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran; Data Science Institute, Southern Methodist University, Dallas, Texas, USA; Scientific Unlimited Horizon, Tucson, AZ, USA.
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8
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Link SL, Rampon G, Osmon S, Scalzo AJ, Rumack BH. Fomepizole as an adjunct in acetylcysteine treated acetaminophen overdose patients: a case series. Clin Toxicol (Phila) 2021; 60:472-477. [PMID: 34709101 DOI: 10.1080/15563650.2021.1996591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Acetaminophen (N-acetyl-para-aminophenol or APAP) is the leading cause of acute liver failure worldwide. Standard therapy for APAP overdose is with IV N-acetylcysteine (NAC). However, overdose patients treated with NAC can still incur hepatotoxicity in some circumstances. Fomepizole has proven safety in methanol and ethylene glycol poisoning and is a potent CYP2E1 and c-Jun-N-terminal Kinase (JNK) inhibitor that is effective even in the metabolic phase. METHODS We present a prospective case series of 14 consecutive, high-risk patients who had elevated APAP levels after overdose who were treated with fomepizole as an adjunct to standard IV-NAC. The attending toxicologist utilized clinical judgement to determine the use of fomepizole, especially if APAP levels persisted due to altered half-life or risk factors for toxicity. RESULTS There were no unfavorable outcomes in any patient, which were better than expected. CONCLUSIONS This case series has demonstrated the safety of fomepizole in high-risk APAP overdose. The efficacy of fomepizole needs to be further elucidated through controlled clinical trials on a larger scale. In massive APAP overdoses, fomepizole should be considered as an adjunct due to the known failure rate of NAC and the safety profile of fomepizole.
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Affiliation(s)
- Stephanie L Link
- Saint Louis University Pulmonary and Critical Care Medicine, St. Louis, MO, USA
| | - Garrett Rampon
- University of Kansas Pulmonary and Critical Care Medicine, Kansas City, MO, USA
| | - Stephen Osmon
- Former Saint Louis University Pulmonary and Critical Care Medicine, St. Louis, MO, USA
| | - Anthony J Scalzo
- Saint Louis University Division of Toxicology, St. Louis, MO, USA
| | - Barry H Rumack
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Shah KR, Beuhler MC. Single bag high dose intravenous N-acetylcysteine associated with decreased hepatotoxicity compared to triple bag intravenous N-acetylcysteine in high-risk acetaminophen ingestions. Clin Toxicol (Phila) 2021; 60:493-498. [PMID: 34549670 DOI: 10.1080/15563650.2021.1979231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION There is controversy that the triple bag intravenous (IV) N-acetylcysteine (NAC) regimen may be underdosing the sickest patients in its current, common usage. We hypothesize that a higher dose IV NAC regimen improves some outcomes. METHODS We conducted a poison center based retrospective observational study from January 1, 2016 to December 31, 2017 comparing a single bag higher dose IV NAC regimen (150 mg/kg over 1 h, 15 mg/kg/hour) to the triple bag IV NAC regimen (150 mg/kg over 1 h, 12.5 mg/kg/hour for 4 h, 6.25 mg/kg/hour). In a high-risk population of patients with acetaminophen ingestion (defined as multiplication product ≥ 10,000 mg/L IU/L, not acute ingestions receiving NAC within 8 h, and not hepatotoxic on first contact), we evaluated the rate of hepatotoxicity, peak transaminase, and rate of laboratory coagulopathy. RESULTS 89 patients met the inclusion criteria. 12 of the 23 patients (52%) who received triple bag NAC became hepatotoxic and 10 (43%) became coagulopathic, while only 19 of 66 patients (29%) who received single bag NAC became hepatotoxic and 15 (23%) became coagulopathic; p = .043 and .057, resp. Mean peak transaminase was 4481 IU/L vs 2143 IU/L in those receiving triple bag NAC vs single bag NAC, difference of means 2338 IU/L; p = .026. CONCLUSION In this exploratory study of a high-risk population of patients with acetaminophen ingestions, the single bag IV NAC regimen was associated with lower peak transaminase and fewer patients becoming hepatotoxic as compared to the triple bag IV NAC regimen.
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Affiliation(s)
- Kartik R Shah
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
| | - Michael C Beuhler
- North Carolina Poison Control, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
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10
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Abstract
Acetaminophen is a common medication taken in deliberate self-poisoning and unintentional overdose. It is the commonest cause of severe acute liver injury in Western countries. The optimal management of most acetaminophen poisonings is usually straightforward. Patients who present early should be offered activated charcoal and those at risk of acute liver injury should receive acetylcysteine. This approach ensures survival in most. The acetaminophen nomogram is used to assess the need for treatment in acute immediate-release overdoses with a known time of ingestion. However, scenarios that require different management pathways include modified-release, large/massive, and repeated supratherapeutic ingestions.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Barker Street, Randwick, New South Wales 2031, Australia.
| | - Nicholas A Buckley
- Pharmacology and Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2050, Australia
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Yen JS, Hu CC, Huang WH, Hsu CW, Yen TH, Weng CH. An artificial intelligence algorithm for analyzing acetaminophen-associated toxic hepatitis. Hum Exp Toxicol 2021; 40:1947-1954. [PMID: 33955253 DOI: 10.1177/09603271211014587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Very little artificial intelligence (AI) work has been performed to investigate acetaminophen-associated hepatotoxicity. The objective of this study was to develop an AI algorithm for analyzing weighted features for toxic hepatitis after acetaminophen poisoning. METHODS The medical records of 187 patients with acetaminophen poisoning treated at Chang Gung Memorial Hospital were reviewed. Patients were sorted into two groups according to their status of toxic hepatitis. A total of 40 clinical and laboratory features recorded on the first day of admission were selected for algorithm development. The random forest classifier (RFC) and logistic regression (LR) were used for artificial intelligence algorithm development. RESULTS The RFC-based AI model achieved the following results: accuracy = 92.5 ± 2.6%; sensitivity = 100%; specificity = 60%; precision = 92.3 ± 3.4%; and F1 = 96.0 ± 1.8%. The area under the receiver operating characteristic curve (AUROC) was approximately 0.98. The LR-based AI model achieved the following results: accuracy = 92.00 ± 2.9%; sensitivity = 100%; specificity = 20%; precision = 92.8 ± 3.4%; recall = 98.8 ± 3.4%; and F1 = 95.6 ± 1.5%. The AUROC was approximately 0.68. The weighted features were calculated, and the 10 most important weighted features for toxic hepatitis were aspartate aminotransferase (ALT), prothrombin time, alanine aminotransferase (AST), time to hospital, platelet count, lymphocyte count, albumin, total bilirubin, body temperature and acetaminophen level. CONCLUSION The top five weighted features for acetaminophen-associated toxic hepatitis were ALT, prothrombin time, AST, time to hospital and platelet count.
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Affiliation(s)
- J-S Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou
| | - C-C Hu
- College of Medicine, Chang Gung University, Taoyuan.,Department of Hepatogastroenterology and Liver Research Unit, Chang Gung Memorial Hospital, Keelung
| | - W-H Huang
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - C-W Hsu
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - T-H Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou
| | - C-H Weng
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
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12
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Chiew AL, James LP, Isbister GK, Pickering JW, McArdle K, Chan BSH, Buckley NA. Early acetaminophen-protein adducts predict hepatotoxicity following overdose (ATOM-5). J Hepatol 2020; 72:450-462. [PMID: 31760072 DOI: 10.1016/j.jhep.2019.10.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND & AIMS Acetaminophen-protein adducts are specific biomarkers of toxic acetaminophen (paracetamol) metabolite exposure. In patients with hepatotoxicity (alanine aminotransferase [ALT] >1,000 U/L), an adduct concentration ≥1.0 nmol/ml is sensitive and specific for identifying cases secondary to acetaminophen. Our aim was to characterise acetaminophen-protein adduct concentrations in patients following acetaminophen overdose and determine if they predict toxicity. METHODS We performed a multicentre prospective observational study, recruiting patients 14 years of age or older with acetaminophen overdose regardless of intent or formulation. Three serum samples were obtained within the first 24 h of presentation and analysed for acetaminophen-protein adducts. Acetaminophen-protein adduct concentrations were compared to ALT and other indicators of toxicity. RESULTS Of the 240 patients who participated, 204 (85%) presented following acute ingestions, with a median ingested dose of 20 g (IQR 10-40), and 228 (95%) were treated with intravenous acetylcysteine at a median time of 6 h (IQR 3.5-10.5) post-ingestion. Thirty-six (15%) patients developed hepatotoxicity, of whom 22 had an ALT ≤1,000 U/L at the time of initial acetaminophen-protein adduct measurement. Those who developed hepatotoxicity had a higher initial acetaminophen-protein adduct concentration compared to those who did not, 1.63 nmol/ml (IQR 0.76-2.02, n = 22) vs. 0.26 nmol/ml (IQR 0.15-0.41; n = 204; p <0.0001), respectively. The AUROC for hepatotoxicity was 0.98 (95% CI 0.96-1.00; n = 226; p <0.0001) with acetaminophen-protein adduct concentration and 0.89 (95% CI 0.82-0.96; n = 219; p <0.0001) with ALT. An acetaminophen-protein adduct concentration of 0.58 nmol/ml was 100% sensitive and 91% specific for identifying patients with an initial ALT ≤1,000 U/L who would develop hepatotoxicity. Adding acetaminophen-protein adduct concentrations to risk prediction models improved prediction of hepatotoxicity to a level similar to that obtained by more complex models. CONCLUSION Acetaminophen-protein adduct concentration on presentation predicted which patients with acetaminophen overdose subsequently developed hepatotoxicity, regardless of time of ingestion. An adduct threshold of 0.58 nmol/L was required for optimal prediction. LAY SUMMARY Acetaminophen poisoning is one of the most common causes of liver injury. This study examined a new biomarker of acetaminophen toxicity, which measures the amount of toxic metabolite exposure called acetaminophen-protein adduct. We found that those who developed liver injury had a higher initial level of acetaminophen-protein adducts than those who did not. CLINICAL TRIAL REGISTRATION Australian Toxicology Monitoring (ATOM) Study-Australian Paracetamol Project: ACTRN12612001240831 (ANZCTR) Date of registration: 23/11/2012.
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Affiliation(s)
- Angela L Chiew
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, Australia; Department of Clinical Toxicology, Prince of Wales Hospital, Sydney, Australia; NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia.
| | - Laura P James
- Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Geoffrey K Isbister
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia; Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - John W Pickering
- Department of Medicine, University of Otago Christchurch, and Emergency Department Christchurch Hospital, Christchurch, New Zealand
| | - Kylie McArdle
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia; Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Betty S H Chan
- Department of Clinical Toxicology, Prince of Wales Hospital, Sydney, Australia; NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia
| | - Nicholas A Buckley
- Department of Pharmacology, School of Medical Sciences, University of Sydney, Sydney, Australia; NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia
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Shah KR, Beuhler MC. Fomepizole as an Adjunctive Treatment in Severe Acetaminophen Toxicity. Am J Emerg Med 2019; 38:410.e5-410.e6. [PMID: 31785979 DOI: 10.1016/j.ajem.2019.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 11/30/2022] Open
Abstract
A 33-year-old male presented to the emergency department with a chief complaint of abdominal pain after taking #50 500 mg acetaminophen tablets over the preceding two days. He was tachycardic and tachypneic, and the initial labs were notable for acetaminophen level, 337 mg/L; AST, 137 IU/L; ALT, 194 IU/L; ABG pH, 7.24; and lactate, 4.1 mmol/L. The patient was started on IV N-Acetylcysteine (NAC) as well as given a single dose of 15 mg/kg fomepizole. The patient did remarkably well, with a peak AST of 198 IU/L, peak ALT of 301 IU/L, and peak INR of 3.1. Biochemical and animal data support fomepizole having hepatoprotective effects in acetaminophen poisoning. To our knowledge, this is the first human case of an intentional dual NAC/fomepizole regimen for severe acetaminophen toxicity.
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Affiliation(s)
- Kartik R Shah
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Medical Education Building, 3rd Floor, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Michael C Beuhler
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, North Carolina Poison Control, 4400 Golf Acres Drive, Suite B-2, Charlotte, NC, 28203, USA.
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Gloor Y, Schvartz D, F Samer C. Old problem, new solutions: biomarker discovery for acetaminophen liver toxicity. Expert Opin Drug Metab Toxicol 2019; 15:659-669. [PMID: 31293190 DOI: 10.1080/17425255.2019.1642323] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Although the hepatotoxicity of acetaminophen is a well-known problem, the search for reliable biomarker of toxicity is still a current issue as clinical tools are missing to assess patients intoxicated following chronic use, sequential ingestion, use of modified release formulations or in case of delayed arrival to hospital. The need for new specific and robust biomarkers for acetaminophen toxicity has prompted many studies exploring the use of blood levels of acetaminophen derivatives, mitochondrial damage markers, liver cell apoptosis and/or necrosis markers and circulating microRNAs. Areas covered: In this review, we present a concise overview of the most promising biomarkers currently under evaluation including descriptions of their properties with respect to exposure type, APAP specificity, and potential clinical application. In addition, we illustrate the power of new technologies for biomarker research and describe their current application to the field of acetaminophen-induced hepatotoxicity. Expert opinion: Recently the use of extracellular vesicles isolation in combination with omics techniques has opened a new perspective to the field of biomarker research. However, the potential of those new technologies for the prediction and monitoring of hepatic diseases and acetaminophen toxicity has not yet been fully taken into consideration.
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Affiliation(s)
- Yvonne Gloor
- a Division of clinical pharmacology and toxicology, Geneva University Hospital , Geneva , Switzerland.,b Laboratory of clinical pharmacology, Faculty of Medicine, University of Geneva , Geneva , Switzerland
| | - Domitille Schvartz
- c Department of internal medicine specialties, Faculty of Medicine, University of Geneva , Geneva , Switzerland
| | - Caroline F Samer
- a Division of clinical pharmacology and toxicology, Geneva University Hospital , Geneva , Switzerland.,b Laboratory of clinical pharmacology, Faculty of Medicine, University of Geneva , Geneva , Switzerland
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15
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Egan H, Isbister GK, Robinson J, Downes M, Chan BS, Vecellio E, Chiew AL. Retrospective evaluation of repeated supratherapeutic ingestion (RSTI) of paracetamol. Clin Toxicol (Phila) 2019; 57:703-711. [DOI: 10.1080/15563650.2018.1547829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Harry Egan
- Prince of Wales Hospital Clinical School, University of NSW, NSW, Australia
| | - Geoffrey K. Isbister
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle and Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
| | - Jennifer Robinson
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle and Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
| | - Michael Downes
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle and Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
| | - Betty S. Chan
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Elia Vecellio
- NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Angela L. Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
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16
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Wong A, McNulty R, Taylor D, Sivilotti M, Greene S, Gunja N, Koutsogiannis Z, Graudins A. The NACSTOP Trial: A Multicenter, Cluster-Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose. Hepatology 2019; 69:774-784. [PMID: 30125376 DOI: 10.1002/hep.30224] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 08/13/2018] [Indexed: 12/07/2022]
Abstract
Historically, intravenous acetylcysteine has been delivered at a fixed dose and duration of 300 mg/kg over 20 to 21 hours to nearly every patient deemed to be at any risk for hepatotoxicity following acetaminophen overdose. We investigated a 12-hour treatment regimen for selected low-risk patients. This was a multicenter, open-label, cluster-controlled trial at six metropolitan emergency departments. We enrolled subjects following single or staggered acetaminophen overdose with normal serum alanine transaminase (ALT) and creatinine on presentation and at 12 hours, and less than 20 mg/L acetaminophen at 12 hours. Patients were allocated to intervention (250 mg/kg over 12-hour) or control (300 mg/kg over 20-hour) regimens by site. The primary outcome was incidence of "hepatic injury" 20 hours following initiation of acetylcysteine treatment, defined as ALT doubling and peak ALT greater than 100 IU/L, indicating the need for further antidotal treatment. Secondary outcomes included incidence of hepatotoxicity (ALT > 1,000 IU/L), peak international normalized ratio (INR), and adverse drug reactions. Of the 449 acetaminophen overdoses receiving acetylcysteine, 100 were recruited to the study. Time to acetylcysteine (median 7 hours [interquartile ratio 6,12] versus 7 hours [6,10]) and initial acetaminophen (124 mg/L [58,171] versus 146 mg/L [66,204]) were similar between intervention and control groups. There was no difference in ALT (18 IU/L [13,22] versus 16 IU/L [13,21]) or INR (1.2 versus 1.2) 20 hours after starting acetylcysteine between groups. No patients developed hepatic injury or hepatotoxicity in either group (odds ratio 1.0 [95% confidence interval 0.02, 50]). No patients represented with liver injury, none died, and 96 of 96 were well at 14-day telephone follow-up. Conclusion: Discontinuing acetylcysteine based on laboratory testing after 12 hours of treatment is feasible and likely safe in selected patients at very low risk of liver injury from acetaminophen overdose.
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Affiliation(s)
- Anselm Wong
- School of Clinical Sciences, Monash University, Victoria, Australia.,Victorian Poisons Information Center and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
| | - Richard McNulty
- Department of Emergency Medicine, Blacktown and Mount Druitt Hospitals, Western Sydney Toxicology Service, NSW, Australia
| | - David Taylor
- Emergency Department and Department of Medicine, Austin Hospital, Heidelberg, Australia
| | - Marco Sivilotti
- Departments of Emergency and Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Shaun Greene
- Victorian Poisons Information Center and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
| | - Naren Gunja
- Western Sydney Toxicology Service, Sydney Medical School, NSW, Australia
| | - Zeff Koutsogiannis
- Victorian Poisons Information Center and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
| | - Andis Graudins
- Monash Toxicology Service and Monash Emergency Research Collaborative, Dandenong Hospital, School of Clinical Sciences, Monash University, Victoria, Australia
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17
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Wong A, Homer N, Dear JW, Choy KW, Doery J, Graudins A. Paracetamol metabolite concentrations following low risk overdose treated with an abbreviated 12-h versus 20-h acetylcysteine infusion. Clin Toxicol (Phila) 2018; 57:312-317. [PMID: 30453788 DOI: 10.1080/15563650.2018.1517881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CONTEXT To compare degree of liver injury and paracetamol metabolite concentrations after treatment with standard of care (20-h) vs. abbreviated (12-h) acetylcysteine regimens used in paracetamol overdose (NACSTOP trial). METHODS Timed blood samples from a cohort of subjects enrolled in the cluster-controlled NACSTOP trial evaluating a 12-h acetylcysteine regimen (200 mg/kg over 4 h, 50 mg/kg over 8 h) were assayed for paracetamol metabolites as a pilot study, using liquid chromatography/mass spectrometry. Control group subjects received a 20-h course of acetylcysteine (200 mg/kg over 4 h, 100 mg/kg over 16 h). The intervention group received a 12-h acetylcysteine regimen (stopped after at least 12 h of treatment). Positive control groups not in the trial with acute liver injury (ALI) or hepatotoxicity were also studied. RESULTS One hundred and forty-one blood samples were collected from 40 patients receiving acetylcysteine after paracetamol overdose. Median ALT after 20 h of acetylcysteine was 12 U/L (IQR 8.14) in the abbreviated regimen group, compared to the control group 16 U/L (IQR 11.21) (p = .46). There was no significant difference in median metabolite concentrations on presentation and after 20 h of acetylcysteine between these two groups (p > .05). Presentation median sum CYP-metabolite/total metabolite percentages were 2.5 and 3.0 in the abbreviated and control NACSTOP groups, respectively. CONCLUSIONS An abbreviated 12-h acetylcysteine regimen for paracetamol overdose used in the NACSTOP trial had similar circulating metabolite concentrations compared to a 20-h regimen in selected subjects with low risk of hepatotoxicity. This suggests that further acetylcysteine may not be needed in the abbreviated group at time of cessation.
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Affiliation(s)
- Anselm Wong
- a Monash Toxicology Unit and Emergency Medicine Service , Monash Health , Victoria , Australia.,b Department of Medicine, School of Clinical Sciences , Monash University , Victoria , Australia.,c Austin Toxicology Service , Austin Health , Victoria , Australia
| | - Natalie Homer
- d Edinburgh Clinical Research Facility , Queen's Medical Research Institute , Edinburgh , UK
| | - James W Dear
- e Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Sciences , University of Edinburgh , Edinburgh , UK
| | - Kay Weng Choy
- f Monash Pathology , Monash Health , Victoria , Australia
| | - James Doery
- b Department of Medicine, School of Clinical Sciences , Monash University , Victoria , Australia.,f Monash Pathology , Monash Health , Victoria , Australia
| | - Andis Graudins
- a Monash Toxicology Unit and Emergency Medicine Service , Monash Health , Victoria , Australia.,b Department of Medicine, School of Clinical Sciences , Monash University , Victoria , Australia
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Pattern of Paracetamol Poisoning: Influence on Outcome and Complications. TOXICS 2018; 6:toxics6040058. [PMID: 30274302 PMCID: PMC6315900 DOI: 10.3390/toxics6040058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/24/2018] [Accepted: 09/28/2018] [Indexed: 02/01/2023]
Abstract
Acute paracetamol poisoning due to a single overdose may be effectively treated by the early administration of N-acetylcysteine (NAC) as an antidote. The prognosis may be different in the case of intoxication due to multiple ingestions or when the antidote is started with delay. The aim of this work was to investigate the outcome of paracetamol poisoning according to the pattern of ingestion and determine the factors associated with the outcome. We performed a retrospective analysis over the period 2007–2017 of the patients who were referred to a tertiary hospital for paracetamol-related hepatotoxicity. Inclusion criteria were: accidental or voluntary ingestion of paracetamol, delay for NAC therapy of 12 h or more, liver enzymes (ALT) >1000 IU/L on admission. Ninety patients were considered. Poisoned patients following multiple ingestion were significantly older (45 ± 12 vs. 33 ± 14) (p = 0.001), with a higher incidence of liver steatosis (p = 0.016) or chronic ethanol abuse (p = 0.04). In comparison with the subgroup of favorable outcome, the patients with poor outcome were older, had higher values for ALT, bilirubin, lactate, and lower values for factor V and arterial pH. In multivariate analysis, the arterial lactate value was associated with a bad prognosis (p < 0.02) (adjusted odds ratio 1.74 and CI 95:1.09–2.77). The risk of poor outcome was greater in the subgroup with staggered overdose (p = 0.02), which had a higher mortality rate (p = 0.01). This retrospective analysis illustrates the different population patterns of patients who were admitted for a single ingestion of a paracetamol overdose versus multiple ingestions. This last subgroup was mainly represented by older patients with additional risk factors for hepatotoxicity; arterial lactate was a good predictor of severity.
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Wong A, Sivilotti MLA, Gunja N, McNulty R, Graudins A. Accuracy of the paracetamol-aminotransferase product to predict hepatotoxicity in paracetamol overdose treated with a 2-bag acetylcysteine regimen. Clin Toxicol (Phila) 2017; 56:182-188. [PMID: 28756679 DOI: 10.1080/15563650.2017.1355058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Paracetamol concentration is a highly accurate risk predictor for hepatotoxicity following overdose with known time of ingestion. However, the paracetamol-aminotransferase multiplication product can be used as a risk predictor independent of timing or ingestion type. Validated in patients treated with the traditional, "three-bag" intravenous acetylcysteine regimen, we evaluated the accuracy of the multiplication product in paracetamol overdose treated with a two-bag acetylcysteine regimen. METHODS We examined consecutive patients treated with the two-bag regimen from five emergency departments over a two-year period. We assessed the predictive accuracy of initial multiplication product for the primary outcome of hepatotoxicity (peak alanine aminotransferase ≥1000IU/L), as well as for acute liver injury (ALI), defined peak alanine aminotransferase ≥2× baseline and above 50IU/L). RESULTS Of 447 paracetamol overdoses treated with the two-bag acetylcysteine regimen, 32 (7%) developed hepatotoxicity and 73 (16%) ALI. The pre-specified cut-off points of 1500 mg/L × IU/L (sensitivity 100% [95% CI 82%, 100%], specificity 62% [56%, 67%]) and 10,000 mg/L × IU/L (sensitivity 70% [47%, 87%], specificity of 97% [95%, 99%]) were highly accurate for predicting hepatotoxicity. There were few cases of hepatotoxicity irrespective of the product when acetylcysteine was administered within eight hours of overdose, when the product was largely determined by a high paracetamol concentration but normal aminotransferase. CONCLUSIONS The multiplication product accurately predicts hepatotoxicity when using a two-bag acetylcysteine regimen, especially in patients treated more than eight hours post-overdose. Further studies are needed to assess the product as a method to adjust for exposure severity when testing efficacy of modified acetylcysteine regimens.
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Affiliation(s)
- Anselm Wong
- a Department of Medicine , School of Clinical Sciences, Monash University , Victoria , Australia.,b Austin Toxicology Service and Victorian Poisons Information Centre, Austin Health , Victoria , Australia
| | - Marco L A Sivilotti
- c Departments of Emergency Medicine and Biomedical & Molecular Sciences , Queen's University , Kingston , Canada
| | - Naren Gunja
- d Westmead and Blacktown Hospitals , Western Sydney Toxicology Service , Sydney , Australia
| | - Richard McNulty
- d Westmead and Blacktown Hospitals , Western Sydney Toxicology Service , Sydney , Australia
| | - Andis Graudins
- a Department of Medicine , School of Clinical Sciences, Monash University , Victoria , Australia.,e Monash Toxicology Service, Monash Health , Dandenong , Australia
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20
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Pharmacokinetic modelling of modified acetylcysteine infusion regimens used in the treatment of paracetamol poisoning. Eur J Clin Pharmacol 2017. [DOI: 10.1007/s00228-017-2277-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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21
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Wong A, Graudins A. Risk prediction of hepatotoxicity in paracetamol poisoning. Clin Toxicol (Phila) 2017; 55:879-892. [DOI: 10.1080/15563650.2017.1317349] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Toxicology Service, Program of Emergency Medicine, Monash Health, Clayton, Australia
| | - Andis Graudins
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Toxicology Service, Program of Emergency Medicine, Monash Health, Clayton, Australia
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22
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Wong A, Sivilotti MLA, Graudins A. Accuracy of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity in modified-release paracetamol overdose. Clin Toxicol (Phila) 2017; 55:346-351. [DOI: 10.1080/15563650.2017.1290253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Heidelberg, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Marco L. A. Sivilotti
- Departments of Emergency Medicine and of Biomedical & Molecular Sciences, Queen’s University, Kingston, Canada
| | - Andis Graudins
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Emergency Medicine and Toxicology Research, Monash Health, Victoria, Australia
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23
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Wong A, Graudins A. N-acetylcysteine regimens for paracetamol overdose: Time for a change? Emerg Med Australas 2016; 28:749-751. [DOI: 10.1111/1742-6723.12610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Anselm Wong
- Emergency and Austin Toxicology Service; Austin Hospital; Melbourne Victoria Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
| | - Andis Graudins
- Monash Emergency Research Collaborative, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
- Monash Toxicology Service, Program of Emergency Medicine; Monash Health; Melbourne Victoria Australia
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36th International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 24-27 May, 2016, Madrid, Spain. Clin Toxicol (Phila) 2016; 54:344-519. [DOI: 10.3109/15563650.2016.1165952] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Riggan M, Sayegh M, Choi W, Hoffman RS. Letter in response to: External validation of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity from paracetamol overdose. Clin Toxicol (Phila) 2015; 53:1155-6. [PMID: 26569383 DOI: 10.3109/15563650.2015.1104537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Morgan Riggan
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , 455 First Avenue 124 , NY 10016 , USA
| | - Mireille Sayegh
- b Department of Medicine , University of Ottawa , Ontario , Canada
| | - Wayne Choi
- c Department of Emergency Medicine , McGill University , Montreal , Quebec , Canada
| | - Robert S Hoffman
- d Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , NY , USA
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26
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Buckley NA, Chiew AL. Re: External validation of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity from paracetamol overdose. Clin Toxicol (Phila) 2015; 53:1152-3. [PMID: 26467097 DOI: 10.3109/15563650.2015.1096367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Nicholas A Buckley
- a Department of Pharmacology , School of Medical Sciences, University of Sydney , Sydney , New South Wales , Australia
| | - Angela L Chiew
- a Department of Pharmacology , School of Medical Sciences, University of Sydney , Sydney , New South Wales , Australia.,b Clinical and Experimental Toxicology Unit, Department of Emergency Medicine , Prince of Wales Hospital , Randwick , NSW , Australia
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