1
|
Mehrpour O, Saeedi F, Hadianfar A, Mégarbane B, Hoyte C. Prognostic factors of acetaminophen exposure in the United States: An analysis of 39,000 patients. Hum Exp Toxicol 2021; 40:S814-S825. [PMID: 34772307 DOI: 10.1177/09603271211061503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acetaminophen is a frequently used over-the-counter or prescribed medication in the United States. Exposure to acetaminophen can lead to acute liver cytolysis, acute liver failure, acute kidney injury, encephalopathy, and coagulopathy. This retrospective cohort study (1/1/2012 to 12/31/2017) investigated the clinical outcomes of intentional and unintentional acetaminophen exposure using the National Poison Data System data. The frequency of outcomes, chronicity, gender, route of exposure, the reasons for exposure, and treatments as described. Binary logistic regression was used to estimate the prognostic factors and odds ratios (OR) with 95% confidence intervals (CI) for outcomes. This study included 39,022 patients with acetaminophen exposure. Our study demonstrated that the likelihood of developing severe outcomes increased by aging (OR = 1.12, 95% CI: 1.08-1.015) and was lower in females (OR = 0.88, 95% CI: 0.78-0.99). Drowsiness/lethargy (OR = 1.48, 95% CI: 1.22-1.82), agitation (OR = 1.66, 95% CI: 1.11-2.50), coma (OR = 23.95, 95% CI: 17.05-33.64), bradycardia (OR = 2.29, 95% CI: 1.22-4.32), rhabdomyolysis (OR = 8.84, 95% CI: 3.71-21.03), hypothermia (OR = 4.1, 95% CI: 1.77-9.51), and hyperthermia 2.10 (OR = 2.10, 95% CI: 1.04-4.22) were likely associated with major outcomes or death. Treatments included intravenous N-acetylcysteine (61%), oral N-acetylcysteine (10%), vasopressor (1%), hemodialysis (0.7%), fomepizole (0.1%), hemoperfusion (0.03%), and liver transplant (0.1%). In conclusion, it is important to consider clinical presentations of patients with acetaminophen toxicity that result in major outcomes and mortality to treat them effectively.
Collapse
Affiliation(s)
- Omid Mehrpour
- Data Science Institute, Southern Methodist University, Dallas, TX, USA
| | - Farhad Saeedi
- Medical Toxicology and Drug Abuse Research Center (MTDRC), 125609Birjand University of Medical Sciences, Birjand, Iran.,Student Research Committee, 125609Birjand University of Medical Sciences, Birjand, Iran
| | - Ali Hadianfar
- Department of Biostatistics, 37552Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, 378772Lariboisière Hospital, INSERM UMRS-University of Paris, Paris, France
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, 439895Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
2
|
KhabazianZadeh F, Kazemi T, Nakhaee S, Ng PC, Mehrpour O. Acetaminophen poisoning-induced heart injury: a case-based review. Daru 2019; 27:839-851. [PMID: 31713183 PMCID: PMC6895290 DOI: 10.1007/s40199-019-00307-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/11/2019] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Acetaminophen (Paracetamol, APAP) poisoning is frequently implicated in self-harm. Cases of acetaminophen-associated cardiotoxicity are rare in relation to the number of patients with acetaminophen poisoning. A review of acetaminophen cardiotoxicity in 1996 concluded that there was no decisive evidence demonstrating that acetaminophen overdose has a cardiotoxic effect. This review study aimed to determine whether acetaminophen could induce heart injury. METHODS We searched for keywords of acetaminophen, paracetamol, cardiotoxicity, heart injury, heart damage, myocarditis, pericarditis, myocardial infarction, and myocardial ischemia in Web of Science, PubMed, Scopus, Embase, Google Scholar, and Persian databases. The search included articles published from January 1950 to October 2018 with no language restrictions. RESULTS The search yielded 64 citations in English; 36 of the articles were excluded as they were not relevant; 5 articles were excluded since they were duplicates, leaving 23 articles. Full-text articles of the 23 citations were obtained and reviewed. Myocardial infarction, heart dysfunction and failure, cardiac arrhythmias, pericarditis, heart cell necrosis, and sudden cardiac death were reported in acetaminophen overdose. CONCLUSIONS Ddysrhythmias, heart failure, and various other cardiac effects could occur following acetaminophen induced hepatic failure. However, the evidence for direct injury on cardiac tissue is weak. Graphical abstract Potential mechanisms for cardiotoxicity of acetaminophen.
Collapse
Affiliation(s)
- Fatemeh KhabazianZadeh
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Tooba Kazemi
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Patrick C Ng
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran.
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
| |
Collapse
|
3
|
Ralapanawa U, Jayawickreme KP, Ekanayake EMM, Dissanayake AMSDM. A study on paracetamol cardiotoxicity. BMC Pharmacol Toxicol 2016; 17:30. [PMID: 27411502 PMCID: PMC4944443 DOI: 10.1186/s40360-016-0073-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 07/01/2016] [Indexed: 11/24/2022] Open
Abstract
Background Sri Lanka has a high suicide rate, with more than 40 % of poisoning admissions due to overdose of drugs with Paracetamol being the commonest. Data regarding cardiotoxicity to paracetamol is very minimal though hepatotoxicity following poisoning is well studied. Paracetamol cardiotoxicity has rarely been clinically significant and may have well been overlooked. The possibility that paracetamol overdose might be directly cardiotoxic has been the subject of a few reports. Unexplained deaths and electrocardiographic changes associated with paracetamol poisoning have also been reported in which cardiac origin cannot be clearly ruled out. Although some studies state that paracetamol poisoning has no direct cardiotoxic effect, electrocardiographic changes due to metabolic derangement of hepatotoxicity have been shown in certain studies. Thus, we conducted this study to assess in detail the cardiotoxic effect of paracetamol poisoning. Methods This is a cross sectional descriptive study done on those with confirmed paracetamol poisoning. Serum paracetamol levels, Electrocardiogram, Echocardiogram, troponin I, and other basic investigations were done. Results Paracetamol ingestion is more common among teenagers and the young population in Sri Lanka. Although several cases of paracetamol poisoning induced cardiotoxicity has been described in the past, this study demonstrated no electrocardiographic, echocardiographic or cardiac biomarkers changes of myocardial toxicity. Conclusion Though literature review support cardiotoxicity following paracetamol poisoning, our study does not provide enough evidence for this. Continuous cardiac monitoring, serial troponin and echocaediogram assessment would be voluble adjunct in its management. Further experiments and research in this subject would be useful with a larger number of samples to further evaluate this important problem.
Collapse
Affiliation(s)
- Udaya Ralapanawa
- Department of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
| | | | | | | |
Collapse
|
4
|
Bertolini A, Ferrari A, Ottani A, Guerzoni S, Tacchi R, Leone S. Paracetamol: new vistas of an old drug. CNS DRUG REVIEWS 2007; 12:250-75. [PMID: 17227290 PMCID: PMC6506194 DOI: 10.1111/j.1527-3458.2006.00250.x] [Citation(s) in RCA: 348] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever. It occupies a unique position among analgesic drugs. Unlike NSAIDs it is almost unanimously considered to have no antiinflammatory activity and does not produce gastrointestinal damage or untoward cardiorenal effects. Unlike opiates it is almost ineffective in intense pain and has no depressant effect on respiration. Although paracetamol has been used clinically for more than a century, its mode of action has been a mystery until about one year ago, when two independent groups (Zygmunt and colleagues and Bertolini and colleagues) produced experimental data unequivocally demonstrating that the analgesic effect of paracetamol is due to the indirect activation of cannabinoid CB(1) receptors. In brain and spinal cord, paracetamol, following deacetylation to its primary amine (p-aminophenol), is conjugated with arachidonic acid to form N-arachidonoylphenolamine, a compound already known (AM404) as an endogenous cannabinoid. The involved enzyme is fatty acid amide hydrolase. N-arachidonoylphenolamine is an agonist at TRPV1 receptors and an inhibitor of cellular anandamide uptake, which leads to increased levels of endogenous cannabinoids; moreover, it inhibits cyclooxygenases in the brain, albeit at concentrations that are probably not attainable with analgesic doses of paracetamol. CB(1) receptor antagonist, at a dose level that completely prevents the analgesic activity of a selective CB(1) receptor agonist, completely prevents the analgesic activity of paracetamol. Thus, paracetamol acts as a pro-drug, the active one being a cannabinoid. These findings finally explain the mechanism of action of paracetamol and the peculiarity of its effects, including the behavioral ones. Curiously, just when the first CB(1) agonists are being introduced for pain treatment, it comes out that an indirect cannabino-mimetic had been extensively used (and sometimes overused) for more than a century.
Collapse
Affiliation(s)
- Alfio Bertolini
- Division of Toxicology and Clinical Pharmacology, University of Modena and Reggio Emilia, Modena, Italy.
| | | | | | | | | | | |
Collapse
|
5
|
Abstract
BACKGROUND There is an increasing gap between the number of patients on the waiting list and the number of transplanted patients. In France, more than 10000 patients waited for an organ transplantation in 2002. Due to the graft shortage, "marginal" donors are now considered. The patients who present brain death after accidental or voluntary poisoning belong to this category. EPIDEMIOLOGY The data available from European or North American organ procurement organisations show that poisoned donors represent about 1% of all organ donors. It seems likely that a significant number of poisoned patients are not referred because poisoning is regarded as a contraindication to organ donation. When organ procurement can be achieved, the results expressed as recipient survival or graft survival are quite encouraging. TOXIC PRODUCTS The most frequently involved toxins are either drugs (psychotropic agents, analgesics...), illicit substances, or environmental agents (gases, alcohols...). The literature data are discussed; some issues remain controversial. PRACTICAL APPROACH Several criteria have to be applied when poisoned patients are considered as potential organ donors. Besides a firm diagnosis of "brain death", the knowledge of the "target organs" of poisoning is of paramount importance, together with careful analysis of the toxicokinetics and toxicodynamics. In most cases, routine biological and morphological data are sufficient to assess graft function.
Collapse
Affiliation(s)
- Philippe Hantson
- Unité de neurotraumatologie et toxicologie, Département des soins intensifs Cliniques St-Luc, Université catholique de Louvain, Bruxelles, Belgique.
| |
Collapse
|
6
|
|
7
|
Abstract
Paracetamol (acetaminophen) has become an antipyretic drug of choice. Due to its widespread use, toxicity secondary to overdose has increased in recent years. Children are especially vulnerable to accidental exposure due to non availability of child proof containers in India. The main clinical features of acute toxicity include anorexia, vomiting, abdominal pain, jaundice, hematuria and metabolic acidoses. Diagnosis is based on history and laboratory findings of acidosis and abnormal liver function tests. N-acetylcysteine is the specific antidote. This article reviews in detail the toxicokinetics, pathophysiology, clinical features and management of paracetamol poisoning in children.
Collapse
Affiliation(s)
- S B Lall
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi
| | | |
Collapse
|
8
|
Hantson P, Vekemans MC, Vanormelingen P, De Meester J, Persijn G, Mahieu P. Organ procurement after evidence of brain death in victims of acute poisoning. Transplant Proc 1997; 29:3341-2. [PMID: 9414740 DOI: 10.1016/s0041-1345(97)01108-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- P Hantson
- Department of Intensive Care, Cliniques Universitaires St-Luc, Brussels, Belgium
| | | | | | | | | | | |
Collapse
|
9
|
Hantson P, Vekemans MC, Laterre PF, Vanormelingen P, Mahieu P, Koerner MM. Heart donation after fatal acetaminophen poisoning. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1997; 35:325-6. [PMID: 9140331 DOI: 10.3109/15563659709001221] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
10
|
Brent J. New ways of looking at an old molecule. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1996; 34:149-53. [PMID: 8618246 DOI: 10.3109/15563659609013762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
11
|
Smilkstein MJ. APAP-induced heart injury? Maybe yes, maybe no. Next question? JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1996; 34:155-6. [PMID: 8618247 DOI: 10.3109/15563659609013763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|