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Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 2021; 59:1196-1227. [PMID: 34424785 DOI: 10.1080/15563650.2021.1961144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations. OBJECTIVES The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal? Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal. METHODS A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations. One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study. RESULTS From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals. CONCLUSIONS This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death. Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.
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Affiliation(s)
- Lotte C G Hoegberg
- Department of Anesthesiology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Silas W Smith
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, California
| | - Sophie Gosselin
- Emergency Department CISSS Montérégie Centre, Greenfield Park, Canada.,Centre antipoison du Québec, Québec, Canada.,Department of Emergency Medicine, McGill Faculty of Medicine, Montreal, Canada
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In Vitro Study of Adsorption Kinetics of Dextromethorphan Syrup onto Activated Charcoal in Simulated Gastric and Intestinal Fluids. J CHEM-NY 2017. [DOI: 10.1155/2017/9290454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Adsorption kinetics of dextromethorphan (DXM) syrup in simulated gastric and intestinal fluids onto activated charcoal (AC) were investigated in an in vitro model. The adsorption studies were performed as a function of time, initial concentration, and temperature. The quantification of DXM adsorbed onto AC was obtained from the Langmuir adsorption isotherms using HPLC. The maximum adsorption capacities (at 95% confidence limits) of AC for DXM were 111.615 [106.38; 126.85] mg in simulated intestinal environment (pH 6.8) and 78.314 [86.206; 70.422] mg in simulated gastric environment (pH 1.2). The adsorption capacity of AC for DXM in simulated gastric fluid (pH 1.2) was not significantly different from the adoption capacity of AC for DXM in simulated intestinal fluid (pH 6.8). Moreover, the adsorption kinetics behavior of dextromethorphan onto AC followed pseudo-second-order kinetics. Our results show that AC in therapeutically acceptable doses can be beneficial in the majority of oral overdose of DXM.
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Jamshidzadeh A, Vahedi F, Farshad O, Seradj H, Najibi A, Dehghanzadeh G. Amitriptyline, clomipramine, and doxepin adsorption onto sodium polystyrene sulfonate. ACTA ACUST UNITED AC 2014; 22:21. [PMID: 24450391 PMCID: PMC3902433 DOI: 10.1186/2008-2231-22-21] [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] [Received: 04/30/2013] [Accepted: 12/24/2013] [Indexed: 11/16/2022]
Abstract
Purpose of the study Comparative in vitro studies were carried out to determine the adsorption characteristics of 3 drugs on activated charcoal (AC) and sodium polystyrene sulfonate (SPS). Activated charcoal (AC) has been long used as gastric decontamination agent for tricyclic antidepressants (TCA). Methods Solutions containing drugs (amitriptyline, clomipramine, or doxepin) and variable amount of AC or SPS were incubated for 30 minutes. Results At pH 1.2 the adsorbent: drug mass ratio varied from 2 : 1 to 40 : 1 for AC, and from 0.4 : 1 to 8 : 1 for SPS. UV–VIS spectrophotometer was used for the determination of free drug concentrations. The qmax of amitriptyline was 0.055 mg/mg AC and 0.574 mg/mg SPS, qmax of clomipramine was 0.053 mg/mg AC and 0.572 mg/mg SPS, and qmax of doxepin was 0.045 mg/mg AC and 0.556 mg/mg SPS. The results of adsorption experiments with SPS revealed higher values for the qmax parameters in comparison with AC. Conclusion In vitro gastric decontamination experiments for antidepressant amitriptyline, clomipramine, and doxepin showed that SPS has higher qmax values than the corresponding experiments with AC. Therefore, we suggest SPS is a better gastric decontaminating agent for the management of acute TCA intoxication.
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Affiliation(s)
- Akram Jamshidzadeh
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Neijzen R, Ardenne PV, Sikma M, Egas A, Ververs T, Maarseveen EV. Activated charcoal for GHB intoxication: An in vitro study. Eur J Pharm Sci 2012; 47:801-3. [DOI: 10.1016/j.ejps.2012.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/19/2012] [Accepted: 09/02/2012] [Indexed: 11/25/2022]
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Hoegberg LCG, Groenlykke TB, Abildtrup U, Angelo HR. Combined paracetamol and amitriptyline adsorption to activated charcoal. Clin Toxicol (Phila) 2010; 48:898-903. [DOI: 10.3109/15563650.2010.524649] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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American Academy of Clinical Toxico, European Association of Poisons Cen. Position Paper: Single-Dose Activated Charcoal. Clin Toxicol (Phila) 2008. [DOI: 10.1081/clt-51867] [Citation(s) in RCA: 291] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Yamamoto K, Onishi H, Ito A, Machida Y. In vitro and in vivo evaluation of medicinal carbon granules and tablet on the adsorption of acetaminophen. Int J Pharm 2006; 328:105-11. [PMID: 16942843 DOI: 10.1016/j.ijpharm.2006.07.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 06/21/2006] [Accepted: 07/27/2006] [Indexed: 11/24/2022]
Abstract
Medicinal carbon (MC) granules were prepared by wet granulation using maltitol (MT), and the MC tablet was produced by compression of the granules. The physical properties and the in vitro adsorption capacity for AA of the formulations were examined. Further, the effects of MC alone and the granules on gastrointestinal absorption of AA were examined in rats when they were administered intragastrically at 15 or 45 min after the intragastrical administration of AA. AA was rapidly adsorbed by MC, and the maximum adsorption capacity of MC was 0.329g AA per gram MC. The granules and tablet exhibited adequate strength, and the tablet disintegrated rapidly. The granules and tablet showed similar adsorption profiles, but somewhat lower adsorption capacity than MC alone. MC alone and granules administered at 15 min reduced the AUC(0-infinity) significantly against the control (no treatment); however, the suppression effect on the plasma concentration was lower with the granules than with MC alone. Thus, granules and tablet are useful as a compact dosage form of MC; though the reduced adsorption capacity must be taken into account in order to expect efficacy equivalent to that of MC alone.
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Affiliation(s)
- Kenta Yamamoto
- Department of Drug Delivery Research, Hoshi University, 2-4-41 Ebara, Shinagawa-ku, Tokyo 142-8501, Japan
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Ito A, Onishi H, Yamamoto K, Machida Y. Evaluation of Binders in the Preparation of Medicinal Carbon Tablets by Wet Granule Compression. YAKUGAKU ZASSHI 2006; 126:315-9. [PMID: 16596024 DOI: 10.1248/yakushi.126.315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Medicinal carbon (MC) tablets were prepared to obtain an oral dosage form that can be easily taken. The MC tablets were made by the wet granule compression method, in which hydroxypropyl cellulose (HPC), carboxymethyl cellulose sodium (CMC-Na) and maltitol (MT) were applied as binders. Brilliant Blue FCF (BB) was used as a model drug. The binders were evaluated in terms of formability of the granules and tablets, their strength, disintegration of the tablets, and their effect on the adsorption potential of MC. HPC and CMC-Na gave the strong granules at a fairly low concentration, but more MT was needed to obtain the strong granules. The tablets could be formed only when using MT at 120% (w/w) of the MC amount. The tablet displayed good hardness and rapid disintegration. The adsorption potential was not affected by CMC-Na, and slightly prevented by MT. However, the adsorption ability of MC was lowered more with the increase in HPC. The granules and tablets exhibited similar adsorption potentials, which were a little lower than that of MC suspended in MT aqueous solution. Similar adsorption characteristics were also observed in a real drug, acetaminophen. It is suggested that the MC tablets prepared by the wet granule compression using MT as a binder should be useful as a compact dosage form of MC.
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Affiliation(s)
- Akihiko Ito
- Department of Drug Delivery Research, Hoshi University, Tokyo, Japan
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Yamamoto K, Onishi H, Ito A, Machida Y. Medicinal Carbon Tablets for Treatment of Acetaminophen Intoxication: Adsorption Characteristics of Medicinal Carbon Powder and Its Tablets. Chem Pharm Bull (Tokyo) 2006; 54:359-62. [PMID: 16508192 DOI: 10.1248/cpb.54.359] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Adsorption characteristics of medicinal carbon powder (JP 14) for acetaminophen were examined at 37 degrees C using conventional incubation in an attempt to obtain an effective oral dosage form. Hydroxypropyl cellulose (HPC) and maltitol (MT), being able to act as a binding agent, were tested as additives. Tablets of medicinal carbon were produced by the wet granulation method. The rate and extent of adsorption of the medicinal carbon powder were roughly similar in water, JP 14 1st fluid (pH 1.2) and JP 14 2nd fluid (pH 6.8). The relationship between concentrations of free and adsorbed acetaminophen indicated that the adsorption followed the Langmuir mode. The maximal adsorption of acetaminophen in water was 0.219 g per gram medicinal carbon powder, little influenced by the addition of MT, but slightly reduced by the addition of HPC. The tablet prepared using MT as a binding agent displayed a favorable hardness and adequate disintegration time. The tablet showed good adsorption potential for acetaminophen, though the adsorption rate and extent of the tablet were reduced to some extent as compared with powder.
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Affiliation(s)
- Kenta Yamamoto
- Department of Drug Delivery Research, Hoshi University, Ebara, Tokyo, Japan
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Groth Hoegberg LC, Christophersen AB, Christensen HR, Angelo HR. Comparison of the Adsorption Capacities of an Activated-Charcoal–Yogurt Mixture Versus Activated-Charcoal–Water Slurry In Vivo and In Vitro. Clin Toxicol (Phila) 2005. [DOI: 10.1081/clt-66067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hoegberg LCG, Angelo HR, Christophersen AB, Christensen HR. The Effect of Food and Ice Cream on the Adsorption Capacity of Paracetamol to High Surface Activated Charcoal: In vitro Studies. ACTA ACUST UNITED AC 2003; 93:233-7. [PMID: 14629735 DOI: 10.1046/j.1600-0773.2003.pto930506.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The effect of added food mixture (as if food was present in the stomach of an intoxicated patient) or 4 different types of ice cream (added as a flavouring and lubricating agent) on the adsorption of paracetamol (acetaminophen) to 2 formulations of activated charcoal was determined in vitro and compared with results from previous investigations showing a maximum adsorption capacity to the two activated charcoal-water slurries at about 0.62-0.72 g paracetamol/g activated charcoal. Activated charcoal (Carbomix or Norit Ready-To-Use), simulated gastric (pH 1.2) or intestinal (pH 7.2) fluid, and paracetamol were mixed with either food mixture or ice cream followed by one hr incubation. The maximum adsorption capacity of paracetamol to activated charcoal was calculated using Langmuirs adsorption isotherm. Paracetamol concentration was analyzed using high pressure liquid chromatography. In the presence of food, the paracetamol adsorption capacity of the 2 activated charcoals was reduced by max. 19% (P<0.05) for Carbomix(R) and by max. 11% (P<0.05) for Norit Ready-to-use compared to control without food (Hoegberg et al. 2002). Depending on which type of ice cream was mixed with the charcoal, the reductions compared to control (Hoegberg et al. 2002) varied between 11% and 26%. Even though a reduction in drug adsorption to activated charcoal was observed when food mixture or ice cream was added, the remaining adsorption capacity of both types of activated charcoal theoretically was still able to provide an effective gastrointestinal decontamination.
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Hoegberg LCG, Angelo HR, Christophersen AB, Christensen HR. Effect of ethanol and pH on the adsorption of acetaminophen (paracetamol) to high surface activated charcoal, in vitro studies. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2002; 40:59-67. [PMID: 11990205 DOI: 10.1081/clt-120002886] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Paracetamol (acetaminophen) intoxication often in combination with ethanol, is seen commonly in overdose cases. Doses of several grams might be close to the maximum adsorption capacity of the standard treatment dose (50g) of activated charcoal. The aim of this study was to determine the maximum adsorption capacity for paracetamol for two types of high surface-activated charcoal [Carbomix and Norit Ready-To-Use (not yet registered trademark in Denmark) both from Norit Cosmara, Amersfoort, The Netherlands] in simulated in vivo environments: At pH 1.2 (gastric environment), at pH 7.2 (intestinal environment), and with and without 10% ethanol. METHODS Activated charcoal, at both gastric or intestinal pHs, and paracetamol were mixed, resulting in activated charcoal-paracetamol ratios from 10:] to 1:1. In trials with ethanol, some of the gastric or intestinal fluid was replaced with an equivalent volume of ethanol, resulting in an ethanol concentration of 10% v/v. After incubation, the concentration of unabsorbed paracetamol was analyzed by high-performance liquid chromatography. The maximum adsorption capacity of paracetamol to activated charcoal was calculated as mg paracetamol adsorbed/g activated charcoal, using Langmuir's isotherm. RESULTS Carbomix [95% confidence limits are shown in square brackets]: 623.7 [612.8;634.5] mg paracetamol adsorbed/g activated charcoal (pH 1.2), 626.2 [611.6;640.9] mg paracetamol adsorbed/g activated charcoal (pH 7.2); Norit Ready-To-Use: 693.6 [676.8;710.5] mg paracetamol adsorbed/g activated charcoal (pH 1.2), 722.6 [687.4;757.9] mg paracetamol adsorbed/g activated charcoal (pH 7.2). For experiments with ethanol (10% v/v) the results with Carbomix were 465.7 [449.2;482.2] mg paracetamol adsorbed/g activated charcoal (pH 1.2), 498.6 [481.8;515.6] mg paracetamol adsorbed/g activated charcoal (pH 7.2); with Norit Ready-To-Use: 617.2 [606.6;627.7] mg paracetamol adsorbed/g activated charcoal (pH 1.2), 640.6 [624.9;656.4] mg paracetamol adsorbed/g activated charcoal (pH 7.2). CONCLUSION Under conditions simulating immediate treatment with charcoal, a standard dose of 50 g of either of the two tested activated charcoals adsorbed a sufficient amount of paracetamol to be beneficial in the treatment of the majority of overdoses of this drug. For both types of activated charcoal, with or without ethanol, there was no significant difference in the adsorption of paracetamol at pH 1.2 and 7.2. Norit Ready-To-Use had a larger maximum adsorption capacity than Carbomix, and was not as sensitive as Carbomix to environmental changes (pH and ethanol). The presence of 10% ethanol lowered the adsorption capacity of the two tested activated charcoal preparations by an amount that might be clinically relevant in cases of intoxications by high-gram doses.
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Atta-Politou J, Skopelitis I, Apatsidis I, Koupparis M. In vitro study on fluoxetine adsorption onto charcoal using potentiometry. Eur J Pharm Sci 2001; 12:311-9. [PMID: 11113650 DOI: 10.1016/s0928-0987(00)00187-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This in vitro investigation was performed to study the adsorption rate constant as well as the adsorption characteristics of fluoxetine (F) to activated charcoal and its commercial formulation Carbomix powder in simulated gastric (pH 1.2) fluid environment. Ion-selective electrode (ISE) potentiometry, based on the selective, direct and continuous monitoring of F with an F-ISE constructed in our laboratory was used. The method used in the kinetic experiments consists of the rapid addition of a slurry containing the charcoal into the drug solution under stirring and continuous recording of the F-ISE potential until the establishment of equilibrium. The free ionized drug concentration at appropriate time intervals was calculated from the recorded adsorption curve and the apparent adsorption rate constant was estimated assuming pseudo first order kinetics. Within run R.S.D. of the estimates ranged from 0.24 to 11.5%, while between run R.S.D. (n=3-4) ranged from 0.90 to 13.8%. A linear relationship was found between the apparent adsorption rate constants and the amount of charcoal used with slopes (+/-S.D.) for activated charcoal and Carbomix equal to 1.14(+/-0.21) and 0.146(+/-0.009) s(-1)g(-1), respectively. Successive additions of microvolumes of F solution were made into a charcoal slurry with measurement of the F-ISE potential at equilibrium. The maximum adsorption capacity values (+/-S.D.) of activated charcoal and Carbomix were 254.8+/-1.8 and 405+/-41 mg/g, respectively while the affinity constant values (+/-S.D.) were 45.6+/-2.2 and 55.5+/-2.9 l/g, respectively. The adsorption of F to charcoals was rapid and for amounts of charcoal 10 times greater than the amount of the drug, 95% of F was adsorbed within the first 5 min. Relative to the toxic and lethal doses in cases of F intoxications, both types of charcoals tested adsorbed effectively F at gastric pH. Carbomix can be considered as appropriate charcoal formulation for medical treatment in cases of F poisoning.
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Affiliation(s)
- J Atta-Politou
- Laboratory of Analytical Chemistry, Department of Chemistry, University of Athens, Panepistimiopolis, 15771, Athens, Greece.
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Chambost M, Liron L, Peillon D, Combe C. [Serotonin syndrome during fluoxetine poisoning in a patient taking moclobemide]. Can J Anaesth 2000; 47:246-50. [PMID: 10730736 DOI: 10.1007/bf03018921] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To present a case of delayed serotonin syndome (SS), a less well-known adverse effect of fluoxetine intoxication. CLINICAL PRESENTATION A 21-yr-old woman was admitted following voluntary intoxication with fluoxetine and benzodiazepines. At the time of admission, she was slightly drowsy and hypotonic but, eight hours later, she developed severe hypertonic coma despite blood concentrations of fluoxetine within the therapeutic range. Repeated toxicological analyses revealed the presence of moclobemide at non-measurable concentrations, suggesting earlier ingestion of this monoamine oxydase inhibitor. Having excluded all other likely causes of the neurological syndrome observed, a SS was postulated. Treatment was symptomatic with mechanical ventilation, sedation with thiopental and fentanyl, and neuromuscular block with pancuronium bromide. The patient recovered spontaneously 20 hr later. CONCLUSION Physicians managing patients presenting with fluoxetine intoxication must be aware of the potential risk of SS. Treatment is symptomatic, but SS may be severe and require vital support in the intensive care environment. Review of published reports does not allow the authors to recommend a specific anesthetic management.
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Affiliation(s)
- M Chambost
- Service de Réanimation, Centre Hospitalier de Villefranche sur Saône, France.
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Atta-Politou J, Kolioliou M, Havariotou M, Koutselinis A, Koupparis MA. An in vitro evaluation of fluoxetine adsorption by activated charcoal and desorption upon addition of polyethylene glycol-electrolyte lavage solution. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1998; 36:117-24. [PMID: 9541057 DOI: 10.3109/15563659809162599] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In drug overdoses, treatment with activated charcoal is frequently used because of its adsorptive properties. Recently, whole-bowel irrigation with polyethylene glycol-electrolyte lavage solution has been used as a gastrointestinal decontamination procedure for ingestions of toxins not well adsorbed to activated charcoal and for toxins with a delayed absorption phase, although well adsorbed to activated charcoal. While a combined approach using activated charcoal and whole-bowel irrigation could theoretically enhance the efficacy of both modalities, this improvement remains speculative, since data demonstrating its clinical advantage in overdose treatment are lacking. Fluoxetine, a selective serotonin uptake inhibitor, is one of the most frequently prescribed antidepressants. Fluoxetine is well adsorbed onto activated charcoal. This in vitro investigation was undertaken to study: a) the effect of polyethylene glycol, as well as polyethylene glycol-electrolyte lavage solution, on the adsorption of fluoxetine to laboratory grade-activated charcoal and a commercial activated charcoal formulation (Carbomix powder) in simulated gastric (pH= 1.2) and intestinal (pH=7.2) fluid environment; b) whether the order of polyethylene glycol-electrolyte lavage solution addition would have any effect on the adsorption of fluoxetine to activated charcoal. METHODS Adsorption of fluoxetine to charcoal in the presence of polyethylene glycol was examined: a) by the simultaneous addition of polyethylene glycol and charcoal to fluoxetine solution and b) by the addition of charcoal to fluoxetine solution and subsequent addition of polyethylene glycol. In both cases, the slurries were incubated at 37 degrees C for 1 hour and filtered. Free fluoxetine concentration was determined in the diluted filtrate by a reversed-phase high-performance liquid chromatography method. RESULTS The amount of fluoxetine adsorbed to activated charcoal (or Carbomix) was dramatically decreased at gastric and intestinal pH by the presence of polyethylene glycol or polyethylene glycol-electrolyte lavage solution added either concurrently or sequentially to activated charcoal. CONCLUSIONS In cases of fluoxetine overdose, administration of activated charcoal is recommended, while a combined approach using activated charcoal and whole-bowel irrigation with polyethylene glycol-electrolyte lavage solution is not recommended since it causes a significant desorption of the drug from activated charcoal.
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