Paracetamol recall: a natural experiment influencing analgesic poisoning

Has the rescheduling of modified-release paracetamol in Australia affected the frequency of overdoses?

OBJECTIVES

In June 2020, modified-release paracetamol (paracetamol-MR) preparations were up-scheduled from schedule-2 (available in pharmacy) to schedule-3 (available by request to a pharmacist only). The present study aims to ascertain whether up-scheduling affected the frequency of paracetamol-MR overdoses.

METHODS

This is a retrospective cohort study of two data sets from 1 June 2017 to 31 May 2022. Monash Health data were extracted using the diagnosis of paracetamol overdose coding and electronic medical records data. Calls regarding paracetamol-MR overdoses to Victorian Poisons Information Centre (VPIC) were extracted from the Poisons centre call database. We used a quasi-experimental research design with interrupted time series analysis to evaluate the immediate impact and change in trend of poisoning-related calls and ED presentations before and after June 2020. The change in proportion of paracetamol-MR cases in both databases was analysed using the Χ2 test.

RESULTS

The proportion of paracetamol-MR cases in both data sets did not change. From Monash Health, there was no level change in monthly paracetamol-MR overdose-related presentations following re-scheduling (rate ratio [RR] = 1.08, 95% confidence interval [CI] = 0.57-2.01). There was no change in monthly paracetamol-MR overdose-related calls to VPIC following re-scheduling (RR = 1.05, 95% CI = 0.96-1.14).

CONCLUSION

The proportion of paracetamol-MR overdoses did not decrease after the up-scheduling to S3. Similarly, the frequency of overdoses by month remained similar. Further limitations on access to paracetamol products may need to be considered.

The inadvertent consequences of drug recalls: A case study of a recall of pantoprazole generics from the markets

Introduction

Drug recalls may impact treatment plans or access to suitable therapies. Thus, they inadvertently affect treatment outcomes.

Objective

We aimed to examine the impact of recalls on patients' safety using pantoprazole-containing products recall as a case study in terms of the occurrence of potential drug-drug interactions (pDDIs).

Methods

This retrospective study used de-identified electronic health records of adult patients who had a prescription for oral proton pump inhibitors (PPIs) including pantoprazole, esomeprazole, lansoprazole, or omeprazole from April 2020 through September 2021 from a large tertiary care hospital. The study outcome definition was the prevalence of pDDIs in PPIs users before and after the recall date (March 2021). Changes in the prevalence of pDDIs were modeled using interrupted time-series. The rate ratio of pDDIs in the 12 months before and 6 months after the recall was modeled using negative binomial regression.

Results

A total of 1,826 pDDIs were identified, and the median monthly prevalence of pDDI before the recall was 102.5 which increased to 115.5 after the recall. A change in the level of pDDIs occurred immediately after the recall date, followed by a gradual decrease over time. The rate of pDDIs was 69% higher after the recall compared to the baseline (rate ratio 1.69; 95% confidence interval, 0.75-1.91).

Discussion

Recall of pantoprazole-containing products was associated with a higher rate of pDDIs. However, the prevalence of pDDIs gradually decreased over time. We highlight the importance of planning of recall process and coordinating all potential stakeholders to avoid potential harms.Word count: 1450.

Sociodemographic Characteristics and Risk Factors for Childhood Poisoning Reported by Parents at a Tertiary Care Teaching Hospital

Background Childhood poisoning is a major health problem. Mostly, it is accidental and associated with low morbidity and mortality. The association between sociodemographic factors and childhood injury rates could be used for improvement to prevent and reduce such injuries. Childhood poisoning is preventable through appropriate education and judicious storage of drugs and household chemicals that might help in reducing and eliminating the accidental ingestion of toxic materials at home. Objectives To recognize the potential risk factors that might be associated with childhood home poisoning in Riyadh City, Kingdom of Saudi Arabia. Design A survey-based questionnaire study. Setting A tertiary care teaching hospital in Riyadh City. Patients and methods A structured questionnaire was created, which included questions on the poisoning incidence, home medication history, and possible risk factors for poisoning and the sociodemographic characteristics, and was disseminated to individuals who visited the King Khalid University Hospital. Main outcome measures Demographic characteristics of participants and risk factors related to childhood poisoning. Results The study included 152 randomly selected participants, 62 men (40.79%) and 90 women (59.21%). Self-ingestion was reported to be the most common mode of poisoning 28/44 (63.6%). The appearance of clinical manifestations suggesting poisoning was reported to be the most frequent method of discovery of children poisoning 20/44 (45.5%). Thirty-six out of the 44 respondents (81.8%) with a positive history of childhood poisoning in their family transferred their children to a hospital immediately. Drugs were the most common causative agent reported for poisoning among the respondents 21/44 (47.7%). Conclusion Accidental and non-intentional self-ingestion still presents as a major mode of childhood home poisoning. Despite the significant advancement in the lifestyle among the majority of Saudi Arabian regions, especially the capital city Riyadh, childhood poisoning remains a significant cause of morbidity and possible mortality. Creating health education and prevention programs might help to prevent such serious preventable problems. Limitations The limited number of participants may not reflect the whole population living in Riyadh City, hence, interpretation of the study results might be taken cautiously. Conflict of interest There was no conflict of interest.

Restricting cough and cold medicines in children

AIMS

Based on concerns about safety and efficacy, international authorities have either advised against the use of cough and cold medication or considering such action. We aimed to systematically review the evidence for the effectiveness and safety of cough and cold medicines in children.

METHODS

We conducted a systematic review to identify studies relating to the use of products to treat symptoms of the common cold, influenza or allergic rhinitis, and relating to poisoning or toxicity from unintentional ingestion or overdose in children (<12 years). Medline, Embase and the Cochrane database were searched. No meta-analysis was undertaken because of the paucity of evidence, multiple medicines available, and the need to consider both effectiveness and safety.

RESULTS

Seventy two relevant studies or clinical reports were identified. There was little support for the effectiveness of these medicines for acute cough or the common cold in children. However, the majority of these medicines do not appear to be highly toxic in children and are not a major cause of severe effects following unintentional poisoning. The common use of these agents does not appear to be responsible for increased deaths in young children. Many cases of toxicity from cough and cold medications in young children are a result of therapeutic error. Particular medications, including diphenhydramine and codeine, appear to be associated with a high frequency of severe adverse effects and toxicity.

CONCLUSION

Restriction of cough and cold medicines in children is supported by currently available evidence.

Legislation restricting paracetamol sales and patterns of self-harm and death from paracetamol-containing preparations in Scotland

AIMS

To describe how changes in legislation to restrict paracetamol sales have affected overdose discharges and death associated with the drug in Scotland.

METHODS

A descriptive analysis of routine death and hospital discharge data for the entire Scottish population between 1995 and 2004. Patients in Scotland participated who were discharged from hospital with a diagnosis of poisoning; deaths in Scotland from diagnosis of poisoning 1995-2003 were also analysed. Outcome measures were changes in mortality and overdose due to poisoning involving paracetamol. A comparison was made of in-hospital and out-of-hospital mortality in fatalities involving paracetamol.

RESULTS

The majority of paracetamol-associated deaths were due to co-proxamol. Deaths associated with paracetamol alone or with ethanol occurred principally in hospital and were a minority of deaths overall. The proportion of in-hospital deaths attributed to paracetamol increased (post/pre ratio 1.347; 95% confidence interval 1.076, 1.639; P = 0.013). Overall numbers of cases discharged with poisoning fell. The proportion of these involving paracetamol in any form increased significantly in all groups except young men aged 10 to <20 years.

CONCLUSIONS

Legislation has not reduced mortality or proportional use of paracetamol in overdose, both of which appear to have increased in Scotland since pack-size limitations. Other approaches are necessary to reduce the death rate from overdoses involving paracetamol.

Acetaminophen Availability Increases in Canada with No Increase in the Incidence of Reports of Inpatient Hospitalizations with Acetaminophen Overdose and Acute Liver Toxicity

In September 1999, several Canadian provinces had place-of-sale restrictions lifted that had limited the sale of acetaminophen >325 mg and packages >24 tablets (any strength) to pharmacies only. This allowed the sale of all strengths of immediate-release acetaminophen in all package sizes in nonpharmacy locations. This study's purpose was to explore the effect that lifting restrictions on acetaminophen place of sale may have had on reported hospitalizations in Canada related to acetaminophen overdose toxicity. Using hospital discharge data, provinces with no preexisting restrictions on place of sale were compared with those in which restrictions were lifted in September 1999. Cases of reported APAP overdose included ICD-9/9-CM code 965.4, ICD-9 code E850.2, or ICD-9-CM code E850.4. Cases with reported acute liver toxicity included ICD-9/9-CM codes 570, 572.2, 572.4, V42.7, or procedure code 50.5. There were no significant differences between the 1.5-year periods pre- and post-September 1999 in annual incidence rates per 100,000 persons ages >/=12 years of hospitalizations reported with acetaminophen overdose, either overall or limited to those with death as an outcome, or in hospitalization reports with both acetaminophen overdose and acute liver toxicity, either overall (provinces with no restrictions: pre = 0.70, post = 0.80, P = 0.6328; provinces with restrictions lifted in September 1999: pre = 0.49, post = 0.47, P = 0.8649) or limited to those with death as an outcome (provinces with no restrictions: pre = 0.22, post = 0.12, P = 0.3030; provinces with restrictions lifted in September 1999: pre = 0.13, post = 0.09, P = 0.3589). In conclusion, the decision to lift Canadian place-of-sale restrictions increased acetaminophen availability and did not increase the rate of reported hospitalizations related to acetaminophen overdose toxicity.

Hospital discharges and 30-day case fatality for drug poisoning: a Danish population-based study from 1979 to 2002 with special emphasis on paracetamol

OBJECTIVE

To examine the number of hospital discharges and 30-day case fatalities due to drug poisoning based on data from a Danish County Hospital Discharge Registry from 1979 to 2002.

METHODS

All patients with a hospital discharge diagnosis of drug poisoning were identified and separated into groups taking: (1) opioid analgesics; (2) non-opioid analgesics; (3) anxiolytics; (4) antidepressants; (5) antipsychotics; or (6) non-specified. Paracetamol and salicylate were analysed separately. From 1994 to 2001, the total amount of drugs sold in the county was identified from a national drug database.

RESULTS

A total of 13,432 patients with a median age 41.5 years at discharge of whom 59% were females accounted for 20,249 discharges for drug poisoning. The overall number of discharges remained essentially stable around 170 discharges per 100,000 inhabitants per year. From the mid-1990's, paracetamol became the most frequently used drug in poisoning with the largest increase in female teenagers. Thirty-day case fatality in poisoning with opioids was 3.6% compared with around 1% in other drug categories. For most drug categories, a sale of around 80,000 defined daily doses was associated with one hospital discharge due to drug poisoning.

CONCLUSION

The overall number of hospital discharges remained stable and seems primarily related to amount of drugs available. With almost 10 years delay, the easier access to paracetamol was followed by an increase in hospitalisation due to poisoning with paracetamol. However, although the majority of hospitalisations were found in the younger age group, the highest mortality was seen among the elderly.

Management of paracetamol poisoning

Paracetamol is the most common substance involved in self-poisoning in the UK. The main advances made over the past five years in the management of early paracetamol poisoning, identification of risk factors for paracetamol poisoning, understanding of the mechanisms and management of late paracetamol poisoning and issues concerning the prevention of paracetamol poisoning are discussed.

The effect of recalling paracetamol on hospital admissions for poisoning in Western Australia

OBJECTIVES

To assess the effect of two recalls of paracetamol products on rates of intentional and unintentional overdoses of paracetamol in all age groups, as well as any effect on poisoning by other agents.

DESIGN

A before-and-after epidemiological study using data from the Western Australian Health Services Research Linked Database, which records all admissions to public and private hospitals throughout the State.

MAIN OUTCOME MEASURES

Hospital admissions in Western Australia for poisonings with all agents, including paracetamol and other over-the-counter analgesics.

RESULTS

There were 11 752 admissions for poisoning from 1996 to 2001. Paracetamol was the primary poisoning agent in 2266 (19.3%) admissions, aspirin in 120 (1%) and ibuprofen in 277 (2%). There was a significant decrease in the admission rate for paracetamol poisoning when sales were restricted in 2000 (rate ratio, 0.82; 95% CI, 0.68-0.99) compared with the same period in other years. There was no increase in poisoning with other agents at this time. However, admissions for paracetamol overdose also showed a large random variation that tended to obscure any effect.

CONCLUSIONS

Our study highlights the need to control for random as well as seasonal fluctuations in admission rates, and for restrictions on paracetamol sales to last for several months across all retail outlets. Limiting access to paracetamol may reduce paracetamol poisonings without a coincident increase in the use of other agents

Data collection in clinical toxicology: are there too many variables?

The evidence base of clinical toxicology suffers in comparison to other clinical disciplines. There is an excess of case reports and case series with little in the way of case control or cohort studies, and very few randomized controlled trials. While randomized controlled trials are rightly regarded as the gold standard for interventional studies, they have limitations that are particularly evident in the practice of clinical toxicology. Properly conducted observational studies using quantitative, epidemiological methods [nonrandomized trials, cohort studies (prospective and retrospective), case control methods] can provide answers that may be impossible to obtain from randomized controlled trials. Development of a strong evidence base is essential for progress in clinical toxicology. Whether that evidence base is derived from randomized controlled trials or observational studies, it is essential to collect data. Important observations can be made from basic clinical data and systematic collection of those data into some form of electronic database has siginificant advantages. A clinical database provides accurate information in the areas of clinical practice, quality assurance (audit), and research. In the area of research, an appropriately designed database can be both a source of hypotheses as well as a vehicle to test them. It can also serve as a repository of research data in subsequent randomized controlled trials.