Analysis of an 8-hour acetylcysteine infusion protocol for repeated supratherapeutic ingestion (RSTI) of paracetamol

Wong, Anselm; Gunja, Naren; McNulty, Richard; Graudins, Andis

doi:10.1080/15563650.2017.1359620

Cited by 14 publications

(13 citation statements)

References 13 publications

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“…Acetylcysteine can be ceased at this stage if the paracetamol concentration is less than 10 mg/L and ALT is less than 50 U/L or static. Patients with significant acute liver injury secondary to paracetamol will have a very high and/or rapidly rising ALT . Small fluctuations in ALT (eg, ± 20 U/L or ± 10%) are common and do not on their own indicate the need for ongoing acetylcysteine.…”

Section: Repeated Supratherapeutic Ingestionmentioning

confidence: 99%

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand

Chiew

Reith

Pomerleau

et al. 2019

Medical Journal of Australia

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Introduction Paracetamol is a common agent taken in deliberate self‐poisoning and in accidental overdose in adults and children. Paracetamol poisoning is the commonest cause of severe acute liver injury. Since the publication of the previous guidelines in 2015, several studies have changed practice. A working group of experts in the area, with representation from all Poisons Information Centres of Australia and New Zealand, were brought together to produce an updated evidence‐based guidance. Main recommendations (unchanged from previous guidelines) The optimal management of most patients with paracetamol overdose is usually straightforward. Patients who present early should be given activated charcoal. Patients at risk of hepatotoxicity should receive intravenous acetylcysteine. The paracetamol nomogram is used to assess the need for treatment in acute immediate release paracetamol ingestions with a known time of ingestion. Cases that require different management include modified release paracetamol overdoses, large or massive overdoses, accidental liquid ingestion in children, and repeated supratherapeutic ingestions. Major changes in management in the guidelines The new guidelines recommend a two‐bag acetylcysteine infusion regimen (200 mg/kg over 4 h, then 100 mg/kg over 16 h). This has similar efficacy but significantly reduced adverse reactions compared with the previous three‐bag regimen. Massive paracetamol overdoses that result in high paracetamol concentrations more than double the nomogram line should be managed with an increased dose of acetylcysteine. All potentially toxic modified release paracetamol ingestions (≥ 10 g or ≥ 200 mg/kg, whichever is less) should receive a full course of acetylcysteine. Patients ingesting ≥ 30 g or ≥ 500 mg/kg should receive increased doses of acetylcysteine.

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Section: Repeated Supratherapeutic Ingestionmentioning

confidence: 99%

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand

Chiew

Reith

Pomerleau

et al. 2019

Medical Journal of Australia

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“…The largest prospective study is by Daly et al [9] who studied 249 patients, they defined a RSTI as more than one ingestion of paracetamol during a period exceeding 8 h that resulted in a cumulative dose of greater than 4 g per 24 h. They found that patients presenting with an AST <50 U/L and paracetamol concentration <10 mg/L are at very low risk of developing hepatotoxicity. Two similar retrospective studies have reported similar findings, although in both studies all patients were treated with acetylcysteine [10,11]. Another tool that has been proposed to help predict which patients will subsequently develop hepatotoxicity is the paracetamol-aminotransferase multiplication product (paracetamol concentration Â ALT or AST [whichever is greater]) [12].…”

Section: Introductionmentioning

confidence: 83%

Retrospective evaluation of repeated supratherapeutic ingestion (RSTI) of paracetamol

Egan

Robinson

Downes

et al. 2019

Clinical Toxicology

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Background: Repeated supratherapeutic ingestion (RSTI) of paracetamol can result in acute liver injury. Management guidelines vary worldwide and in Australia, acetylcysteine treatment is recommended in patients with a paracetamol concentration !20 mg/L and/or alanine transaminase (ALT) !50 U/L. Objectives: To investigate patients with RSTI of paracetamol and determine whether admission ALT <50 U/L rules out those who develop hepatotoxicity (ALT >1000 U/L). Method: Retrospective review of paracetamol RSTI presentations to two toxicology services over a four-year period. Patients were included if they ingested >4 g per 24 h of paracetamol for a period >8 h, regardless of intent. Data collected included demographics, ingestion history, pathology results, treatments and outcomes. Results: 266 patients were identified with median ingested dose of 9 g per 24 h (IQR: 6-12 g) over a median of 2 days (IQR: 1-5 days). On presentation, paracetamol was detected in 192 (72%), with median concentration of 14 mg/L

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“…( ) A retrospective review of supratherapeutic acetaminophen ingestions receiving an 8‐hour acetylcysteine regimen reported liver injury in 0 of 46 patients if ALT was less than 50 IU/L on presentation. ( )…”

Section: Discussionmentioning

confidence: 99%

“…(17) A retrospective review of supratherapeutic acetaminophen ingestions receiving an 8-hour acetylcysteine regimen reported liver injury in 0 of 46 patients if ALT was less than 50 IU/L on presentation. (34) In practice, just under half of the patients requiring acetylcysteine treatment would be eligible for the NACSTOP protocol ( Fig. 2) and more in countries with lower treatment thresholds.…”

Section: Discussionmentioning

confidence: 99%

The NACSTOP Trial: A Multicenter, Cluster‐Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose

et al. 2019

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Analysis of an 8-hour acetylcysteine infusion protocol for repeated supratherapeutic ingestion (RSTI) of paracetamol

Abstract: An 8-hour acetylcysteine infusion regimen for treatment of paracetamol RSTI may be safe and is likely to reduce length of stay for patients at low risk of hepatotoxicity. Larger prospective studies are needed to examine the efficacy of this abbreviated acetylcysteine protocol.

Cited by 14 publications

References 13 publications

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand

Retrospective evaluation of repeated supratherapeutic ingestion (RSTI) of paracetamol

The NACSTOP Trial: A Multicenter, Cluster‐Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose

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