Summary
The first cases of fulminant hepatic failure due to paracetamol poisoning were reported in 1966, and in the United Kingdom this condition is now responsible for more cases of acute hepatic failure than any other cause. Adults account for the majority of serious and fatal cases of paracetamol poisoning and it is extremely rare for young children to ingest sufficient paracetamol to cause more than minimal liver damage. A single measurement of the plasma paracetamol concentration is an accurate predictor of liver damage provided that it is taken not earlier than 4 hours after ingestion of the overdose. Peak disturbance of liver function occurs 2 to 4 days after the overdose, often accompanied by mild jaundice, after which recovery is usually rapid and complete. In a few patients, fulminant hepatic failure, manifested by increasing jaundice and encephalopathy, may develop by the third to fifth day. Acute renal failure may complicate paracetamol poisoning, often in the context of severe liver damage. Renal failure, which is often non-oliguric, typically becomes apparent 24 to 72 hours after overdosage.
The treatment of paracetamol intoxication should include gastric lavage, which has been shown to be of value for up to 6 hours after ingestion of a paracetamol overdose. Further general treatment may include parenteral fluid replacement and a prophylactic infusion of dextrose (5–10%) in patients at risk of hepatic failure. Specific protective agents in those patients at risk of paracetamol-induced liver damage include N-acetylcysteine and methionine which are most effective if given within 8 to 10 hours of ingestion of the overdose. Hepatic and renal failure should be managed conventionally.
In recent years in the United Kingdom there has been a gradual decline in the number of hospital admissions and the number of deaths from aspirin poisoning. Salicylates in overdose directly stimulate the respiratory centre and so cause a respiratory alkalosis. Metabolic acidosis occurs in severe poisoning because of impairment of the oxidative metabolism of energy substrates. At very high salicylate concentrations respiratory depression may occur, possibly associated with neuroglycopenia, adding respiratory acidosis to the worsening metabolic acidosis. In addition to a mixed acid-base disturbance, hypokalaemia and hypoglycaemia may be present. Nausea and vomiting increase the fluid deficit. If dehydration is sufficiently severe, decreasing cardiac output may hasten development of lactic acidosis and acute renal failure. Young children quickly develop a metabolic acidosis following the ingestion of aspirin in overdose but, by the age of 12 years, the usual adult picture of a mixed respiratory alkalosis and metabolic acidosis is seen.
The treatment of salicylate poisoning is directed towards prevention of absorption, correction of acid-base, fluid and electrolyte disturbance and measures to increase the elimination of salicylate in those who are moderately or severely poisoned. It is now recognised that if alkaline diuresis is employed urine pH is of far greater importance than the volume of urine excreted.
Despite the widespread therapeutic use of non-steroidal anti-inflammatory drugs (NSAIDs) the current number of reported cases of poisoning is small. Initially, propionic acid derivatives were thought to have a low toxicity in overdose but, in addition to anticipated gastrointestinal symptoms (nausea, vomiting, abdominal pain, haematemesis), headache, tinnitus, hyperventilation, sinus tachycardia, hypoprothrombinaemia, haematuria, proteinuria and acute renal failure have been described. In addition, drowsiness, coma, nystagmus, diplopia, hypothermia, hypotension, respiratory depression and cardiac arrest have been reported in severe cases of poisoning. The oxicam derivative, piroxicam, is potentially very toxic in overdose.
Oxyphenbutazone and phenylbutazone are very toxic in overdose but indomethacin appears to be much less toxic. An overdose of mefenamic acid may result in nausea, vomiting, muscle twitching, convulsions and coma.
Management of NSAID overdose is essentially supportive and symptomatic. If a substantial overdose of an NSAID has been ingested (e.g. more than 10 therapeutic doses in an adult; 5 doses in a child), and if the patient presents not more than 4 hours after a substantial overdose, an attempt should be made to reduce absorption of toxic material by undertaking gastric lavage. Alternatively, if the patient presents within 1–2 hours of overdose, activated charcoal 50 to 100g may be administered. Thereafter supportive measures may be needed and dialysis will be required if renal failure becomes established. As most NSAIDs are highly protein bound and extensively metabolised, forced, diuresis, dialysis and haemoperfusion are unlikely to enhance elimination significantly.
Similar content being viewed by others
References
Ahlfors, C.E.; Shwer, M.L and Ford, K.B.: Bilirubin — albumin binding in neonatal salicylate intoxication. Developmental Pharmacology and Therapeutics 4: 47–60 (1982).
Alam, S.N.; Roberts, R.J. and Fischer, L.J.: Age-related differences in salicylamide and acetaminophen conjugation in man. Journal of Pediatrics 90: 130–135 (1977).
Anderson, R.J.; Potts, D.E.; Gabow, P.A.; Rumack, B.H. and Schrier, R.W.: Unrecognised adult salicylate intoxication. Annals of Internal Medicine 85: 745–748 (1976).
Anon.: Butazolidin fatality. Pharmaceutical Journal 194: 604 (1965).
Anon.: Death after N-acetylcysteine. Lancet 1: 1421 (1984).
Appleby, D.H.: Fenoprofen (Nalfon) overdose. Drug Intelligence and Clinical Pharmacy 15: 129–130 (1981).
Arena, J.M.; Rourke, M.H. and Sibrack C.D.: Acetaminophen: Report of an unusual poisoning. Pediatrics 61: 68–72 (1978).
Balali-Mood, M. and Prescott, I.F.: Failure of alkaline diuresis to enhance diflunisal elimination. British Journal of Clinical Pharmacology 10: 163–165 (1980).
Balali-Mood, M.; Critchley, J.A.J.H, Proudfoot, A.T. and Prescott, L.F.: Mefenamic acid overdosage. Lancet 1: 1354–1356 (1981).
Barry, W.S.; Meinzinger, M.M. and Howse, C.R.: Ibuprofen overdose and exposure in utero: Results from a post-marketing voluntary reporting system. American Journal of Medicine (Symposium) July 13th, 35–39 (1984).
Bateman, D.N.; Woodhouse, K.W. and Rawlins, M.D.: Adverse reactions to N-acetylcysteine. Human Toxicology 3: 393–398 (1984).
Bates, T.: Phenylbutazone. Pediatrics 17: 967–968 (1956).
Benson, G.D.: Hepatotoxicity following the therapeutic use of antipyretic analgesics. American Journal of Medicine 75 (Suppl.): 85–93 (1983).
Berg, K.J.: Acute acetylsalicylic acid poisoning: Treatment with forced alkaline diuresis and diuretics. European Journal of Clinical Pharmacology 12: 111–116 (1977).
Beringer, T.R.O.: Salicylate intoxication in the elderly due to benorylate. British Medical Journal 288: 1344–1355 (1984).
Berlinger, W.G.; Spector, R.; Flanigan, M.J.; Johnson, G.F. and Groh, M.R.: Hemoperfusion for phenylbutazone poisoning. Annals of Internal Medicine 96: 334–335 (1982).
Black, R.A. and Bensinger, R.E.: Bilateral subconjunctival haemorrhage after acetylsalicylic acid overdose. Annals of Ophthalmology 14: 1024–1025 (1982).
Boldy, D.A.R. and Vale, J.A.: Treatment of salicylate poisoning with repeated oral charcoal. British Medical Journal 292: 136 (1986).
Boyd, E.H. and Bereczky, G.M.: Liver necrosis from paracetamol. British Journal of Pharmacology 26: 606–614 (1966).
Boyd, J.A. and Eling, T.E.: Prostaglandin endoperoxide synthetase-dependent cooxidation of acetaminophen to intermediates which covalently bind in vitro to rabbit renal medullary microsomes. Journal of Pharmacology and Experimental Therapeutics 219: 659–664 (1981).
Brancato, D.J. and Nelson, R.C.: Poisoning mortality in the United States 1980. Veterinary and Human Toxicology 26: 273–275 (1984).
Budd, R.D.: Gas Chromatographic determination of butazolidin (phenylbutazone) I in biological fluids. Journal of Chromatography 243: 368–371 (1982).
Bury, R.W.; Mashford, M.L.; Glaun, B.P. and Saaroni, G.: Acute phenylbutazone poisoning in a child. Medical Journal of Australia 1: 478–479 (1983).
Caldwell, J.; Smith, R.L. and Davies, S.A.: Drug metabolism in a case of progeria. Gerontology 24: 373–380 (1978).
Canalese, J.; Gimson, A.E.S.; Davis, M. and Williams, R.: Factors contributing to mortality in paracetamol-induced hepatic failure. British Medical Journal 282: 199–201 (1981).
Clark, R.; Borirakchanyavat, V.; Davidson, A.R.; Thompson, R.P.H.; Widdop, B.; Goulding, R. and Williams, R.: Hepatic damage and death from overdose of paracetamol. Lancet 1: 66–70 (1973a).
Clark, R.; Borirakchanyavat, V.; Gazzard, B.G.; Rake, M.O.; Shilkin, K.B.; Flute, P.T. and Williams, R.: Disordered hemostasis in liver damage from paracetamol overdose. Gastroenterology 65: 788–795 (1973b).
Clarke, J.H. and Wilson, W.G.: A 16-day-old breast-fed infant with metabolic acidosis caused by salicylate. Clinical Pediatrics 20: 53–54 (1981).
Cobden, I.; Record, C.O.; Ward, M.K. and Kerr, D.N.S.: Paracetamol-induced acute renal failure in the absence of fulminant liver damage. British Medical Journal 284: 21–22 (1982).
Cohen, C.: Salicylate intoxication in the elderly due to benorylate. British Medical Journal 288: 1617 (1984).
Cotton, E.K. and Fahlberg, V.l.: Hypoglycaemia with salicylate poisoning: A report of two cases. American Journal of Diseases of Children 108: 171–173 (1964).
Court, H. and Volans, G.N.: Poisoning after overdose with non-steroidal anti-inflammatory drugs. Adverse Drug Reactions and Acute Poisoning Reviews 3: 1–21 (1984).
Court, H.; Streete, P. and Volans, G.N.: Acute poisoning with ibuprofen. Human Toxicology 2: 381–384 (1983).
Crome, P.; Vale, J.A.; Volans, G.N.; Widdop, B. and Goulding, R.: Oral methionine in the treatment of severe paracetamol (acetaminophen) overdose. Lancet 2: 829–830 (1976).
Cumming, G.; Dukes, D.C. and Widdowson, G.: Alkaline diuresis in treatment of aspirin poisoning. British Medical Journal 2: 1033–1036 (1964).
Curry, R.W.; Robinson, J.D. and Sughrue, M.J.: Acute renal failure after acetaminophen poisoning. Journal of the American Medical Association 247: 1012–1014 (1982).
Davidson, A.R.; Rojas-Bueno, A.; Thompson, R.P.H. and Williams, R.: Early unconjugated hyperbilirubinaemia after paracetamol overdosage. Scandinavian Journal of Gastroenterology 11: 623–628 (1976).
Davidson, D.G.D. and Eastham, W.N.: Acute liver necrosis following overdose of paracetamol. British Medical Journal 2: 497–499 (1966).
Davies, M.G.; Vella Briffa, D. and Greaves, M.W.: Systemic toxicity from topically applied salicylic acid. British Medical Journal 1: 661 (1979).
Davis, M.; Ideo, G.; Harrison, N.G. and Williams, R.: Early inhibition of hepatic bilirubin conjugation after paracetamol (acetaminophen) administration in the rat. Digestion 13: 42–48 (1975).
Demole, V.: Mesure de l’effet sédatil de la Novaminesulphone. Helvetica Physiologica Pharmacologica Acta 16: C10–C12 (1958).
Devalia, J.L. and McLean, A.E.M.: Covalent binding and the mechanism of paracetamol toxicity. Biochemical Pharmacology 32: 2602–2603 (1983).
Devalia, J.L.; Ogilve, R.C. and McLean, A.E.M.: Dissociation of cell death from covalent binding of paracetamol by flavones in a hepatocyte system. Biochemical Pharmacology 31: 3745–3749 (1982).
Dixon, M.F.: Paracetamol hepatotoxicity. Lancet 1: 35 (1976).
Dixon, M.F.; Nimmo, J. and Prescott, L.F.: Experimental paracetamol-induced hepatic necrosis: A histopathological study. Journal of Pathology 103: 225–229 (1971).
Done, A.K. Aspirin overdosage: Incidence, diagnosis, and management. Pediatrics 62 (Suppl.): 890–897 (1978).
Dordoni, B.; Willson, R.A.; Thompson, R.P.H. and Williams, R.: Reduction of absorption of paracetamol by activated charcoal and cholestyramine: A possible therapeutic approach. British Medical Journal 3: 86–87 (1973).
Douglas, A.P.; Hamlyn, A.N. and James, O.: Controlled trial of cysteamine in treatment of acute paracetamol (acetaminophen) poisoning. Lancet 1: 111–115 (1976).
Dukes, D.C.; Blainey, J.D.; Cumming, G. and Widdowson, G.: The treatment of severe aspirin poisoning. Lancet 1: 329–331 (1963).
El-Bahie, N., Allen, E.M., Williams, J., Routledge, PA. The effect of activated charcoal and hyoscine butylbromide alone and in combination on the absorption of mefenamic acid. British Journal of Clinical Pharmacology 19: 836–838 (1985).
Emby, D.J. and Fraser, B.N.: Hepatotoxicity of paracetamol enhanced by ingestion of alcohol. South African Medical Journal 51: 208–209 (1977).
Farid, N.R.; Glynn, J.P. and Kerr, D.N.S.: Haemodialysis in paracetamol self-poisoning. Lancet 2: 396–398 (1972).
Farrand, R.J.; Green, J.H. and Haworth, C.: Enteric-coated aspirin overdose and gastric perforation. British Medical Journal 3: 85–86 (1975).
Ferguson, R.K. and Boutros, A.R.: Death following self-poisoning with aspirin. Journal of the American Medical Association 213: 1186–1187 (1970).
Forrest, J.A.H.; Roscoe, P.; Prescott, L.F. and Stevenson, I.H.: Abnormal drug metabolism after barbiturate and paracetamol overdose. British Medical Journal 4: 499–502 (1974).
Fredell, E.W. and Strand, L.J.: Naproxen overdose. Journal of the American Medical Association 238: 938 (1977).
Freestone, S. and Critchley, J.A.J.H.: Self poisoning with sutoprofen. British Medical Journal 289: 470 (1984).
Gabow, P.A.; Anderson, R.J.; Potts, D.E. and Schrier, R.W.: Acid-base disturbances in the salicylate-intoxicated adult. Archives of Internal Medicine 138: 1481–1484 (1978).
Gazzard, B.G.; Clark, R.; Borirakchanyavat, V. and Williams, R.: A controlled trial of heparin therapy in the coagulation defect of paracetamol-induced hepatic necrosis. Gut 15: 89–93 (1974a).
Gazzard, B.G.; Willson, R.A.; Weston, M.J.; Thompson, R.P.H. and Williams, R.: Charcoal haemoperfusion for paracetamol overdose. British Journal of Clinical Pharmacology 1: 271–275 (1974b).
Gazzard, B.G.; Henderson, J.M. and Williams, R.: Early changes in coagulation following a paracetamol overdose and a controlled trial of fresh plasma therapy. Gut 16: 617–620 (1975).
Gazzard, B.G.; Hughes, R.D.; Widdop, B.; Goulding, R.; Davis, M. and Williams, R.: Early prediction of the outcome of a paracetamol overdose based on an analysis of 163 patients. Postgraduate Medical Journal 53: 243–247 (1977).
Gerber, J.G.; MacDonald, J.S.; Harbison, R.D.; Villeneuve, J.-P.; Wood, A.J.Y. and Nies, A.S.: Effect of N-acetylcysteine on hepatic covalent binding of paracetamol (acetaminophen). Lancet 1: 657–658 (1977).
Goldfinger, R.; Ahmed, K.S.; Pitchumoni, C.S. and Weseley, S.A.: Concomitant alcohol and drug abuse enhancing acetaminophen toxicity. American Journal of Gastroenterology 70: 385–388 (1978).
Gross, G.E.: Granulocytosis and a sulindac overdose. Annals of Internal Medicine 96: 793–794 (1982).
Hamlyn, A.N.: Paracetamol poisoning. British Medical Journal 2: 1089 (1978).
Hamlyn A.N.; Douglas, A.P.; James, O.F.W.; Lesna, M. and Watson, A.J.: Liver function and structure in survivors of acetaminophen poisoning. A follow-up study of serum bile acids and liver histology. Digestive Diseases 22: 605–610 (1977).
Hamlyn, A.N.; Douglas, A.P. and James, O.: The spectrum of paracetamol (acetaminophen) overdose: Clinical and epidemiological studies. Postgraduate Medical Journal 54: 400–404 (1978).
Hamlyn, A.N.; Lesna, M.; Record, C.O.; Smith, P.A.; Watson, A.J.; Meredith, T.J.; Volans, G.N. and Crome, P.: Methionine and cysteamine in paracetamol (acetaminophen) overdose, prospective controlled trial of early therapy. Journal of International Medical Research 9: 226–231 (1981).
Hartwig-Otto, H.: Pharmacokinetic considerations of common analgesics and antipyretics. American Journal of Medicine 75 (Suppl.): 30–37 (1983).
Harvey, J.G. and Spooner, J.B.: Paracetamol poisoning. British Medical Journal 2: 832–833 (1978).
Helliwell, M.; Vale, A. and Goulding, R.: Haemoperfusion in ‘late’ paracetamol poisoning. Human Toxicology 1: 25–30 (1981).
Hillman, R.J. and Prescott, L.F.: Salicylate intoxication: Rapid drug removal with repeated oral charcoal. British Medical Journal 291: 1472 (1985).
Ho, S.W.-E. and Beilin, L.J.: Asthma associated with N-acetylcysteine infusion and paracetamol poisoning: report of two cases. British Medical Journal 287: 876–877 (1983).
Howrie, D.L.; Moriarty, R. and Breit, R.: Candy flavouring as a source of salicylate poisoning. Pediatrics 75: 869–871 (1985).
Hughes, R.D.; Trewby, P. and Williams, R.: Cysteamine for paracetamol poisoning. Lancet 1: 536 (1976).
James, O.; Lesna, M.; Roberts, S.H.; Pulman, L.; Douglas, A.P.; Smith, P.A. and Watson, A.J.: Liver damage after paracetamol overdose. Comparison of liver function tests, fasting serum bile-acids, and liver histology. Lancet 2: 579–581 (1975).
Johnson, P.N. and Welch, D.W.: Methyl salicylate/aspirin (salicylate) equivalence: Who do you trust? Veterinary and Human Toxicology 26: 317–318 (1984).
Jones, D.I.R.: Self-poisoning with drugs: The past 20 years in Sheffield. British Medical Journal 1: 28–29 (1977).
Jones, G. and Thomas, P.: Treatment of acute paracetamol poisoning. British Medical Journal 2: 1224 (1977).
Juul, J.: Acute poisoning with butazolidin. Acta Pediatrica Scandinavica 54: 503–507 (1965).
Kaufman, F.L. and Dubanksy, A.S.: Darvon poisoning with delayed salicylism: a case report. Pediatrics 49: 610–611 (1972).
Kleinman, J.G.; Breitenfield, R.V. and Roth, D.A.: Acute renal failure associated with acetaminophen ingestion: Report of a case and review of the literature. Clinical Nephrology 14: 201–205 (1980).
Klein-Schwartz, W. and Oderda, G.M.: Adsorption of oral antidotes for acetaminophen poisoning (methionine and n-acetylcysteine) by activated charcoal. Clinical Toxicology 18: 283–290 (1981).
Koppel, C.; Wagemann, A.; Tenczer, J. and Muth, H.: Tiaprofenic acid overdose. Arzneimittel-Forschung 34: 836–837 (1984).
Kramer, M.: Chronic toxicity of pyrazolones: The problem of nitrosation. British Journal of Clinical Pharmacology 10: 313S–317S (1980).
Labadarios, D.; Davis, M.; Portmann, B. and Williams, R.: Paracetamol-induced hepatic necrosis in the mouse — relationship between covalent binding, hepatic glutathione depletion and the protective effect of α-mercaptopropionylglycine. Biochemical Pharmacology 26: 31–35 (1977).
Lauterberg, B.H. and Mitchell, J.R.: Toxic doses of acetaminophen suppress hepatic glutathione synthesis in rats. Hepatology 2: 8–12 (1982).
Lawson, A.A.H.; Proudfoot, A.T.; Brown, S.S.; Macdonald, H.; Fraser, A.G.; Cameron, J.C. and Matthew, H.: Forced diuresis in the treatment of acute salicylate poisoning in adults. Quarterly Journal of Medicine 38: 31–48 (1969).
Leaf, G. and Neuberger, A.: The effect of diet on the glutathione content of the liver. Biochemical Journal 41: 280–287 (1947).
Lee, C.S.; Wang, L.H.; Marbury, T.C. and Cade, J.R.: Hemodialysis for acetaminophen detoxification. Clinical Toxicology 18: 431–439 (1981).
Levy, G.: Clinical pharmacokinetics of aspirin. Pediatrics 62 (Suppl.): 867–872 (1978).
Levy, G. and Houston, J.B.: Effect of activated charcoal on acetaminophen absorption. Pediatrics 58: 432–435 (1976).
Levy, G.; Khanna, N.N.; Soda, D.M.; Tsuzuki, O. and Stern, L.: Pharmacokinetics of acetaminophen in the human neonate: Formation of acetaminophen glucuronide and sulfate in relation to plasma bilirubin concentration and D-glucaric acid excretion. Pediatrics 55: 818–825 (1975).
Lien-Lai, M.W.; Sarnaik, A.P.; Newton, J.F.; Miceli, J.N.; Fleischmann, L.E.; Hook, J.B. and Kauffman, R.E.: Metabolism and pharmacokinetics of acetaminophen in a severely poisoned young child. Journal of Pediatrics 105: 125–128 (1984).
Lo, G.O.C. and Chan, J.Y.W.: Piroxicam poisoning. British Medical Journal 287: 798 (1983).
Lynd, P.A.; Andreasen, A.C. and Wyatt, R.J.: Intrauterine salicylate intoxication in a newborn. Clinical Pediatrics 15: 912–913 (1976).
Macdougall, L.G.: Taylor-Smith, A.; Rothberg, A.D. and Thomson, P.D.: Piroxicam poisoning in a 2-year-old child. South African Medical Journal 61: 31–34 (1984).
Maclean, D.; Peters, T.J.; Brown, R.A.G.; McCathie, M.; Baines, G.F. and Robertson, P.G.C.: Treatment of acute paracetamol poisoning. Lancet 2: 849–852 (1968).
Makela, A.-L.; Lang, H. and Korpela, P.: Toxic encephalopathy with hyperammonaemia during high-dose salicylate therapy. Acta Neurologica Scandinavica 61: 146–151 (1980).
Mant, T.G.K.; Tempowski, J.H.; Volans, G.N. and Talbot, J.C.C.: Adverse reactions to acetylcysteine and effects of overdose. British Medical Journal 289: 217–219, (1984).
Matthew, H.; Mackintosh, T.F.; Tompsett, S.L. and Cameron, J.C.: Gastric aspiration and lavage in acute poisoning. British Medical Journal 1: 1333–1337 (1966).
McCraken, J.S.: Salicylate intoxication in the elderly due to benorylate. British Medical Journal 288: 1694 (1984).
McLean, A.E.M. and Day, P.A.: The effect of diet on the toxicity of paracetamol and the safety of paracetamol-methionine mixtures. Biochemical Pharmacology 24: 37–42 (1975).
Meredith, T.J.: Epidemiology of paracetamol poisoning. Report from 3rd Joint Meeting of the World Health Organisation, Regional Office for Europe and European Association of Poisons Control Centres, Copenhagen, May 20–22, pp 46–50 (1981).
Meredith, T.J. and Goulding, R.: Paracetamol. Postgraduate Medical Journal 56: 459–473 (1980).
Meredith, T.J. and Vale, J.A.: Salicylate poisoning; in Vale and Meredith (Eds.) Poisoning: Diagnosis and Treatment, pp. 97–103, (Update Books, London 1981).
Meredith, T.J. and Vale, J.A.: Epidemiology of analgesic overdose in England and Wales. Human Toxicology 3: 61S–74S (1984).
Meredith, T.J.; Crome, P.; Volans, G. and Goulding, R.: Treatment of paracetamol poisoning. British Medical Journal 1: 1215–1216 (1978a).
Meredith, T.J.; Newman, B. and Goulding, R.: Paracetamol poisoning in children. British Medical Journal 2: 478–479 (1978b).
Meredith, T.J.; Vale, J.A. and Goulding, R.: The epidemiology of acute acetaminophen poisoning in England and Wales. Archives of Internal Medicine 141: 397–400 (1981).
Miller, R.P.; Roberts, R.J. and Fischer, L.J.: Acetaminophen elimination kinetics in neonates, children, and adults. Clinical Pharmacology and Therapeutics 19: 284–294 (1976).
Mitchell, J.R.; Schenker, S.; Avant, G.R. and Speeg, K.V.: Cimetidine protects against acetaminophen hepatotoxicity in rats. Gastroenterology 81: 1052–1060 (1981).
Mohandas, J.; Duggin, G.G.; Horvath, J.S. and Tiller, D.J.: Metabolic oxidation of acetaminophen (paracetamol) mediated by cytochrome P450 mixed-function oxidase and prostaglandin endoperoxide synthetase in rabbit kidney. Toxicology and Applied Pharmacology 61: 252–259 (1981).
Moldeus, P.; Andersson, B.; Norling, A. and Ormstad, K.: Effect of chronic ethanol administration on drug metabolism in isolated hepatocytes with emphasis on paracetamol activation. Biochemical Pharmacology 29: 1741–1745 (1980).
Mongan, E.; Kelly, P.; Nies, K.; Porter, W.W. and Paulus, H.E.: Tinnitus as an indication of therapeutic serum salicylate levels. Journal of the American Medical Association 226: 142–145 (1973).
Mortimer, E.A. and Lepow, M.L.: Varicella with hypoglycemia possibly due to salicylates. American Journal of Diseases of Children 103: 583–590 (1962).
Mosvold, J.; Mellem, H.; Stave, R.; Osnes, M. and Laufen, H.: Overdosage of piroxicam. Acta Medica Scandinavica 216: 335–336 (1984).
Myers, E.N.; Bernstein, J.M. and Fostiropolous, G.: Salicylate ototoxicity: A clinical study. New England Journal of Medicine 273: 587–590 (1965).
National Poisons Information Service Monitoring Group: Analgesic poisoning: A multicentre, prospective study. Human Toxicology 1: 7–23 (1981).
Netter, P.; Lambert, H.; Larcan, A.; Godbillon, J. and Gosset, G.: Diclofenac sodium-chlormezanone poisoning. European Journal of Clinical Pharmacology 26: 535–536 (1984)
Neuvonen, P.J. and Elonen, E.: Effect of activated charcoal on absorption and elimination of phenobarbitone, carbamazepine and phenylbutazone in man. European Journal of Clinical Pharmacology 17: 51–57 (1980).
Newman, T.J. and Bargman, G.J.: Acetaminophen hepatotoxicity and malnutrition. American Journal of Gastroenterology 72: 647–650 (1979).
Nogen, A.G. and Bremner, J.E.: Fatal acetaminophen overdosage in a young child. Journal of Pediatrics 92: 832–833 (1978).
North, D.S.; Peterson, R.G. and Krenzelok, E.P.: Effect of activated charcoal administration on acetylcysteine serum levels in humans. American Journal of Hospital Pharmacy 38: 1022–1024 (1981).
Nusynowitz, M.L. and Forsham, P.H.: The antidiuretic action of acetaminophen. American Journal of the Medical Sciences 252: 429–435 (1966).
Oie, S.; Lowenthal, D.T.; Briggs, W.A. and Levy, G.: Effect of hemodialysis on kinetics of acetaminophen elimination by anephric patients. Clinical Pharmacology and Therapeutics 18: 680–686 (1976).
Okonek, S.: Intoxication with pyrazolones. British Journal of Clinical Pharmacology 10: 385S–390S (1980).
Olkkola, K.T. and Neuvonen, P.J.: Do gastric contents modify antidotal efficacy of oral activated charcoal? British Journal of Clinical Pharmacology 18: 663–669 (1984).
Paulozzi, L.J.: Seasonality of reported poison exposures. Pediatrics 71: 891–893 (1983).
Paynter, A.S. and Alexander, F.W.: Salicylate intoxication caused by teething ointment. Lancet 2: 1132 (1979).
Pessayre, D.; Dolder, A.; Artigou, J.-Y.; Wandscheer, J.-C.; Descatoire, V.; Degott, C. and Benhamou, J.-P.: Effect of fasting on metabolite-mediated hepatotoxicity in the rat. Gastroenterology 77: 264–271 (1979).
Pessayre, D.; Wanscheer, J.-C.; Cobert, B.; Level, R.; Degott, C.; Batt, A.M.; Martin, N. and Benhamou, J.P.: Additive effects of inducers and fasting on acetaminophen hepatotoxicity. Biochemical Pharmacology 29: 2219–2223 (1980).
Peterson, F.J.; Holloway, D.E.; Erickson, R.R.; Duquette, P.H.; McClain, C.J. and Holtzman, J.L.: Ethanol induction of acetaminophen toxicity and metabolism. Life Sciences 27: 1705–1711 (1980).
Peterson, G.R.; Hostetler, R.M.; Lehman, T. and Covault, H.P.: Acute inhibition of oxidative drug metabolism by propoxyphene (Darvon). Biochemical Pharmacology 28: 1783–1789 (1979).
Peterson, R.G. and Rumack, B.H.: Treating acute acetaminophen poisoning with acetylcysteine. Journal of the American Medical Association 237: 2406–2407 (1977).
Peterson, R.G. and Rumack, B.H.: Age as a variable in acetaminophen overdose. Archives of Internal Medicine 141: 390–393 (1981).
Pimstone, B.L. and Uys, C.J.: Liver necrosis and myocardiopathy following paracetamol overdosage. South African Medical Journal 42: 259–262 (1968).
Portmann, B.; Talbot, I.C.; Day, D.W.; Davidson, A.R.; Murray-Lyon, I.M. and Williams, R.: Histopathological changes in the liver following a paracetamol overdose: Correlation with clinical and biochemical parameters. Journal of Pathology 117: 169–181 (1975).
Prescott, L.F.: Haemodialysis in paracetamol self-poisoning. Lancet 1: 652 (1972).
Prescott, L.F.: The nephrotoxicity and hepatotoxicity of antipyretic analgesics. British Journal of Clinical Pharmacology 7: 453–462 (1979).
Prescott, L.F.: Paracetamol overdosage. Pharmacological considerations and clinical management. Drugs 25: 290–314 (1983).
Prescott, L.F.: Drug conjugation in clinical toxicology. Biochemical Society Transactions 12: 96–99 (1984).
Prescott, L.F. and Critchley, J.A.J.H.: Drug interactions affecting analgesic toxicity. American Journal of Medicine 75 (Suppl.): 113–116 (1983)
Prescott, L.F. and Wright, N.: The effects of hepatic and renal damage on paracetamol metabolism and excretion following overdosage. A pharmacokinetic study. British Journal of Pharmacology 49: 602–613 (1973).
Prescott, L.F.; Wright, N.; Roscoe, P. and Brown, S.S.: Plasma-paracetamol half-life and hepatic necrosis in patients with paracetamol overdosage. Lancet 1: 519–522 (1971).
Prescott, L.F.; Newton, R.W.; Swainson, C.P.; Wright, N.; Forrest, A.R.W. and Matthew, H.: Successful treatment of severe paracetamol overdosage with cysteamine. Lancet 1: 588–592 (1974).
Prescott, L.F.; Park, J.; Sutherland, G.R.; Smith, I.J. and Proudfoot, A.T.: Cysteamine, methionine and penicillamine in the treatment of paracetamol poisoning. Lancet 2: 109–113 (1976a).
Prescott, L.F.; Park, J. and Proudfoot, A.T.: Cysteamine for paracetamol poisoning. Lancet 1: 357 (1976b).
Prescott, L.F.; Park, J.; Ballantyne, A.; Adriaenssens, P. and Proudfoot, A.T.: Treatment of paracetamol (acetaminophen) poisoning with N-acetylcysteine. Lancet 2: 432–434 (1977).
Prescott, L.F.; Oswald, I. and Proudfoot, A.T.: Repeated self-poisoning with paracetamol. British Medical Journal 2: 1399 (1978a).
Prescott, L.F.; Stewart, M.J. and Proudfoot, A.T.: Cysteamine or N-acetylcysteine for paracetamol poisoning? British Medical Journal 1: 856 (1978b).
Prescott, L.F.; Illingworth, R.N.; Critchley, J.A.J.H.; Stewart, M.J.; Adam, R.D. and Proudfoot, A.T.: Intravenous N-acetylcysteine: The treatment of choice for paracetamol poisoning. British Medical Journal 2: 1097–1100 (1979).
Prescott, L.F.; Critchley, J.A.J.H. and Balali-Mood, M.: Phenbylbutazone overdosage: Abdominal metabolism associated with hepatic and renal damage. British Medical Journal 281: 1106–1107 (1980).
Prescott, L.F.; Critchley, J.A.J.H.; Balali-Mood, M. and Pentland, B.: Effects of microsomal enzyme induction on paracetamol metabolism in man. British Journal of Clinical Pharmacology 12: 149–153 (1981).
Prescott, L.F.; Balali-Mood, M; Critchley, J.A.J.H.; Johnstone, A.F. and Proudfoot, A.T.: Diuresis or urinary alkalinisation for salicylate poisoning. British Medical Journal 285: 1383–1386 (1982a).
Prescott, L.F.; Proudfoot, A.T. and Cregeen, R.J.: Paracetamol-induced acute renal failure in the absence of fulminant liver damage. British Medical Journal 284: 421–422 (1982b).
Price, V.F. and Jollow, D.J.: Increased resistance of diabetic rats to acetaminophen-induced hepatotoxicity. Journal of Pharmacology and Experimental Therapeutics 220: 504–513 (1982).
Proudfoot, A.T.: Toxicity of salicylates. American Journal of Medicine 75 (Suppl.): 99–103 (1983).
Proudfoot, A.T. and Brown, S.S.: Acidaemia and salicylate poisoning in adults. British Medical Journal 2: 547–550 (1969).
Proudfoot, A.T. and Wright, N.: Acute paracetamol poisoning. British Medical Journal 3: 557–558 (1970).
Queneau, P.; Barthelemy, C. and Fulchiron, P.: Ingestion massive d’indometacine en prise unique (A propos de 2 observations personnelles). Lyon Médical 239: 133–136 (1978).
Record, C.O.; Chase, R.A.; Alberti, K.G.M.M. and Williams, R.: Disturbances in glucose metabolism in patients with liver damage due to paracetamol overdose. Clinical Science and Molecular Medicine 49: 473–479 (1975).
Roberts I.; Robinson, M.J.; Mughal, M.Z.; Ratcliffe, J.G. and Prescott, L.F.: Paracetamol metabolites in the neonate following maternal overdose. British Journal of Clinical Pharmacology 18: 201–206 (1984).
Roberts, S.M. and Franklin, M.R.: Modification of hepatic microsomal oxidative drug metabolism in rats by the opiate maintenance drugs acetylmethadol, propoxyphene and methadone. Life Sciences 25: 845–852 (1979).
Robins, J.B.; Turnbull, J.A. and Robertson, C.: Gastric perforation after acute aspirin overdose. Human Toxicology 4: 527–528 (1985).
Rose, P.G.: Paracetamol overdose and liver damage. British Medical Journal 1: 381–382 (1969).
Rumack, B.H.: Acetaminophen overdose in young children. Treatment and effects of alcohol and other additional ingestants in 417 cases. American Journal of Diseases of Children 138: 428–433 (1984).
Rumack, B.H.; Peterson, R.C.; Koch, G.G. and Amara, I.A.: Acetaminophen overdose: 662 cases with evaluation of oral acetylcysteine treatment. Archives of Internal Medicine 141: 380–385 (1981).
Sanerkin, N.G.: Acute myocardial necrosis in paracetamol poisoning. British Medical Journal 3: 478 (1971).
Scherz, R.G.: Safety packaging impact on childhood poisonings in the United States. Veterinary and Human Toxicology 21 (Suppl.): 127–131 (1979).
Shi, E.C.P.; Fisher, R.; McEvoy, M.; Ventol, R.; Rose, M. and Ham, J.M.: Factors influencing hepatic glutathione concentrations: A study in surgical patients. Clinical Science 62: 279–283 (1982).
Shipton, E.A. and Müller, F.O.: Severe mefenamic acid poisoning. A case report. South African Medical Journal 67: 823–824 (1985).
Sibert, J.R.; Craft, A.W. and Jackson, R.H.: Child-resistant packaging and accidental child poisoning. Lancet 2: 289–290 (1977).
Siegers, C.P.; Strubelt, O. and Schutt, A.: Relations between hepatotoxicity and pharmacokinetics of paracetamol in rats and mice. Pharmacology 16: 273–278 (1978).
Slattery, J.T. and Levy, G.: Acetaminophen kinetics in acutely poisoned patients. Clinical Pharmacology and Therapeutics 25: 184–195 (1979).
Smith, J.M.; Roberts, W.O.; Hall, S.M.; White, T.A. and Gilbertson, A.A.: Late treatment of paracetamol poisoning with mercaptamine. British Medical Journal 1: 331–333 (1978).
Spooner J.B. and Cleaver G.J.: Hepatotoxic dose of paracetamol. Letter to Editor. Lancet 2: 89 (1977).
Stachura, I.; Jayakumar, S. and Bourke, E.: T and B lymphocyte subsets in fenoprofen nephropathy. American Journal of Medicine 75: 9–16 (1983).
Stewart, M.J. and Simpson, E.: Prognosis in paracetamol self-poisoning: The use of plasma paracetamol concentration in a region without a poisoning treatment centre. Annals of Clinical Biochemistry 10: 173–178 (1973).
Streeter, A.J. and Timbrell, J.A.: The effect of dichloralphenazone pretreatment on paracetamol hepatotoxicity in mice. Biochemical Pharmacology 28: 3035–3037 (1979).
Strong, J.E.; Wilson, J.; Douglas, J.F. and Coppel, D.L.: Phenylbutazone self-poisoning treated by charcoal haemoperfusion. Anaesthesia 34: 1038–1040 (1979).
Strubelt, O.: Interactions between ethanol and other hepatotoxic agents. Biochemical Pharmacology 29: 1445–1449 (1980).
Strubelt, O.; Siegers, C.P. and Schutt, A.: The curative effects of cysteamine, cysteine and dithiocarb in experimental paracetamol poisoning. Archives of Toxicology 33: 55–64 (1974).
Strubelt, O.; Obermeier, F. and Siegers, C.P.: The influence of ethanol pretreatment in the effects of nine hepatotoxic agents. Acta Pharmacologica et Toxicologica 43: 211–218 (1978).
Symon, D.N.K. and Russell, G.: Fatal benorylate poisoning in a child with cystic fibrosis. Lancet 1: 77 (1983).
Symon, D.N.K.; Gray, E.S.; Hanmer, O.J. and Russell, G.: Fatal paracetamol poisoning from benorylate therapy in a child with cystic fibrosis. Lancet 2: 1153–1154 (1982).
Temple, A.R.: Pathophysiology of aspirin overdosage toxicity, with implications for management. Pediatrics 62 (Suppl.): 873–876 (1978).
Temple, A.R.; George, D.J.; Done, A.K. and Thompson, J.A.: Salicylate poisoning complicated by fluid retention. Clinical Toxicology 9: 61–68 (1976).
Tenenbein, M.: Hypersensitivity-like reactions to N-acetylcysteine. Veterinary and Human Toxicology 26(Suppl. 2): 3–5 (1984).
Teschke, R.; Stutz, G. and Strohmeyer, G.: Increased paracetamol-induced hepatotoxicity after chronic alcohol consumption. Biochemical and Biophysical Research Communications 91: 368–374 (1979).
Thomson, J.S. and Prescott, L.F.: Liver damage and impaired glucose tolerance after paracetamol overdosage. British Medical Journal 2: 506–507 (1966).
Thurston, J.H.; Pollock, P.G.; Warren, S.K. and Jones, E.M.: Reduced brain glucose with normal plasma glucose in salicylate poisoning. Journal of Clinical Investigation 49: 2139–2145 (1970).
Toghill, P.J.; Williams, R.; Stephens, J.D. and Carroll, J.D.: Acute hepatic necrosis following an overdose of paracetamol. Gastro-enterology 56: 773–776 (1969).
Upadhyay, H.P. and Gupta, S.K.: Diflunisal (Dolobid) overdose. British Medical Journal 2: 640 (1978).
Vale, J.A. and Buckley, B.M.: Asthma associated with N-acetylcysteine infusion and paracetamol poisoning. British Medical Journal 287: 1223 (1983).
Vale, J.A. and Meredith, T.J.: Metabolic acidosis in paracetamol poisoning. British Medical Journal 285: 1208 (1982).
Vale, J.A. and Meredith, T.J.: Acute poisoning with non-steroidal anti-inflammatory drugs: Clinical features and management. Medical Toxicology 1: 12–31 (1986).
Vale, J.A. and Wheeler, D.C.; Anaphylactoid reactions to acetylcysteine. Lancet 2: 988 (1982).
Vale, J.A.; Meredith, T.J.; Crome, P.; Helliwell, M.; Volans, G.N.; Widdop, B. and Goulding, R.: Intravenous N-acetylcysteine: The treatment of choice in paracetamol poisoning? British Medical Journal 2: 1435–1436 (1979).
Vale, J.A.; Meredith, T.J. and Goulding, R.: Treatment of acetaminophen poisoning. The use of oral methionine. Archives of Internal Medicine 141: 394–396 (1981).
Vale, J.A.; Buckley, B.M. and Meredith, T.J.: Deaths from paracetamol and dextropropoxyphene (Distalgesic) poisoning in England and Wales in 1979. Human Toxicology 3: 135S–143S (1984).
Walker, B.E.; Kelleher, J.; Dixon, M.F. and Losowsky, M.S.: Vitamin E protection of the liver from paracetamol in the rat. Clinical Science and Molecular Medicine 47: 449–459 (1974).
Walker, R.M.; McElligott, T.E.; Power, E.M.; Massey, T.E. and Racz, W.J.: Increased acetaminophen-induced hepatotoxicity after chronic ethanol consumption in mice. Toxicology 28: 193–206 (1983).
Waltner, J.G.: The effect of salicylates on the inner ear. Annals of Otology, Rhinology and Laryngology 64: 617–622 (1955).
Walton, N.G.; Mann, T.A.N. and Shaw, K.M.: Anaphylactoid reaction to N-acetylcysteine. Lancet 2: 1298 (1979).
Waugh, P.K. and Keatinge, D.W.: Hypoprothrombinaemia in naproxen overdose. Drug Intelligence and Clinical Pharmacy 17: 549–550 (1983).
Weiser, J.R.; Botzler, R.; Pentz, R. and Siegers, C.-P.: Klinik und verlauf einer Vergiftung mit piroxicam. Deutsche Medizinische Wochenschrift 109: 1583 (1984).
Wendel, A.; Feuerstein, S. and Konz, K.-H.: Acute paracetamol intoxication of starved mice leads to lipid peroxidation in vivo. Biochemical Pharmacology 28: 2051–2055 (1979).
Weston, M.T.; Talbot, I.C.; Howorth, P.J.N.; Mant, A.K.; Capildeo, R. and Williams, R.: Frequency of arrhythmias and other cardiac abnormalities in fulminant hepatic failure. British Heart Journal 38: 1179–1188 (1976).
Wilkinson, S.P.; Moodie, H.; Arroyo, V.A. and Williams, R.: Frequency of renal impairment in paracetamol overdose compared with other causes of acute liver damage. Journal of Clinical Pathology 30: 141–143 (1977).
Wilson, J.T.; Kasantikul, V.; Harbison, R. and Martin, D.: Death in an adolescent following an overdose of aetaminophen and phenobarbital. American Journal of Diseases of Children 132: 466–473 (1978).
Winchester, J.F.; Gelfand, M.C.; Knepshield, J.H. and Schreiner, G.E.: Dialysis and hemoperfusion of poisons and drugs — update. Transactions of the American Society of Artificial and Internal Organs 23: 762–842 (1977).
Winters, R.W.; White, J.S.; Hughes, M.D. and Ordway, M.C.: Disturbance of acid-base equilibrium in salicylate intoxication. Pediatrics 23: 260–285 (1959).
Wolhoff, H.; Altrogge, G.; Pola, W.; Sistovaris, N.: Metamizole — a case of acute overdosage with suicidal intent. Deutsche Medizinische Wochenschrift 108: 1761–1764 (1983).
Wrammer, T.: A case of poisoning with 10 grams of butazolidin. Acta Rheumatologica Scandinavica 3: 83–91 (1957).
Wright, N. and Prescott, L.F.: Potentiation by previous drug therapy of hepatotoxicity following paracetamol overdosage. Scottish Medical Journal 18: 56–58 (1973).
Young, R.J.: Mefenamic acid poisoning and epilepsy. British Medical Journal 2: 672 (1979).
Zezulka, A. and Wright, N.: Severe metabolic acidosis early in paracetamol poisoning. British Medical Journal 285: 851–852 (1982).
Zimmerman, H.J.: Effects of aspirin and acetaminophen on the liver. Archives of Internal Medicine 141: 333–342 (1981).
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Meredith, T.J., Vale, J.A. & Vale, Y.A. Non-Narcotic Analgesics. Drugs 32 (Suppl 4), 177–205 (1986). https://doi.org/10.2165/00003495-198600324-00013
Published:
Issue Date:
DOI: https://doi.org/10.2165/00003495-198600324-00013