Use of fomepizole as an adjunct in the treatment of acetaminophen overdose: a case series

Rampon, Garrett; Wartman, Haley; Osmon, Stephen; Scalzo, Anthony J.

doi:10.1080/24734306.2019.1705596

Cited by 25 publications

(22 citation statements)

References 14 publications

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“…Widespread clinical data regarding the efficacy of fomepizole in acetaminophen toxicity remains sparse. In a series of six cases treated with fomepizole due to persistently elevated acetaminophen concentration levels at levels at risk of developing hepatic injury, Rampon et al documented the successful management of six pediatric and adult patients treated with a combination of NAC therapy and fomepizole with no hepatic injury [20]. The decision to use fomepizole in these patients was because of the persistently elevated [APAP] despite intravenous NAC treatment.…”

Section: Discussionmentioning

confidence: 99%

Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis

Chiu

Jaworska

et al. 2021

Case Reports in Critical Care

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Acetaminophen overdose is one of the most common causes of acute hepatic failure in the developed world. There is strong evidence for N-acetylcysteine (NAC) as a safe and effective antidote for acetaminophen toxicity. However, there is less clarity in the management of massive overdoses (acute, single ingestions > 500 mg/kg with 4-hour equivalent concentrations ~6000 μmol/L) which are often associated with metabolic acidosis and multiorgan dysfunction. In such ingestions, the role of adjuvant treatments such as fomepizole and extracorporeal removal is unclear. We present a case of a 20-year-old female presenting with an acute ingestion of over 120 grams (1764.7 mg/kg) and an acetaminophen concentration of 5880 μmol/L who developed refractory shock, decreased level of consciousness, and metabolic acidosis requiring mechanical ventilation and vasopressor support. She was treated with gastric decontamination with activated charcoal, IV NAC, fomepizole, and hemodialysis. The patient had complete clearance of acetaminophen by 32 hours after presentation and normalization of her acid base and hemodynamic status without any organ failure. This case highlights the potential benefit of a triple strategy of NAC, fomepizole, and early hemodialysis in massive acetaminophen overdose, potentially sparing complications of prolonged intubation and ICU hospitalization.

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Section: Discussionmentioning

confidence: 99%

Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis

Chiu

Jaworska

et al. 2021

Case Reports in Critical Care

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“…Adverse side effects associated with intravenous administration include flushing, rash, nausea, vomiting, and itching, besides tachycardia, bronchospasm, and hypotension in severe cases (1,3). They occur in the first two hours after infusion in 15% of patients (3,11). Some patients presented oliguria, anuria, uremia, and a 40% reduction in GFR on the first day of overdosing on NAC, leading to acute kidney failure (12).…”

Section: Discussionmentioning

confidence: 99%

Acute Renal Failure and Hemolytic Uremic Syndrome in Overdose With N-acetyl Cysteine After Acetaminophen Poisoning

Asadzadeh¹,

Khalighi²,

Mamizadeh³

et al. 2021

Nephro-Urol Mon

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Context: Acetylcysteine is an effective treatment for acetaminophen poisoning. The preparation and dose calculation of acetylcysteine is associated with medical errors. The prevalence of this error is 84.3% globally. Case report: A 15-year-old girl took an overdose of acetaminophen in a suicide attempt. Acetylcysteine intravenous was ordered. Due to the medication error by the nurse, she received a 10-fold overdose of intravenous acetylcysteine in both initial loading dose and maintenance dose. On the second day, the patient showed abdominal pain, nausea, vomiting, and elevated liver enzymes. Her hemoglobin, hematocrit, and platelet quickly decreased. Subsequently, she developed oliguria, anuria, and rising serum creatinine levels. The patient was diagnosed with uremic hemolytic syndrome. She underwent hemodialysis and was treated with plasmapheresis, blood transfusions, and platelets. Discussion: The effects of acetaminophen poisoning and acetylcysteine overdose may be much more severe and have a greater impact on patient survival. Timely and accurate treatment measures can help prevent long-term side effects.

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“…40 Besides, some studies reported the efficacy of fomepizole in treating acetaminophen exposure. [41][42][43][44] Hemodialysis is reported as an effective treatment in the severe acetaminophen exposure. 45,46 However, hemodialysis is generally not recommended to treat acetaminophen-poisoned patients.…”

Section: Discussionmentioning

confidence: 99%

Prognostic factors of acetaminophen exposure in the United States: An analysis of 39,000 patients

et al. 2021

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Acetaminophen is a frequently used over-the-counter or prescribed medication in the United States. Exposure to acetaminophen can lead to acute liver cytolysis, acute liver failure, acute kidney injury, encephalopathy, and coagulopathy. This retrospective cohort study (1/1/2012 to 12/31/2017) investigated the clinical outcomes of intentional and unintentional acetaminophen exposure using the National Poison Data System data. The frequency of outcomes, chronicity, gender, route of exposure, the reasons for exposure, and treatments as described. Binary logistic regression was used to estimate the prognostic factors and odds ratios (OR) with 95% confidence intervals (CI) for outcomes. This study included 39,022 patients with acetaminophen exposure. Our study demonstrated that the likelihood of developing severe outcomes increased by aging (OR = 1.12, 95% CI: 1.08–1.015) and was lower in females (OR = 0.88, 95% CI: 0.78–0.99). Drowsiness/lethargy (OR = 1.48, 95% CI: 1.22–1.82), agitation (OR = 1.66, 95% CI: 1.11–2.50), coma (OR = 23.95, 95% CI: 17.05–33.64), bradycardia (OR = 2.29, 95% CI: 1.22–4.32), rhabdomyolysis (OR = 8.84, 95% CI: 3.71–21.03), hypothermia (OR = 4.1, 95% CI: 1.77–9.51), and hyperthermia 2.10 (OR = 2.10, 95% CI: 1.04–4.22) were likely associated with major outcomes or death. Treatments included intravenous N-acetylcysteine (61%), oral N-acetylcysteine (10%), vasopressor (1%), hemodialysis (0.7%), fomepizole (0.1%), hemoperfusion (0.03%), and liver transplant (0.1%). In conclusion, it is important to consider clinical presentations of patients with acetaminophen toxicity that result in major outcomes and mortality to treat them effectively.

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Use of fomepizole as an adjunct in the treatment of acetaminophen overdose: a case series

Cited by 25 publications

References 14 publications

Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis

Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis

Acute Renal Failure and Hemolytic Uremic Syndrome in Overdose With N-acetyl Cysteine After Acetaminophen Poisoning

Prognostic factors of acetaminophen exposure in the United States: An analysis of 39,000 patients

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