Acetaminophen Overdoses: A Review of Intentional and Unintentional Cases

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Acetaminophen Overdoses A Review of
Intentional and Unintentional Cases

• Hospital of the University of Pennsylvania
• Philadelphia, PA
• Sarah Erush, PharmD, BCPS
• Karen Shalaby, PharmD

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Hospital of the University of Pennsylvania

• 700 bed tertiary academic medical facility
• Level I Trauma Center/Transplant Services
• Serves tri-state region
• Averages 35,000 admissions per year
• No pediatric admissions

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Adverse Drug Event Program

• Operated by Drug Information Service
• Averages 600 reports per year
• Spontaneous and targeted reporting methods
• Acetaminophen overdoses reported despite
  recommendations otherwise
• Unintentional overdose trend noted

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Acetaminophen Case Series1998 2002 YTD
54 Reports
52 Charts Received
49 Reviewed
3 Incomplete
47 Acetaminophen
2 Not Acetaminophen
23 Intentional
23 Unintentional
1 unknown
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Psychiatry Consult Service
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Patient Demographics
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Acetaminophen Dose
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Acetaminophen Formulation

• INTENTIONAL
• RX 3
• Percocet? n2
• Darvocet? n1
• OTC 21
• Single Entity n8
• Combo Entity n13

• UNINTENTIONAL
• RX 3
• Percocet? n2
• Darvocet? n1
• OTC 20
• Single Entity n15
• Combo Entity n5

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Causality Unintentional Cases
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Acute Exposure (lt 7 days)
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Lab Results Average Peak Levels
INTENTIONAL UNINTENTIONAL
APAP 115.1 mg/L 115.1 mg/L 27.8 mg/L
ALT 3,065 units/L 3,065 units/L 5,193 units/L
AST 2,742 units/L 2,742 units/L 6,819 units/L
INR 2.5 2.5 4
T Bili 1.87 mg/dL 1.87 mg/dL 5.87 mg/dL
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Length of Stay
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Patient Outcome
INTENTIONAL UNINTENTIONAL
Resolved 22/23 (96) 16/23 (69)
Evaluated 9/23 (39) 11/23 (48)
Transplant 0/23 (0) 2/23 (9)
Death 0/23 (0) 3/23 (13)
Transplant and Death 1/23 (4) 0/23 (0)

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Risk Factors
INTENTIONAL UNINTENTIONAL
Hepatic Disease 1/23 (4) 2/23 (9)
Alcohol Use (Acute or Chronic) 14/23 (61) 20/23 (87)
Drug Abuse (Current or Past) 10/23 (43) 8/23 (35)
Concomitant Disease 1/23 (4) 3/23 (13)
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Alcohol Use
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Multiple Risk Factors
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Data Summary

• Unintentional overdoses accounted for 50 cases
• Doses are lower and ingested over 1 to 3 days
• Unintentional cases had greater toxicity when
  judged by LFT, INR, and length of stay
• Unintentional cases had higher transplant and
  death rates

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Data Summary cont.

• Influence of risk factors remains unclear
• Hospital Costs (mean)
• Intentional 12,671
• Unintentional 23,380
• Extrapolated Cost Data
• Results similar to those previously published

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Recommendations

• Continue availability of OTC Acetaminophen
• Education of healthcare practitioners
• Encourage reporting of acetaminophen overdoses
• Awareness of unintentional overdoses
• Education of patients
• Awareness of potential toxicity

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Recommendations cont.

• Labeling
• Maximum dose and duration
• Combination products
• Packaging
• Limit purchase size
• Consider unit dose application
• Manufacturing
• Consider addition of N-Acetylcysteine to
  Acetaminophen preparations.

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Quote

• If I had known it would make me this sick, I
  never would have taken it