Following a review by the Commission on Human Medicines of the treatment of paracetamol poisoning, the Medicines & Healthcare Products Regulatory Agency (MHRA) have issued changes to treatment guidelines for patients presenting with acute paracetamol overdose. The new guidelines have been published in the current edition of the British National Formulary and are available via Toxbase, the database of the National Poisons Information Service. As a means of simplifying treatment decisions; all patients ingesting greater than 75mg/kg of paracetamol will be assessed in accordance with a single ‘treatment line’ plotted on a nomogram – at the previous ‘high risk’ threshold - regardless of hepatotoxicity risk.
We conducted a retrospective review of 52 overdose patients with positive serum paracetamol levels who presented to our Emergency Department between June and July 2012. The results indicate that the proportion of patients with positive paracetamol levels requiring admission for treatment is likely to increase from around one third (17/52) to one half (26/52); as the number of patients assessed by nomogram who require inpatient stay is likely to double after assessment using the new guidelines. In our review period, 10 patients were treated due to serum paracetamol levels above the previous ‘normal treatment line’. According to the new guidelines, nine of the 11 patients above the ‘high-risk treatment line’ - who were medically discharged due to an absence of high risk features – would require admission for a 21-hour acetylcysteine infusion. The new guidelines aim to reduce hypersensitivity reactions by increasing the duration of administration of the first dose of acetylcysteine from 15 minutes to 1 hour. This iatrogenic morbidity will likely still occur, albeit with reduced prevalence, but within a larger patient group increased by the addition of a previously untreated cohort. In our review, five patients were treated for staggered overdose; the principles of their management will not change with the new guidelines.
We feel it is important to raise awareness of the implications of the new paracetamol overdose management guidelines, which will inevitably increase the number of patients admitted to emergency department short stay wards and hospital medical admission units at a time where great effort is being made to reduce inpatient admissions.
Rapid Response:
Re: Management of paracetamol poisoning
Following a review by the Commission on Human Medicines of the treatment of paracetamol poisoning, the Medicines & Healthcare Products Regulatory Agency (MHRA) have issued changes to treatment guidelines for patients presenting with acute paracetamol overdose. The new guidelines have been published in the current edition of the British National Formulary and are available via Toxbase, the database of the National Poisons Information Service. As a means of simplifying treatment decisions; all patients ingesting greater than 75mg/kg of paracetamol will be assessed in accordance with a single ‘treatment line’ plotted on a nomogram – at the previous ‘high risk’ threshold - regardless of hepatotoxicity risk.
We conducted a retrospective review of 52 overdose patients with positive serum paracetamol levels who presented to our Emergency Department between June and July 2012. The results indicate that the proportion of patients with positive paracetamol levels requiring admission for treatment is likely to increase from around one third (17/52) to one half (26/52); as the number of patients assessed by nomogram who require inpatient stay is likely to double after assessment using the new guidelines. In our review period, 10 patients were treated due to serum paracetamol levels above the previous ‘normal treatment line’. According to the new guidelines, nine of the 11 patients above the ‘high-risk treatment line’ - who were medically discharged due to an absence of high risk features – would require admission for a 21-hour acetylcysteine infusion. The new guidelines aim to reduce hypersensitivity reactions by increasing the duration of administration of the first dose of acetylcysteine from 15 minutes to 1 hour. This iatrogenic morbidity will likely still occur, albeit with reduced prevalence, but within a larger patient group increased by the addition of a previously untreated cohort. In our review, five patients were treated for staggered overdose; the principles of their management will not change with the new guidelines.
We feel it is important to raise awareness of the implications of the new paracetamol overdose management guidelines, which will inevitably increase the number of patients admitted to emergency department short stay wards and hospital medical admission units at a time where great effort is being made to reduce inpatient admissions.
Competing interests: No competing interests