# Presentation: 660096

## Acetaminophen Overdoses:  A Review of Intentional and Unintentional Cases

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

## 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

## 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

## Acetaminophen Case Series1998 – 2002 YTD

- 54 Reports

- 52 Charts Received

- 49 Reviewed

- 47 Acetaminophen

- 23 Intentional

- 23 Unintentional

- 1 unknown

- 3 Incomplete

- 2 Not Acetaminophen

## Psychiatry Consult Service

## Patient Demographics

## Acetaminophen Dose

## Acetaminophen Formulation

- _INTENTIONAL_
- RX = 3
- Percocet n=2
- Darvocet n=1
- OTC =21
- Single Entity n=8
- Combo Entity n=13

- _UNINTENTIONAL_
- RX = 3
- Percocet n=2
- Darvocet n=1
- OTC = 20
- Single Entity n=15
- Combo Entity n=5

## Causality:  Unintentional Cases

## Acute Exposure (< 7 days)

## Lab Results:  Average Peak Levels

|  |  | INTENTIONAL | UNINTENTIONAL |
| --- | --- | --- | --- |
| APAP: | 115.1 mg/L |  | 27.8 mg/L |
| ALT: | 3,065 units/L |  | 5,193 units/L |
| AST: | 2,742 units/L |  | 6,819 units/L |
| INR: | 2.5 |  | 4 |
| T Bili: | 1.87 mg/dL |  | 5.87 mg/dL |

## Length of Stay

## 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%)
  |
|  |  |  |

## 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%)  |

## Alcohol Use

## Multiple Risk Factors

## 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

## 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

## 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

## 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.

## Quote					

*“**If I had known it would make me this sick, I never would have taken it”*