Activated charcoal

Activated charcoal: Drug information
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(For additional information see “Activated charcoal: Patient drug information” and see “Activated charcoal: Pediatric drug information”)

Brand Names: U.S. Actidose® with Sorbitol [OTC], Actidose®-Aqua [OTC], Char-Caps [OTC], Charcoal Plus® DS [OTC], CharcoCaps® [OTC], EZ-Char® [OTC], Kerr Insta-Char® [OTC], Requa® Activated Charcoal [OTC]
Brand Names: Canada Charcadole®; Charcadole® TFS; Charcadole®, Aqueous
Pharmacologic Category Antidote
Dosing: Adult
Acute poisoning:

Oral: 25-100 g as a single dose; if multiple doses are needed, additional doses may be given as 12.5 g/hour or equivalent (eg, 25 g every 2 hours)

Note: ~10 g of activated charcoal for each 1 g of toxin is considered adequate; this may require multiple doses. If sorbitol is also used, sorbitol dose should not exceed 1.5 g/kg. When using multiple doses of charcoal, sorbitol should be given with every other dose (not to exceed 2 doses/day)

Dietary supplement: Oral: 500-520 mg after meals; may repeat in 2 hours if needed (maximum: 10 g/day)

Dosing: Pediatric
(For additional information see “Activated charcoal: Pediatric drug information”)

Acute poisoning: Oral:

Children:

<1 year: 0.5-1 g/kg (10-25 g) as a single dose; if multiple doses are needed, give as 0.25 g/kg/hour or equivalent (eg, 0.5 g/kg every 2 hours)

1-12 years: 0.5-1 g/kg (25-50 g) as a single dose; if multiple doses are needed, give as 0.25 g/kg/hour or equivalent (eg, 0.5 g/kg every 2 hours)

>12 years: Refer to adult dosing.

Note: ~10 g of activated charcoal for each 1 g of toxin is considered adequate; this may require multiple doses. If sorbitol is also used, sorbitol dose should not exceed 1.5 g/kg. When using multiple doses of charcoal, sorbitol should be given with every other dose (not to exceed 2 doses/day).

Dosing: Geriatric Refer to adult dosing.
Dosage Forms: U.S. Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, oral:

Char-Caps: 260 mg

CharcoCaps®: 260 mg [dietary supplement]

Pellets for suspension, oral:

EZ-Char®: 25 g/bottle (1s)

Powder for suspension, oral: USP: 100% (30 g, 240 g)

Suspension, oral:

Actidose®-Aqua: 15 g (72 mL); 25 g (120 mL); 50 g (240 mL)

Kerr Insta-Char®: 25 g (120 mL); 50 g (240 mL) [contains propylene glycol (in flavoring packet), sodium benzoate]

Kerr Insta-Char®: 50 g (240 mL) [contains sodium benzoate]

Suspension, oral [with sorbitol]:

Actidose® with Sorbitol: 25 g (120 mL); 50 g (240 mL)

Kerr Insta-Char®: 25 g (120 mL); 50 g (240 mL) [contains propylene glycol (in flavoring packet), sodium benzoate, sorbitol]

Tablet, oral:

Requa® Activated Charcoal: 250 mg

Tablet, enteric coated, oral:

Charcoal Plus® DS: 250 mg

Generic Equivalent Available: U.S. Yes: Powder
Administration Flavoring agents (eg, chocolate, concentrated fruit juice) or thickening agents (eg, bentonite, carboxymethylcellulose) can enhance charcoal’s palatability. If treatment includes ipecac syrup, induce vomiting prior to administration of charcoal. Often given with a laxative or cathartic; check for presence of bowel sounds before administration. I.V. antiemetics may be required to reduce the risk of vomiting during multiple-dose therapy with charcoal.
Use Emergency treatment in poisoning by drugs and chemicals; aids the elimination of certain drugs and improves decontamination of excessive ingestions of sustained-release products or in the presence of bezoars; repetitive doses have proven useful to enhance the elimination of certain drugs (eg, carbamazepine, dapsone, phenobarbital, quinine, or theophylline); repetitive doses for gastric dialysis in uremia to adsorb various waste products; dietary supplement (digestive aid)
Medication Safety Issues
Sound-alike/look-alike issues:
Actidose® may be confused with Actos®

Adverse Reactions Significant Frequency not defined.
Endocrine & metabolic: Hypernatremia, hypokalemia, and hypermagnesemia may occur with coadministration of cathartics

Gastrointestinal: Vomiting (incidence may increase with sorbitol), diarrhea (with sorbitol), constipation, swelling of abdomen, bowel obstruction, appendicitis

Respiratory: Aspiration (both gastric contents and charcoal)

Miscellaneous: Fecal discoloration (black)

Contraindications Hypersensitivity to charcoal or any component of the formulation; intestinal obstruction; GI tract not anatomically intact; patients at risk of hemorrhage or GI perforation; patients with an unprotected airway (eg, CNS depression without intubation); if use would increase risk and severity of aspiration
Warnings/Precautions
Concerns related to adverse effects:

• Vomiting: Charcoal may cause vomiting; avoid use in hydrocarbon and caustic ingestions.

Disease-related concerns:

• Decreased peristalsis: Use with caution in patients with decreased peristalsis.

Concurrent drug therapy issues:

• Ipecac: When using ipecac with charcoal, ensure ipecac-induced vomiting has ceased prior to administering charcoal.

• Cathartics (eg, sorbitol, mannitol, magnesium sulfate): Coadministration of a cathartic is not recommended secondary to lack of compelling evidence and the increased morbidity associated with their use. If charcoal is administered with a cathartic, avoid excessive fluid and electrolyte losses, especially in children <1 year of age.

Special populations:

• Pediatrics: Charcoal with sorbitol not recommended in children <1 year of age.

Dosage form specific issues:

• Propylene glycol: Commercial charcoal products may contain propylene glycol.

Other warnings/precautions:

• Appropriate use: Not effective for cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, methanol, or lithium poisoning

• Efficacy: Most effective when administered within 30-60 minutes of ingestion.

Drug Interactions
(For additional information: Launch Lexi-Interact™ Drug Interactions Program )
Leflunomide: Charcoal, Activated may decrease serum concentrations of the active metabolite(s) of Leflunomide. Management: Unless using this combination to intentionally enhance leflunomide elimination, consider an alternative to charcoal when possible. Separating drug administration is not likely to be effective at avoiding this interaction. Risk D: Consider therapy modification

Ethanol/Nutrition/Herb Interactions Food: The addition of some flavoring agents (eg, milk, ice cream, sherbet, marmalade) are known to reduce the adsorptive capacity of activated charcoal and should be avoided in preference to activated charcoal-water slurries; nevertheless, these flavoring agents do not completely compromise the effectiveness of activated charcoal and may be necessary in some circumstances (eg, administration in pediatric patients) to enhance compliance (Cooney, 1995; Dagnone, 2002).
Pregnancy Risk Factor C (show table)
Lactation Does not enter breast milk/compatible
International Brand Names Bekarbon (ID); Ca-R-Bon (TH); Carbo Medicinalis (PL); Carbomix (FR, SE); Carbon Natural (UY); Carbosorb (NZ); Carbosorb S (NZ); Carbosorb X (AU); Carbosorb XS (AU); Carbotural (MX); Charcodote (GB, HK, KP); Charcotrace (AU); Deltacarbon (TH); Mamograf (AR); Norit (IL); RCOL (IN); Ultracarbon (SG)
Mechanism of Action Adsorbs toxic substances or irritants, thus inhibiting GI absorption; adsorbs intestinal gas; the addition of sorbitol results in hyperosmotic laxative action causing catharsis
Pharmacodynamics/Kinetics Excretion: Feces (as charcoal)

REFERENCES
Alaspää AO, Kusima MJ, Hoppu K, et al, “Feasibility Study on Activated Charcoal Given Prehospital by Emergency Medical System (EMS) in Acute Intoxications,” J Toxicol Clin Toxicol, 2002, 40(3):312-3.
Bond GR, “The Role of Activated Charcoal and Gastric Emptying in Gastrointestinal Decontamination: A State-of-the-Art Review,” Ann Emerg Med, 2002, 39(3):273-86. [PubMed 11867980]
Christophersen AB, Hoegberg LC, Angelo HR, et al, “Activated Charcoal in a Simulated Paracetamol Overdose: Downscaling of Dose to 10 Grams – Preliminary Results,” J Toxicol Clin Toxicol, 2002, 40(5):696.
Chyka PA, Seger D, Krenzelok EP, et al, American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists, “Position Paper: Single-Dose Activated Charcoal,” Clin Toxicol (Phila), 2005, 43(2):61-87 (review).
Cooney DO, “Development of Palatable Formulations,” Activated Charcoal in Medical Applications, Cooney DO, ed, New York, NY: Marcel Dekker, Inc, 1995, 397-417.
Cooper GM, Le Coteur DG, Richardson DB, et al, “A Randomized Clinical Trial of Activated Charcoal for the Routine Management of Oral Drug Overdose,” Acad Emerg Med, 2002, 9(5):487.
Dagnone D, Matsui D, and Reider MJ, “Assessment of the Palatability of Vehicles for Activated Charcoal in Pediatric Volunteers,” Pediatr Emerg Care, 2002, 18(1):19-21. [PubMed 11862132]
Dorrington CL, Johnson DW, Brant R, “The Frequency of Complications Associated With the Use of Multiple-Dose Activated Charcoal,” Ann Emerg Med, 2003, 41(3):370-7. [PubMed 12605204]
Heard K, “Gastrointestinal Decontamination,” Med Clin N Am, 2005, 89(6):1067-78 (review). [PubMed 16227054]
Higgins T, Curry S, Brooks D, et al, “Iatrogenic Administration of Propylene Glycol With Activated Charcoal,” J Toxicol Clin Toxicol, 2000, 38(5):529.
Holmes C, Schauben J, and Hasan MY, “An Evaluation of the Incidence of Emesis Following Oral Bolus Dosing vs Gradual Administration Regimens of Activated Charcoal,” J Toxicol Clin Toxicol, 1998, 36(5):431-2.
Justice HM, Knapp BJ, Pianalto DA, et al, “Failure of Emergency Medical Services Providers to Administer Activated Charcoal Add to Emergency Delay,” Acad Emerg Med, 2006, 13(5):S180.
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Merigian KS and Blaho KE, “Single-Dose Oral Activated Charcoal in the Treatment of the Self-Poisoned Patient: A Prospective, Randomized, Controlled Trial,” Am J Ther, 2002, 9(4):301-8. [PubMed 12115019]
Seger D, “Single-Dose Activated Charcoal-Backup and Reassess,” J Toxicol Clin Toxicol, 2004, 42(1):101-10. [PubMed 15083946]
Vale JA, Krenzelok EP and Barceloux GD et al, American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists, “Position Statement and Practice Guidelines on the Use of Multiple-Dose Activated Charcoal in the Treatment of Acute Poisoning,” Clin Toxicol, 1999, 37(6):731-51.