Charcoal, Activated (Oral-Local)

This monograph includes information on the following:

1) Activated Charcoal
2) Activated Charcoal and Sorbitol


JAN:
Activated Charcoal—Medicinal carbon {04}

VA CLASSIFICATION
Primary: AD900

Commonly used brand name(s): Actidose with Sorbitol2; Actidose-Aqua1; Aqueous Charcodote1; Aqueous Pediatric Charcodote1; CharcoAid2; CharcoAid 20001; CharcoAid G1; Charcodote2; Charcodote TFS-252; Charcodote TFS-502; Insta-Char Pediatric in an Aqueous Base with Cherry Flavor1; Insta-Char Pediatric with Cherry Flavor in a Sorbitol Base2; Insta-Char in an Aqueous Base1; Insta-Char in an Aqueous Base with Cherry Flavor1; Insta-Char with Cherry Flavor in a Sorbitol Base2; Liqui-Char1; Liqui-Char with Sorbitol2; Pediatric Charcodote2.

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).



Category:


Antidote (adsorbent)—Activated Charcoal USP; Activated Charcoal Oral Suspension;

Antidote (adsorbent)-laxative—Activated Charcoal and Sorbitol Oral Suspension;

Indications

Accepted

Toxicity, nonspecific (treatment)—A single dose of activated charcoal, in the form of activated charcoal powder (prepared as an aqueous slurry) or oral suspension, or activated charcoal and sorbitol oral suspension, is indicated for use as an emergency antidote in the treatment of poisoning by most drugs and chemicals. {02} {05} {06} {13} {16} {20} {28} {29} {33} {34} {37} {39} Activated charcoal is most effective when it is administered within 1 hour following ingestion of the toxic substance. {16} However, use may be considered more than 1 hour after the toxic ingestion. {06} {16} {19} Activated charcoal may be beneficial when administered several hours after ingestion of long-acting or extended-release drugs, or drugs that slow gastrointestinal motility. {35} But, the efficacy of activated charcoal when administered more than 1 hour after most other toxic ingestions has been neither proven nor disproven. {16}
—Activated charcoal administered in multiple doses (MDAC) is indicated in the treatment of severe intoxications {19} {26} {41} with drugs that are secreted into the stomach or that undergo clinically significant enterohepatic or enteroenteric cycling; {28} {42} {43} or drugs that have low intrinsic clearances, long half-lives, nonrestrictive protein binding, and small volumes of distribution. {28} {36} {42} Some drugs for which MDAC therapy may be effective include carbamazepine, dapsone, phenobarbital, quinine, and theophylline. {06} {26} {33} {62} MDAC also may be used to accelerate the elimination of some industrial and environmental toxicants and heavy metals and their radioactive isotopes. {41}

Unaccepted
Activated charcoal is ineffective in adsorbing caustic alkalis, boric acid, lithium, alcohols, ethylene glycol, iron salts, and mineral acids. {02} {05} {20} {29} {33} {34} {41} {65} Activated charcoal adsorbs some hydrocarbons, but its use is not recommended because aliphatic hydrocarbons such as gasoline and kerosene rarely result in toxicity other than that associated with aspiration. {16}

The U.S. Food and Drug Administration (FDA) has classified activated charcoal as lacking substantial evidence of efficacy as an antiflatulent or digestive aid. {14} {15}


Pharmacology/Pharmacokinetics

Mechanism of action/Effect:


Activated charcoal:


Antidote (adsorbent)—

Single-dose therapy—Activated charcoal adsorbs the toxic substance ingested, thus inhibiting gastrointestinal absorption {11} {16} and reducing or preventing toxicity. {11} {16}

Multiple-dose therapy—When administered in multiple doses, activated charcoal creates and maintains a concentration gradient across the wall of the gastrointestinal tract that facilitates passive diffusion of the toxic substance from the blood stream into the gastrointestinal tract lumen where it is adsorbed and thereby prevented from being reabsorbed. {06} {36} {39} {41} {44} {65} In this manner, activated charcoal interrupts the enterohepatic or enteroenteric cycle and enhances the rate of elimination of the toxic substance from the body. {19} {26} {28} {29} {39} {41} This process has been termed “gastrointestinal dialysis.” {39}




Sorbitol:

Laxative, hyperosmotic: It has been suggested that sorbitol either promotes osmotic retention of fluid or extracts water from the gastrointestinal circulation, resulting in an increase in intraluminal contents, which stimulates gastrointestinal motility and promotes catharsis. {37} {65}

Flavoring agent: Sorbitol decreases the grittiness of activated charcoal and provides a sweet vehicle to enhance palatability. {37}


Absorption:

Activated charcoal—Not absorbed from the gastrointestinal tract. {01}

Sorbitol—Poorly absorbed from the gastrointestinal tract. {01}

Biotransformation:

Activated charcoal—Not metabolized. {01}

Sorbitol—Hepatic; slowly converted to fructose. {01}

Onset of action:

Activated charcoal—Immediately after ingestion. {19} {36}

Sorbitol (catharsis)—1 to 1.5 hours. {65}

Duration of action:

Sorbitol (catharsis)—8 or more hours. {65}

Elimination:
    Activated charcoal—Intestinal.


Precautions to Consider

Pregnancy/Reproduction

Pregnancy—
Problems in humans have not been documented.

Breast-feeding

Problems in humans have not been documented.

Pediatrics


:

Preparations of activated charcoal with sorbitol usually are not recommended for use in children younger than 1 year of age because of the risk of fluid and electrolyte imbalance. {26} {55} In older children, the weight of the child must be taken into account to determine a safe dosage of sorbitol, which should not exceed 3 grams per kg of body weight. {20} {31} {33}

Children should not receive preparations of activated charcoal with sorbitol unless they are under the direct supervision of a physician, so proper attention may be given to the patients' fluid and electrolyte needs. {21}



Geriatrics



:

Although adequate and well-controlled studies have not been done in the geriatric population, caution is recommended when using preparations of activated charcoal with sorbitol because of the increased risk of catharsis, which may result in fluid and electrolyte loss in geriatric patients. {37} Caution also is recommended when using multiple doses of activated charcoal in geriatric patients with poor gastrointestinal motility because of the increased risk of constipation in this population. {43}


Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

Acetylcysteine, oral    (adsorbed by activated charcoal in in vitro studies; {46} {47} {48} however, studies in humans have demonstrated that the efficacy of acetylcysteine is not significantly affected by administration of activated charcoal {18} {19} {44} {45})


Chocolate syrup or
Ice cream or sherbet{06}    (should not be used as vehicles for the administration of activated charcoal since they may decrease the adsorptive capacity of the activated charcoal {06})


Ipecac{19}    (if both ipecac and activated charcoal are to be used in the treatment of oral poisoning, it is generally recommended that the charcoal be administered only after vomiting has been completed; however, in some clinical trials in which activated charcoal was administered pre-emesis 10 minutes after high doses of ipecac, the emetic properties of ipecac were not inhibited {24} {25} {33})


Oral medications, other    (the efficacy of other concurrently used medications may be decreased because of decreased adsorption caused by the activated charcoal; {59} patients should be advised not to take any other medication within at least 2 hours of the activated charcoal {05} {33})


Polyethylene glycol and electrolytes{38}    (concurrent use may decrease the binding capacity of activated charcoal {38})


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Except under special circumstances, this medication should not be used when the following medical problems exist:
» Bowel sounds, absence of{29}{37} or
» Hemorrhage, gastrointestinal, risk of{16} or
» Obstruction, gastrointestinal{29}{37}{42} or
» Perforation, gastrointestinal{16}{37} or
» Surgery, recent{16}{37}    (increased risk of gastrointestinal complications {16} {22} {31} {33})


» Electrolyte imbalance{37} or
» Volume depletion{37}    (use of cathartics, such as sorbitol, is not recommended {37})


Risk-benefit should be considered when the following medical problems exist
» Decreased patient alertness{16}    (endotracheal intubation is required prior to administration of activated charcoal to assist in prevention of pulmonary aspiration {16})


Gastrointestinal motility, impaired{39}{42}    (efficacy of activated charcoal in increasing elimination of toxic substances may be decreased {39} {42})


For preparations containing sorbitol or flavoring:
Hypersensitivity or intolerance to fructose{58}{65}


Side/Adverse Effects
The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Note: There have been reports of pulmonary aspiration following administration of activated charcoal. {16} {28} {49} However, this complication is not caused by activated charcoal but is a result of inadequate airway protection {16} {49} or misplacement of an orogastric tube into the lung. {58} Pulmonary aspiration may be avoided in patients with a decreased level of consciousness by correct placement of an endotracheal tube prior to activated charcoal administration. {16} {49}
Dehydration, cardiac arrest, and brain damage occurred as a result of fluid loss secondary to sorbitol overdose in a 3-month-old child who was being treated with activated charcoal and sorbitol combination for an overdose of theophylline. {32}


Those indicating need for medical attention
Incidence less frequent or rare
    
Electrolyte disturbances {41}{55}
    
hypotension {41}
    
pain or swelling in abdomen {33}

Note: Electrolyte disturbances and hypotension may be caused by repeated administration of large doses of sorbitol-containing preparations. {41}




Those indicating need for medical attention only if they continue
Incidence more frequent
    
Diarrhea {41}{55}{65}

Note: Diarrhea may persist for several hours; precautions should be taken against possible fluid and electrolyte loss.


Incidence less frequent or rare
    
Constipation {26}{41}
    
vomiting {16}{17}{37}{41}—incidence increased with administration of sorbitol{16}



Those not indicating need for medical attention
Incidence more frequent
    
Black stools {54}{55}{65}





Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Charcoal, Activated (Oral) .

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
»   Conditions affecting use, especially:
Hypersensitivity or intolerance to fructose (for preparations containing sorbitol or flavoring only)





Use in children—Preparations with sorbitol are not recommended for children younger than 1 year of age and should be used only under a physician's supervision in older children because of risk of fluid and electrolyte imbalance






Use in the elderly—Risk of fluid and electrolyte loss with preparations containing sorbitol; increased risk of constipation when multiple doses are used in patients with poor gastrointestinal motility
Other medical problems, especially absence of bowel sounds; decreased patient alertness; electrolyte imbalance; gastrointestinal hemorrhage, obstruction, or perforation; recent surgery; or volume depletion

Proper use of this medication
» Calling poison control center, physician, or emergency room before taking medication

To avoid scattering activated charcoal powder, taking care when opening container and preparing slurry

» Importance of shaking the oral liquid dosage form vigorously; after taking dose, rinsing container with water, shaking again, and drinking mixture to get full dose

» Taking activated charcoal only after vomiting has been completed if ipecac syrup also is used

Importance of not taking medication mixed with chocolate syrup, ice cream, or sherbet

» Taking doses of other oral medications at least 2 hours before or after doses of activated charcoal

» Proper dosing

» Proper storage


Side/adverse effects
Signs of potential side effects, especially electrolyte disturbances and hypotension (with repeated administration of large doses of sorbitol-containing preparations) and pain or swelling in abdomen

Medication will color stools black, which may be alarming to patient although medically insignificant


General Dosing Information
Activated charcoal is most effective when it is administered early in acute poisoning, preferably within 1 hour following ingestion of the poison. {16} However, use still may be considered more than 1 hour after the toxic ingestion. {06} {16} {19} Activated charcoal may be beneficial when administered several hours after ingestion of long-acting or extended-release drugs, or drugs that slow gastrointestinal motility. {35} But, the efficacy of activated charcoal when administered more than 1 hour after most other toxic ingestions has been neither proven nor disproven. {16}

To ensure that a full dose of activated charcoal is received, the container should be shaken vigorously just before administration and, after administration, rinsed with water, shaken, and the mixture drunk. {50}

The administration of activated charcoal as an aqueous slurry is generally preferred. However, to improve the palatability of activated charcoal, it has been administered in combination with suspending agents such as bentonite or carboxymethylcellulose. Also, a flavoring agent such as chocolate syrup has been added to the combination at the time of administration. However, some studies have shown that these agents, especially the flavoring agents, decrease the adsorptive capacity of activated charcoal and should not be used.

Following administration of activated charcoal, cathartics have been administered to enhance removal of the drug/charcoal complex. However, based on available data, the use of cathartics in combination with activated charcoal cannot be recommended. {26} {37} If an activated charcoal product containing sorbitol is used, additional cathartic should not be administered. {51}

When multiple doses of activated charcoal are required, preparations that contain sorbitol should not be used in each dose of the multiple-dose regimen since they may produce excessive catharsis, which may result in dehydration and hypotension. {21} {29} Instead, one to two doses of cathartic may be administered every 24 hours, {43} {52} with the first dose administered with the first dose of activated charcoal. {29} {43}

The presence of normal bowel sounds is necessary to determine whether to continue multiple-dose activated charcoal therapy. If bowel sounds are absent or hypoactive, continuing multiple dosing of activated charcoal with or without sorbitol is not recommended because of the possibility of constipation (or aggravation of) and the possibility of pooling of fluids in the colon if sorbitol continues to be administered with the activated charcoal. {22} {31} {33}

Multiple-dose activated charcoal therapy should continue until the patient recovers or until the major symptoms of toxicity resolve. {43}

ACTIVATED CHARCOAL


Oral-Local Dosage Forms

ACTIVATED CHARCOAL USP

Usual adult and adolescent dose
Antidote (adsorbent)
Single-dose therapy: Oral, as a slurry in water, 25 to 100 grams.

Multiple-dose therapy: Oral, as a slurry in water, 50 {26} {40} to 100 {26} grams initially, followed by 12.5 grams every hour, {26} {41} 25 grams every two hours, or 50 grams every four hours. {41}


Usual pediatric dose
Antidote (adsorbent)


Single-dose therapy:
Children up to 1 year of age—Oral, as a slurry in water, 10 to 25 grams {62} or 0.5 to 1 gram per kg of body weight. {66}

Children 1 through 12 years of age—Oral, as a slurry in water, 25 to 50 grams {07} {34} or 0.5 to 1 gram per kg of body weight. {66}

Children 13 years of age or older—See Usual adult and adolescent dose .



Multiple-dose therapy:
Children up to 13 years of age—Oral, as a slurry in water, 10 to 25 grams initially, {26} followed by 1 to 2 grams per kg of body weight every two to four hours. {42}

Children 13 years of age or older—See Usual adult and adolescent dose .



Usual geriatric dose
See Usual adult and adolescent dose .

Size(s) usually available:
U.S.—


15 grams (OTC)[Generic]{30}


25 grams (OTC)[Generic]{60}{63}


30 grams (OTC)[Generic]{08}


50 grams (OTC)[Generic]{30}{60}


100 grams (OTC)[Generic]{08}

Canada—


25 grams (OTC)[Generic]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container. {53}

Note: Consider providing on the label the telephone number for physician, poison control center, or emergency room.



ACTIVATED CHARCOAL ORAL SUSPENSION

Usual adult and adolescent dose
Antidote (adsorbent)
Single-dose therapy: Oral, 25 to 100 grams. {07}

Multiple-dose therapy: Oral, 50 {26} {40} to 100 {26} grams initially, followed by 12.5 grams every hour, {26} {41} 25 grams every two hours, or 50 grams every four hours. {41}


Usual pediatric dose
Antidote (adsorbent)


Single-dose therapy:
Children up to 1 year of age—Oral, 10 to 25 grams {62} or 0.5 to 1 gram per kg of body weight. {66}

Children 1 through 12 years of age—Oral, 25 to 50 grams {07} {34} or 0.5 to 1 gram per kg of body weight. {66}

Children 13 years of age or older—See Usual adult and adolescent dose .



Multiple-dose therapy:
Children up to 13 years of age—Oral, 10 to 25 grams initially, {26} followed by 1 to 2 grams per kg of body weight every two to four hours. {42}

Children 13 years of age or older—See Usual adult and adolescent dose .



Usual geriatric dose
See Usual adult and adolescent dose .

Strength(s) usually available
U.S.—


15 grams per 72 mL (OTC) [Actidose-Aqua{02}][Generic]


15 grams per 75 mL (OTC) [Liqui-Char{27}]


15 grams per 120 mL (OTC) [CharcoAid G{56}]


25 grams per 120 mL (OTC) [Actidose-Aqua{02}] [Liqui-Char{27}] [Insta-Char Pediatric in an Aqueous Base with Cherry Flavor{12}{65}][Generic]{08}


30 grams per 120 mL (OTC) [Liqui-Char{27}]


50 grams per 240 mL (OTC) [Actidose-Aqua{02}] [CharcoAid 2000{57}] [Insta-Char in an Aqueous Base{12}{65}] [Insta-Char in an Aqueous Base with Cherry Flavor{65}] [Liqui-Char{27}][Generic]

Canada—


25 grams per 125 mL (Rx) [Aqueous Pediatric Charcodote{03}]


50 grams per 250 mL (Rx) [Aqueous Charcodote{03}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. Protect from freezing.

Auxiliary labeling:
   • Before use, shake vigorously until the product is resuspended. {51}
   • After use, rinse container with water, shake, and drink to get full dose of medication.

Note: Consider providing on the label the telephone number for poison control center, physician, or emergency room.



ACTIVATED CHARCOAL AND SORBITOL


Oral-Local Dosage Forms

ACTIVATED CHARCOAL AND SORBITOL ORAL SUSPENSION

Usual adult and adolescent dose
Antidote (adsorbent)
Oral, 50 to 100 grams of activated charcoal as a single dose. {65}

Note: Use is not recommended for multiple-dose therapy because of the potential for excessive catharsis. {21} {29} Not more than one or two doses of sorbitol should be administered within twenty-four hours, with the first dose administered with the first dose of activated charcoal. {61}
Sorbitol content varies among the different preparations available. The product label should be consulted to determine the amount of sorbitol. For adults, the usual dose of sorbitol is 1 to 2 grams per kg of body weight. {62}



Usual pediatric dose
Antidote (adsorbent)
Children up to 1 year of age: Use is not recommended. {55} {65}

Children 1 through 12 years of age: Oral, 25 to 50 grams of activated charcoal as a single dose.

Note: Use is not recommended for multiple-dose therapy because of the potential for excessive catharsis. {21} {29} Not more than one or two doses of sorbitol should be administered within twenty-four hours, with the first dose administered with the first dose of activated charcoal. {61}
Sorbitol content varies among the different preparations available. The product label should be consulted to determine the amount of sorbitol. For children, the usual dose of sorbitol 70% (90.15 grams per 100 mL {34}) is 2 mL per kg of body weight, or a dose not to exceed 3 grams of sorbitol per kg of body weight. {20} {31} {33}



Usual geriatric dose
See Usual adult and adolescent dose.

Strength(s) usually available
U.S.—


25 grams of activated charcoal and 25 grams of sorbitol per 120 mL (OTC) [Insta-Char Pediatric with Cherry Flavor in a Sorbitol Base{12}{65}]


25 grams of activated charcoal and 27 grams of sorbitol per 120 mL (OTC) [Liqui-Char with Sorbitol]{27}


25 grams of activated charcoal and 48 grams of sorbitol per 120 mL (OTC) [Actidose with Sorbitol{02}]


30 grams of activated charcoal and 30 grams of sorbitol per 150 mL (OTC) [CharcoAid{57}]


50 grams of activated charcoal and 50 grams of sorbitol per 240 mL (OTC) [Insta-Char with Cherry Flavor in a Sorbitol Base{12}{65}]


50 grams of activated charcoal and 54 grams of sorbitol per 240 mL (OTC) [Liqui-Char with Sorbitol]{27}


50 grams of activated charcoal and 96 grams of sorbitol per 240 mL (OTC) [Actidose with Sorbitol{02}]

Canada—


25 grams of activated charcoal and 25 grams of sorbitol per 125 mL (Rx) [Charcodote TFS-25{03}]


25 grams of activated charcoal and 90 grams (approximately) of sorbitol per 125 mL (Rx) [Pediatric Charcodote{03}]


50 grams of activated charcoal and 50 grams of sorbitol per 250 mL (Rx) [Charcodote TFS-50{03}]


50 grams of activated charcoal and 180 grams (approximately) of sorbitol per 250 mL (Rx) [Charcodote{03}]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. Protect from freezing.

Auxiliary labeling:
   • Before use, shake vigorously until the product is resuspended. {51}

Note: Consider providing on the label the telephone number for physician, poison control center, or emergency room.




Revised: 06/11/1999



References
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  1. Krenzelok EP, Lush RM. Container residue after the administration of aqueous activated charcoal products. Am J Emerg Med 1991; 9: 144-6.
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  1. Panel comment, 05/04/99.
  1. Manufacturer comment, 05/04/99.
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  1. Panel comment, 05/31/99.
  1. Manufacturer comment, 05/31/99.
  1. Panel comment, 05/31/99.
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  1. Reviewers' consensus on monograph revision of 05/31/99.
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