Charcoal, Activated

Class: Antacids and Adsorbents
VA Class: GA900
CAS Number: 16291-96-6
Brands: Actidose, Adsorba, CharcoAid G, Charcoal Plus DS, CharcoCaps, EZ-Char, Flatulex, Insta-Char, Liqui-Char

Introduction

Adsorbent and antidote;a destructive distillation residue of organic materials with small particle size, treated to increase adsorptive power.106 a

Uses for Charcoal, Activated

Poisonings

May be used for treatment (GI decontamination)104 in most oral poisonings101 102 103 105 106 107 108 110 112 116 a except those involving corrosive agents (e.g., strong acids or alkalis) or substances for which its absorptive capacity is too low to be clinically useful (e.g., iron salts, lithium, boric acid, arsenic, malathion, or organic solvents such as methanol, ethanol, or ethylene glycol).102 103 105 107 108 110 112 113 116

Slideshow: Worried About Ebola? You’re More Likely to Get These 10 Serious Infections

Most commonly used agent for GI decontamination in poisoned patients;132 however, routine administration in poisoned patients is not recommended by American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT).113 Controlled studies demonstrating reduced morbidity and mortality generally are lacking.101 113 (See General: Poisonings, under Dosage and Administration.)

Hemoperfusion

Hemoperfusion through columns of activated charcoal to remove endogenous or exogenous toxins in uremia, hepatic failure, or acute toxicity associated with overdose of certain drugs.102 a

GI Disorders

Adsorption of intestinal gases in the treatment of flatulence, intestinal distention, and dyspepsia;102 a FDA classified as lacking substantial evidence of efficacy as antiflatulent or digestive aid.107

Has been used alone or combined with kaolin in the management of diarrhea, but value has not been established.a

Wounds and Ulcers

Has been used in dressings for suppurating wounds or ulcers to decrease odor and promote healing.102 a

Charcoal, Activated Dosage and Administration

General

Poisonings

  • Most effective when administered early, preferably within 30–60 minutes of poison ingestion.101 102 103 104 105 113

  • Multiple-dose regimens may be considered for drugs that undergo enterohepatic or enteroenteric circulation, those with a small volume of distribution, those that are not extensively protein bound, and those with a low endogenous clearance.102 104 107 Also may be considered for life-threatening ingestions of phenobarbital, carbamazepine, quinine, dapsone, theophylline, paraquat, or Amanita phalloides.103 105 110 114

  • Tablets or granules of activated charcoal are less effective than powder and should not be used in the treatment of poisonings.a

  • If help from a poison control center (800-222-1222), emergency medical facility (911), or other qualified health professional cannot be obtained quickly by medically unsupervised individuals attempting to manage acute poisoning, follow directions on the container of activated charcoal.100 103 107 117

Administration

Oral Administration

Administer activated charcoal powder orally107 or via nasogastric or orogastric tube113 129 as extemporaneously prepared slurry or suspension or commercially available suspension.101 102 107

Continuous nasogastric infusion or division of the total dose into smaller amounts given more frequently may improve tolerance of large doses.129

If an antiemetic is required to successfully administer high dosages, a serotonin type 3 ( 5-HT3) receptor antagonist (e.g., ondansetron) or metoclopramide may be preferred.129

Sorbitol may be administered with single-dose activated charcoal or with first dose of multiple-dose regimen for palatability and laxative action; additional suspending and flavoring agents generally not recommended.107 102 103 a

Reconstitution

Extemporaneously, mix powder with sufficient tap water (e.g., 20–30 g in at least 240 mL) to form a slurry.100

Dosage

Pediatric Patients

Poisonings
Oral
Single-Dose or Multiple-Dose Regimens for Treatment of Poisoning in Children

Age

Single Dose

Multiple Doses

Infants up to 1 year of age

10–25 g or 0.5–1 g/kg 107 113

Children up to 13 years of age

25–50 g or 0.5–1 g/kg107 113

10–25 g initially, then 1–2 g/kg every 2–4 hours107

Adolescents ≥13 years of age

25–100 g 102 103 104 105 107 108 110 113

50–100 g initially, then 12.5 g every hour, 25 g every 2 hours, or 50 g every 4 hours 102 105 107 114

Adults

Poisonings
Oral

Single dose: 25–100 g102 103 104 105 107 108 110 113 or 0.5–1 g /kg;129 for massive ingestion of a highly toxic substance or if limited adsorption of a lethal substance may provide substantial clinical benefit, 1.5–2 g/kg may be given.129

Multiple doses: 50–100 g, then 12.5 g every hour, 25 g every 2 hours, or 50 g every 4 hours.102 105 107 114 Alternatively, 0.5–1 g/kg every 4–6 hours for lower-risk ingestions and larger doses (e.g., 1–1.5 g/kg per hour) for more serious ingestions (e.g., life-threatening ingestion of extended-release theophylline).129 Continue multiple-dose therapy until patient recovers or major toxicity resolves.105 107

GI Disorders
Oral

0.6–5 g as a single dosea or 0.975–3.9 g 3 times daily after meals.a

Cautions for Charcoal, Activated

Contraindications

  • Before endoscopy after ingestion of corrosive agents,105 unless necessary to adsorb another ingested toxin; may obscure endoscopic evaluation of gastroesophageal lesions.103 107 113 a

  • Patients with an unprotected airway, a GI tract that is not anatomically intact, and where risk or severity of aspiration may be increased (e.g., hydrocarbon ingestions).107 113 114

  • Multiple-dose regimen in presence of ileus or bowel obstruction.103 107 114

Warnings/Precautions

Warnings

Petroleum Distillates Ingestion

Do not use for ingestion of petroleum distillates (e.g., gasoline, kerosene);103 limited efficacy, and toxicity other than aspiration is rare.105 107 100 103 113

Sorbitol and Cathartics

Sorbitol, present in many commercial preparations, should be administered only with a single dose of activated charcoal or the first dose of multiple-dose activated charcoal; no more than 1 or 2 doses of sorbitol or another cathartic (if required) should be used in a 24-hour period because of potential for dehydration, hypotension, electrolyte disturbances (e.g., hypernatremia) associated with excessive catharsis.103 107 129

If sorbitol is used with an initial dose of activated charcoal, a second cathartic generally should not be administered.107

Use sorbitol with caution in children and geriatric patients; monitor hydration and electrolytes.103 107

General Precautions

GI Effects

May cause vomiting,102 constipation,102 diarrhea,102 and GI obstruction102 114 or fecal impaction102 in dehydrated patients.102 103 108 114

Generally should not be used when decreased peristalsis present (reduced or absent bowel sounds); if risk of GI obstruction, perforation, or hemorrhage exists; if surgery has occurred recently; or if electrolyte imbalance or volume depletion exists.103 107 113

Pulmonary Effects

Aspiration of activated charcoal may lead to more severe complications than aspiration of gastric contents alone.101 102 Aspiration from vomiting or misdirected nasogastric catheter has resulted in granulomatous reactions, bronchiolitis obliterans, tissue reaction to suspension agents (sorbitol, povidone), increased lung permeability, and rarely, death.101 102 104 111 114 130

Take measures to reduce the risk of aspiration (e.g., placement of a cuffed endotracheal tube in patients with impaired laryngeal reflexes).102 107 113

Use of Fixed Combination

When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

Common Adverse Effects

Vomiting, diarrhea, constipation, black stools.103

Interactions for Charcoal, Activated

May decrease absorption of and therapeutic response to other orally administered drugs.102 106 107 a Drugs other than those used for GI decontamination or antidotes for ingested toxins should not be given within 2 hours of activated charcoal; if necessary, concomitant drug therapy can be given parenterally.102 107

Specific Drugs

Drug

Interaction

Comments

Acetylcysteine, oral

Adsorption of acetylcysteine in vitro;105 107 no substantial decrease in efficacy apparent in human studies105 107

Ipecac syrup

Ipecac-induced emesis may interfere with adsorptive efficacy of activated charcoal;107 decreased emesis with ipecac unlikely103 107

Ipecac not generally recommended;103 105 109 117 118 119 120 if ipecac has been used to induce emesis, administer activated charcoal after vomiting has ceased107

Polyethylene glycol and electrolyte solutions

Potential decreased adsorptive capacity of activated charcoal107 a

Charcoal, Activated Pharmacokinetics

Absorption

Bioavailability

Not absorbed from the GI tract.a

Elimination

Metabolism

Does not undergo metabolism.a

Elimination Route

Excreted in feces.a

Stability

Storage

Oral

Well-closed glass or metal containers.a

Actions

  • Nonspecific adsorbent; inhibits GI absorption of various drugs and chemicals.a

  • Broader spectrum of adsorptive activity than other adsorbents (attapulgite, Arizona montmorillonite, evaporated milk).a

  • Inadequate adsorption of alcohols (e.g., ethanol, methanol, ethylene glycol), iron salts, lithium, corrosive agents (e.g. strong acids and alkalis), boric acid, arsenic, malathion, or organic solvents for clinical use in GI decontamination.101 105

  • Adsorbs enzymes, vitamins, amino acids, minerals, and other nutrients from the GI tract; of no importance when used in the management of acute poisoning.a

  • Effectiveness of activated charcoal in the lower GI tract is questionable.107

Advice to Patients

  • Importance of calling poison control center (800-222-1222), physician, or emergency department before administration.107

  • Shake liquid well, drink, then rinse container with water, shake again, and drink to get full dose.107

  • Administer only after vomiting has ceased.107

  • Importance of not mixing with milk, ice cream, or sherbet.107

  • Importance of taking oral drugs not used for poisoning at least 2 hours before or after administration of activated charcoal.107

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Activated Charcoal

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Extracorporeal

Hemoperfusion System

150 g

Adsorba 150 C Pediatric

Gambro

300 g

Adsorba 300 C

Gambro

Oral

Capsules

260 mg

Charcoal Activated Capsules

Mason

CharcoCaps

Requa

For suspension

15 g

CharcoAid G

Little Remedies

Pellets

25 g

EZ-Char

Paddock

Suspension

0.625 g/5 mL (15 or 25 g)

Actidose-Aqua (in aqueous solution)

Paddock

1 g/5 mL (15, 25, or 50 g)

Actidose-Aqua (in aqueous solution)

Paddock

Actidose with Sorbitol (in sorbitol solution)

Paddock

Insta-Char Adult (in aqueous or sorbitol solution; cherry- or original-flavor)

Kerr

Insta-Char Pediatric (in aqueous or sorbitol solution; cherry-flavor)

Kerr

Liqui-Char (in aqueous solution)

Monarch

Tablets, delayed-release (enteric-coated core)

250 mg

Charcoal Plus DS

Kramer

Activated Charcoal Combinations

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, delayed-release (enteric-coated core)

250 mg with Simethicone 80 mg

Flatulex

Dayton

250 mg with Simethicone 125 mg

Flatulex Maximum Strength

Dayton

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions April 1, 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

100. Food and Drug Administration. Poison treatment drug products for over-the-counter human use; tentative final monograph. (21CFR Part 357] Fed Regist. 1985; 50:2244-62.

101. Bond CR. The role of activated charcoal and gastric emptying in gastrointestinal decontamination: A state-of-the-art review. Ann Emerg Med. 2002; 39:273-86. [IDIS 478717] [PubMed 11867980]

102. Sweetman SC, ed. Martindale: the complete drug reference. 33rd ed. London: The Pharmaceutical Press; 2002:1000-1.

103. Ellenhorn MJ, ed. Ellenhorn’s Medical Toxicology. 2nd ed. Baltimore, MD: Williams & Wilkins; 1997: 66-78.

104. Shannon M. Ingestion of toxic substances by children. N Engl J Med. 2000; 342:186-91. [IDIS 439237] [PubMed 10639545]

105. Ahya SN, Flood K, Paranjothi S, eds. Washington Manual of Medical Therapeutics. 30th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001: 544-73.

106. Jones Pharma. Liqui-Char(r) (activated charcoal) suspension prescribing information (dated 2001 May 1). In: Physicians’ desk reference. 56th ed. Montvale, NJ: Medical Economics Company Inc; 2002:1823.

107. USP DI: drug information for the health care professional, 22nd ed. Greenwood Village, CO: Micromedex; 2002;1:848-51.

108. Fountain JS, Beasley DM. Activated charcoal supersedes ipecac as gastric decontaminant. NZ Med J. 1998; 111:402-4. [IDIS 416732] [PubMed 9830429]

109. Henry JA, Hoffman JR. Continuing controversy on gut decontamination. Lancet. 1998; 352:420-1. Editorial. [IDIS 415080] [PubMed 9708747]

110. Burns MM. Activated charcoal as the sole intervention for treatment after childhood poisoning. Curr Opin Pediatr. 2000; 12:166-71. [PubMed 10763768]

111. Sabga E, Dick A, Lertzman M et al. Direct administration of charcoal into the lung and pleural cavity. Ann Emerg Med. 1997; 30:695-7. [IDIS 396070] [PubMed 9360585]

112. Decker WJ, Combs HF, Corby DG. Adsorption of drugs and poisons by activated charcoal. Toxicol Appl Pharmacol. 1968; 13:454-60. [PubMed 5726670]

113. American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position statement: single-dose activated charcoal. Clin Toxicol. 2005; 43:61-87.

114. American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. Clin Toxicol. 1999; 37:731-51. [IDIS 439026] [PubMed 10584586]

115. The adsorption of salicylates by a milk chocolate-charcoal mixture. Ann Emerg Med. 1991; 20:143-6.

116. Oderda GM, Klein-Schwartz W, Insley BM. In vitro study of boric acid and activated charcoal. Clin Toxicol. 1987; 25:13-9. [IDIS 242405] [PubMed 3586083]

117. American Academy of Pediatrics. Committee on Injury, Violence, and Poison Prevention. Policy Statement. Poison Treatment in the Home. Pediatrics. 2003; 112 (No. 5): 1182-85. [PubMed 14595067]

118. Manoguerra AS, Cobaugh DJ and the Members of the Guidelines for the Management of Poisonings Consensus Panel for the American Association of Poison Control Centers. Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons. [2004]. From AAPCC website. Accessed 2004 Sep 21.

119. The American Academy of Clinical Toxicology. Position Statements: Ipecac Syrup. Available from website. Accessed 2003 Nov 4.

120. Bond GR. Home Syrup of Ipecac Use Does Not Reduce Emergency Department Use or Improve Outcome. Pediatrics. 2003; 112 (No. 5): 1161-64.

121. Cooney DO. In vitro evidence for ipecac inactivation by activated charcoal. J Pharm Sci. 1978; 67:427-7. [PubMed 25328]

122. Freedman GE, Pasternak S, Krenzelok EP. A clinical trial using syrup of ipecac and activated charcoal concurrently. Ann Emerg Med. 1987; 16:164-6 [PubMed 2879488]

123. American Heart Association, American National Red Cross. Guidelines 2005 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 10: First aid. Circulation. 2005; 112 (Suppl I):III114-125.

124. Kornberg AE, Dolgin J. Pediatric ingestions: charcoal alone versus ipecac and charcoal. Ann Emerg Med. 1991; 20:648-51 [PubMed 1674842]

125. Underhill TJ, Greene, MK, Dove AF. A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetamol overdose. Arch Emerg Med. 1990; 7:148-54. [PubMed 1983801]

126. McKinney P, Phillips S, Gomez HF et al. Corneal abrasions secondary to activated charcoal. Am J Emerg Med. 1993; 11:562. [PubMed 8363692]

127. Boyd R, Hanson J. Prospective single blinded randomised controlled trial of two orally administered activated charcoal preparations. J Accid Emerg Med. 1999; 16:24-5. [PubMed 9918281]

128. Fischer TF, Singer AJ. Comparison of the palatabilities of standard and superactivated charcoal in toxic ingestions: a randomized trial. Acad Emerg Med. 1999; 6:895-9. [PubMed 10490250]

129. Smilkstein MJ. Techniques used to prevent gastrointestinal absorption of toxic compounds. In: Goldfrank LR, Flomenbaum NE, Lewin NA et al, eds. Goldfrank’s toxicologic emergencies. 7th ed. New York: McGraw-Hill; 2002: 45-57.

130. Menzies DG, Busuttil A, Prescott LF. Fatal pulmonary aspiration of oral activated charcoal. Br Med J. 1988; 297:459-60. [PubMed 3139147]

131. Osterhoudt KC, Durbin D, Alpern ER et al. Risk factors for emesis after therapeutic use of activated charcoal in acutely poisoned children. Pediatrics. 2004; 113:806-10. [PubMed 15060231]

132. Watson WA, Litovitz TL, Rodgers Jr GC et al. 2004 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Available from website. Accessed 2006 Sep 26.

a. AHFS Drug Information 2006. McEvoy GK, ed. Charcoal, Activated. Bethesda, MD: American Society of Health-System Pharmacists; 2006:2858-61.

Hide
(web5)