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Charcoal

Common Name(s): Activated charcoal, Animal charcoal, Charcoal, Gas black, Lamp black, Oral charcoal adsorbent

Clinical Overview

Use

Activated charcoal's main use is as an antidote in poisoning. It is promoted for use as an antiflatulent and in dyslipidemia, and has demonstrated benefit in wound healing, kidney disease, and diarrhea; however, clinical studies to support these uses are lacking.

Dosing

Acute poisoning antidote: In the management of poisonings, refer to local protocols. The recommended dosing of activated charcoal is as follows:

Children 1 year and younger: 10 to 25 g, or 0.5 to 1 g/kg.

Children 1 to 12 years: 25 to 50 g, or 0.5 to 1 g/kg.

Adolescents and adults: 25 to 100 g.

Flatulence: As an antiflatulent, a dose range of 520 to 975 mg has been suggested, to be taken after meals or at the first sign of discomfort and repeated as needed up to 4.16 g daily.

Contraindications

The American Academy of Pediatrics does not recommend administration of activated charcoal in the home, especially in cases of acute poisoning in children.

Charcoal is contraindicated in individuals with unprotected airways and decreased levels of consciousness if not intubated; ingestion of acids or alkalis; cases in which the risk or severity of aspiration is increased; or isolated ingestions of lithium, iron, heavy metals, or ethanol.

Caution should be used in those at risk of gastric hemorrhage or perforation, or in those who have ingested a substance that increases the risk of sudden onset of seizures or sudden decreases in mental status.

Pregnancy/Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking.

Interactions

None well documented.

Adverse Reactions

Emesis is the most common adverse reaction. Use in poisoning is associated with a risk of aspiration and subsequent chemical pneumonitis. GI obstruction can develop in patients receiving repeated doses.

Toxicology

Minimal toxicity is associated with the use of charcoal in hemoperfusion.

Source

Charcoal is produced by pyrolysis and high temperature oxidation of organic materials. Animal charcoal is obtained from items such as charred bones, meat, and blood. Activated charcoal is obtained from charred wood or vegetable matter and treated with various substances to increase its adsorptive power. Amorphous carbons (or charcoals) are taken from the incomplete combustion of natural gas, fats, oils, or resins.Lapus 2007

History

Charcoal has been used for medicinal purposes for thousands of years. Ancient Egyptian papyri document use of charcoal as early as 1500 BC for the adsorption of odor from rotting wounds. Hindu documents from 450 BC record the use of charcoal and sand filters for the purification of drinking water. Hippocrates and Pliny describe the use of charcoal to treat epilepsy, chlorosis, and anthrax.

In 1773, the German-Swedish pharmaceutical chemist Carl Scheele recognized the specific adsorptive powers of charcoal with various gases. At a meeting of the French Academy of Sciences in 1831, a pharmacist ingested several times the lethal dose of strychnine with equal amounts of charcoal and survived. However, the Academy members were unimpressed by this demonstration, and charcoal continued to be used primarily for industrial purposes.

In 1911, the first industrially activated charcoal was made in Austria. Shortly afterward, the use of toxic gases in World War I drove the mass production of activated charcoal suitable for respirators. However, it was not until 1963, after a review article was published in the Journal of Pediatrics, that activated charcoal became more widely accepted in the management of ingested toxins.Lapus 2007

Chemistry

The chemistry of charcoal is complex. Although the purest forms essentially consist of all carbon, the small amounts of impurities that remain following combustion of the source material have been difficult to characterize. Medicinal charcoals have been developed with a high surface area-to-weight ratio in order to maximize adsorption capacity.

The adsorptive properties of charcoal can be increased by treatment with substances such as carbon dioxide, oxygen, air, steam, sulfuric acid, zinc chloride, or phosphoric acid (or combinations of these) at high temperatures (500°C to 900°C). These materials help remove impurities and reduce the particle size of carbon, allowing more adsorption due to increased surface area. One milliliter of finely subdivided and activated medicinal charcoal has a total surface area of approximately 1,000 m2. Medicinal or activated charcoal is a fluffy, fine, black, odorless, and tasteless powder without gritty material. It is insoluble in water or other common solvents but may be suspended for a short time after vigorous shaking.Gennaro 1995

Uses and Pharmacology

Acute poisoning antidote

Activated charcoal has been used in the management of acute toxicity for almost a century. Its large surface area permits the adsorption of a variety of complex chemicals, thereby rendering toxic material unavailable for systemic absorption. In addition, charcoal may interrupt the enterohepatic circulation of compounds excreted into the bile. It is usually coadministered with a laxative, which may hasten the elimination of toxins from the GI tract, resulting in diarrhea and more rapid GI transit time.Juurlink 2016

The use of activated charcoal in the treatment of poisoning is associated with a risk of aspiration and subsequent chemical pneumonitis. Refer to local protocols or seek medical advice regarding use of charcoal in poisoning.

Animal data

Charcoal has been used successfully in animals as an acute poisoning antidoteEl Bahri, Juurlink 2016; however, extrapolation of animal data to the clinical setting is not advised.Juurlink 2016

Clinical data

Volunteer studies suggest that single-dose activated charcoal is more likely to be beneficial if given within 1 hour following ingestion; however, benefit after 1 hour cannot be excluded for poisons with slow gastric motility (eg, anticholinergic substances/drugs, opiates, salicylates). Some authors suggest that activated charcoal is beneficial more than 4 hours following acetaminophen overdose.Chyka 2005, Lapus 2007 In a nonrandomized, prospective, multicenter, observational case series, the administration of activated charcoal to patients more than 4 hours after ingestion of acetaminophen was associated with reduced incidence of liver injury, as measured by elevated serum transaminases and prothrombin time.Spiller 2006

There are no satisfactorily designed clinical studies assessing benefit from single-dose activated charcoal. One study of symptomatic patients who received activated charcoal and some form of gastric evacuation (eg, gastric lavage, ipecac, gastric aspiration) showed that patients receiving gastric aspiration and activated charcoal were less likely to be admitted to an intensive care unit.Chyka 2005

Diarrhea

Clinical data

Limited studies evaluating the use of activated charcoal in irinotecan-induced diarrhea showed reduced severity of diarrhea, resulting in a parallel reduction in loperamide consumption.Michael 2004, Sergio 2008

Dyslipidemia

Animal data

Research reveals no animal data regarding the use of charcoal in dyslipidemia; however, in a study evaluating the effect of charcoal on induced atherosclerosis secondary to nephrectomy in rats, no effect on serum cholesterol or triglycerides was noted.Yamamoto 2011

Clinical data

Older clinical studies suggest that charcoal has an effect on dyslipidemia. Reductions in blood lipid levels in uremic patients treated with charcoal hemoperfusion have been observed, and repeated oral doses of activated charcoal have been reported to be effective in reducing blood lipid concentrations in uremicFriedman 1977 and diabetic patients.Manis 1980 In a study of hypercholesterolemic patients given 8 g of activated charcoal 3 times a day for 4 weeks, total cholesterol and low-density lipoprotein (LDL) cholesterol levels decreased 25% and 41%, respectively. High-density lipoprotein (HDL) cholesterol and the ratio of HDL to LDL increased.Kuusisto 1986 This study has resulted in an increased interest in the use of oral charcoal for the reduction of blood lipid levels, but there is insufficient evidence to confirm the effect on lipid parameters or to determine an appropriate dose.

Gout

Evidence is lacking to support the use of charcoal for treatment of acute gout.Khanna 2012

Flatulence

Clinical data

Capsules of powdered medicinal charcoal are promoted for use in relieving the discomfort of abdominal gas and flatulenceGennaro 1995; however, limited clinical studies have been conducted to support this concept, and 1 study found no effect of charcoal on bloating, abdominal pain, number of flatus episodes, abdominal girth, or cumulative breath hydrogen excretion.Di Stefano 2000

Nephropathy

Clinical data

Limited clinical studies report on adsorption of toxins by charcoal in chronic kidney disease and hemodialysis patients.Schulman 2006, Wang 2012

Wound healing

Clinical data

Limited studies suggest accelerated healing rates using activated charcoal dressings with or without silver.Keiheul 2010, Verdú 2004 In a study of rectal application of activated charcoal, 35.7% of patients had complete healing of chronic anal fistulas after 8 weeks. Zawadzki 2017

Dosing

Acute poisoning antidote

The recommended dosing of activated charcoal is as follows:

Children 1 year and younger

10 to 25 g, or 0.5 to 1 g/kg.

Children 1 to 12 years

25 to 50 g, or 0.5 to 1 g/kg.

Adolescents and adults

25 to 100 g.Chyka 2005, Lapus 2007

On average, activated charcoal should be administered in at least a 10:1 ratio (charcoal to estimated poison dose). It is administered as an aqueous slurry and may be flavored, although flavoring may reduce its effectiveness.Lapus 2007 Use of a charcoal wafer cookie has been evaluated as an alternative to the slurry form of delivery.Klein-Schwartz 2010

The use of multiple-dose activated charcoal is based on the theory that after absorption, drugs will reenter the gut by passive diffusion if the concentration in the gut is lower than in the blood. Administration of more than 2 doses of activated charcoal may maintain a concentration gradient, causing the drug to continuously pass into the gut where it is adsorbed by the charcoal. Multiple-dose activated charcoal is likely to assist in decreasing absorption when large amounts of the drug are ingested and dissolution is delayed (masses and bezoars [ie, salicylates]), when drugs exhibit a delayed- or prolonged-release phase (ie, enteric coated, sustained release), or when reabsorption can be prevented (enterohepatic circulation of active drug or active metabolites [eg, carbamazepine]).Lapus 2007

Flatulence

Capsules should be taken 2 hours before or 1 hour after any oral medication. A dose range of 520 to 975 mg has been suggested, to be taken after meals or at the first sign of discomfort and repeated as needed up to 4.16 g daily.Gennaro 1995

Pregnancy / Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking.

Interactions

Because activated charcoal can adsorb drugs in the GI tract, it should be taken 2 hours before or 1 hour after other medications.Gennaro 1995

Avoid simultaneous administration of charcoal and the emetic ipecac; charcoal may adsorb the ipecac and render it ineffective. The American Academy of Pediatrics and the American Association of Poison Control Centers recommend that ipecac syrup and charcoal not be stocked at home.AAP 2003

Adverse Reactions

Of the complications reported with the administration of charcoal as a slurry (antidote), aspiration has the potential to be the most serious but is rare (possibly less than 2% incidence).Juurlink 2016, Lapus 2007 When aspiration does occur following charcoal administration, it is difficult to attribute subsequent pulmonary problems to the charcoal as opposed to the gastric contents; complications are likely due to the presence of both gastric contents and charcoal.Chyka 2005 Chemical pneumonitis may occur subsequent to aspiration.Juurlink 2016, Lapus 2007

Emesis is the most common adverse reaction in the administration of activated charcoal, with a reported incidence of 6% to 26%.Lapus 2007 The American Academy of Clinical Toxicology position statement on single-dose activated charcoal states that the influences of rate and volume of charcoal administration, ingested toxic substances, and premorbid conditions on the incidence of vomiting are unknown. However, in a study of children 18 years and younger, previous vomiting and nasogastric tube administration were found to be the most important independent risk factors for vomiting sorbitol content. Large charcoal volume or rapid administration rate did not increase vomiting risk.Graff 2002, Osterhoudt 2004

The oral use of charcoal has been associated with adverse reactions, including GI obstruction due to formation of briquettes, which was observed in patients who received repeated doses.Anderson 1987, Watson 1986

Toxicology

In general, there is little toxicity associated with the charcoal component of hemoperfusion when used for the removal of toxins from the blood following acute overdose.

References

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. American Academy of Pediatrics policy statement: poison treatment in the home. Pediatrics. 2003;112(5):1182-1185.14595067
Anderson IM, Ware C. Syrup of ipecacuanha. Br Med J. 1987;294:578.
Chyka PA, Seger D, Krenzelok EP, Vale JA; 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):61-87.15822758
de Souza JB, Okomo U, Alexander ND, et al. Oral activated charcoal prevents experimental cerebral malaria in mice and in a randomized controlled clinical trial in man did not interfere with the pharmacokinetics of parenteral artesunate. PLoS One. 2010;5(4):e9867.20419161
Di Stefano M, Strocchi A, Malservisi S, Veneto G, Ferrieri A, Corazza GR. Non-absorbable antibiotics for managing intestinal gas production and gas-related symptoms. Aliment Pharmacol Ther. 2000;14(8):1001-1008.10930893
Donoso A, Linares M, León J, et al. Activated charcoal laryngitis in an intubated patient. Pediatr Emerg Care. 2003;19(6):420-421.14676494
El Bahri L. Pharm profile: activated charcoal. Compend Contin Educ Vet. 2008;30(11):596-598.19140102
Eroglu A, Kucuktulu U, Erciyes N, Turgutalp H. Multiple dose-activated charcoal as a cause of acute appendicitis. J Toxicol Clin Toxicol. 2003;41(1):71-73.12645971
9. Farley TA. Severe hypernatremic dehydration after use of an activated charcoal-sorbitol suspension. J Pediatr. 1986;109(4):719-722.
Friedman EA. Oral sorbents in uremia: charcoal-induced reduction in plasma lipids. Am J Med. 1977;62(4):541-542.851128
Gennaro AR, ed. Remington: The Science and Practice of Pharmacy. 19th ed. Easton, PA: Mack Printing Co; 1995.
Graff GR, Stark J, Berkenbosch JW, Holcomb GW 3rd, Garola RE. Chronic lung disease after activated charcoal aspiration. Pediatrics. 2002;109(5):959-961.11986462
Harris CR, Kingston R. Gastrointestinal decontamination. Which method is best? Postgrad Med. 1992;92(2):116-122, 125, 128.1353876
Harsch HH. Aspiration of activated charcoal. N Engl J Med. 1986;314(5):318.3941725
Juurlink DN. Activated charcoal for acute overdose: a reappraisal. Br J Clin Pharmacol. 2016;81(3):482-487.26409027
Kerihuel JC. Effect of activated charcoal dressings on healing outcomes of chronic wounds. J Wound Care. 2010;19(5):208, 210-212, 214-215.20505594
Khanna D, Khanna PP, Fitzgerald JD, et al; American College of Rheumatology. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012; 64(10):1447-1461.23024029
Klein-Schwartz W, Doyon S, Dowling T. Drug adsorption efficacy and palatability of a novel charcoal cookie formulation. Pharmacotherapy. 2010;30(9):888-894.20795844
Krenzelok EP, Dunmire SM. Acute poisoning emergencies. Resolving the gastric decontamination controversy. Postgrad Med. 1992;91(2):179-182, 185-186.1738738
Kuusisto P, Vapaatalo H, Manninen V, Huttunen JK, Neuvonen PJ. Effect of activated charcoal on hypercholesterolaemia. Lancet. 1986;2(8503):366-367.2874369
Lapus RM. Activated charcoal for pediatric poisonings: the universal antidote? Curr Opin Pediatr. 2007;19(2):216-222.17496769
Manis T, Deutsch J, Feinstein EI, Lum GY, Friedman EA. Charcoal sorbent-induced hypolipidemia in uremia and diabetes. Am J Clin Nutr. 1980;33(7):1485-1488.6967252
Michael M, Brittain M, Nagai J, et al. Phase II study of activated charcoal to prevent irinotecan-induced diarrhea. J Clin Oncol. 2004;22(21):4410-4417.15514383
Osterhoudt KC, Durbin D, Alpern ER, Henretig FM. Risk factors for emesis after therapeutic use of activated charcoal in acutely poisoned children. Pediatrics. 2004;113(4):806-810.15060231
Pederson JA, Matter BJ, Czerwinski AW, Llach F. Relief of idiopathic generalized pruritus in dialysis patients treated with activated oral charcoal. Ann Intern Med. 1980;93(3):446-448.7436164
Pond SM. Role of repeated oral doses of activated charcoal in clinical toxicology. Med Toxicol. 1986;1(1):3-11.3784838
Schulman G. A nexus of progression of chronic kidney disease: charcoal, tryptophan and profibrotic cytokines. Blood Purif. 2006;24(1):143-148.16361855
Sergio GC, Félix GM, Luis JV. Activated charcoal to prevent irinotecan-induced diarrhea in children. Pediatr Blood Cancer. 2008;51(1):49-52. 18253955.18253955
Spiller HA, Winter ML, Klein-Schwartz W, Bangh SA. Efficacy of activated charcoal administered more than four hours after acetaminophen overdose. J Emerg Med. 2006;30(1):1-5.16434328
Verdú Soriano J, Rueda López J, Martínez Cuervo F, Soldevilla Agreda J. Effects of an activated charcoal silver dressing on chronic wounds with no clinical signs of infection. J Wound Care. 2004;13(10):419, 421-423.15575569
Wang Z, Cui M, Tang L, et al. Oral activated charcoal suppresses hyperphosphataemia in haemodialysis patients. Nephrology (Carlton). 2012;17(7):616-620.22697887
Watson WA, Cremer KF, Chapman JA. Gastrointestinal obstruction associated with multiple-dose activated charcoal. J Emerg Med. 1986;4(5):401-407.3805698
Yamamoto S, Zuo Y, Ma J, et al. Oral activated charcoal adsorbent (AST-120) ameliorates extent and instability of atherosclerosis accelerated by kidney disease in apolipoprotein E-deficient mice. Nephrol Dial Transplant. 2011;26(8):2491-2497.21245127
Zawadzki A, Johnson LB, Bohe M, Johansson C, Ekelund M, Nielsen OH. An open prospective study evaluating efficacy and safety of a new medical device for rectal application of activated carbon in the treatment of chronic, uncomplicated perianal fistulas. Int J Colorectal Dis. 2017;32(4):509-512.27878619

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