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Charcoal, Activated

Pronunciation

(CHAR kole AK tiv ay ted)

Index Terms

  • Activated Carbon
  • Activated Charcoal
  • Adsorbent Charcoal
  • Liquid Antidote
  • Medicinal Carbon
  • Medicinal Charcoal

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Liquid, Oral:

Actidose-Aqua: 15 g/72 mL (72 mL); 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [sweet flavor]

Actidose/Sorbitol: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [sweet flavor]

Kerr Insta-Char: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [contains fd&c red #40, methylparaben sodium, propylene glycol, propylparaben sodium, sodium benzoate; cherry flavor]

Kerr Insta-Char: 50 g/240 mL (240 mL) [contains propylene glycol]

Kerr Insta-Char in Sorbitol: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [contains fd&c red #40, methylparaben sodium, propylene glycol, propylparaben sodium, sodium benzoate; cherry flavor]

Suspension, Oral:

Char-Flo with Sorbitol: 25 g (120 mL)

Suspension Reconstituted, Oral:

EZ Char: 25 g (1 ea) [contains bentonite]

Brand Names: U.S.

  • Actidose-Aqua [OTC]
  • Actidose/Sorbitol [OTC]
  • Char-Flo with Sorbitol [OTC]
  • EZ Char [OTC]
  • Kerr Insta-Char in Sorbitol [OTC]
  • Kerr Insta-Char [OTC]

Pharmacologic Category

  • Antidote

Pharmacology

Adsorbs toxic substances, thus inhibiting GI absorption and preventing systemic toxicity. Administration of multiple doses of charcoal may interrupt enteroenteric, enterohepatic, and enterogastric circulation of some drugs; may also adsorb any unabsorbed drug which remains in the gut.

Absorption

Not absorbed from the GI tract

Excretion

Feces (as charcoal)

Use: Labeled Indications

Suspension: Activated charcoal is a nonabsorbable adsorbent that may be considered in the management of poisonings when gastrointestinal decontamination of drugs or chemicals is indicated (eg, presentation to a treatment facility within 1 hour of ingestion). Activated charcoal is generally an effective adsorbent of drugs and chemicals with a molecular weight range of 100-1000 daltons. Multidose activated charcoal may be considered if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline (Vale, 1999).

Capsules, tablets: Digestive aid

Contraindications

There are no absolute contraindications listed within the manufacturer’s labeling.

Note: The American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) consider the following to be contraindications to the use of charcoal (Chyka, 2005; Vale, 1999): Presence of intestinal obstruction or GI tract not anatomically intact; patients at risk of GI hemorrhage or perforation; patients with an unprotected airway (eg, CNS depression without intubation); if use would increase the risk and severity of aspiration

Dosing: Adult

Acute poisoning: Oral, NG: Note: Some products may contain sorbitol; coadministration of a cathartic, including sorbitol, is not recommended. Some clinicians still recommend dosing activated charcoal in a 10:1 (charcoal:poison) ratio for optimal efficacy (Gude, 2009); however, the amount of poison ingested is commonly unknown, which makes this approach challenging and often impractical (Chyka, 2005).

Single dose (Chyka, 2005): 25-100 g

Multidose: Initial dose: 50-100 g followed by 25-50 g every 4 hours

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Acute poisoning: Oral, NG: Note: Some products may contain sorbitol; coadministration of a cathartic, including sorbitol, is not recommended. Some clinicians still recommend dosing activated charcoal in a 10:1 (charcoal:poison) ratio for optimal efficacy (Gude, 2009); however, the amount of poison ingested is commonly unknown, which makes this approach challenging and often impractical (Chyka, 2005).

Single dose (Chyka, 2005):

Infants <1 year: 10-25 g; Note: Although dosing by body weight is reported in children (0.5-1 g/kg) and published in many resources, there are no data or scientific rationale to support this recommendation.

Children 1-12 years: 25-50 g

Children >12 years: Refer to adult dosing.

Multidose: Initial dose: 25-50 g; followed by multiple doses of 10-25 g every 4 hours

Reconstitution

Powder: Dilute with at least 8 mL of water per 1 g of charcoal, or mix in a charcoal to water ratio of 1:4 to 1:8; mix vigorously to form a slurry (eg, mix 25 g with sufficient tap water to create a 4-ounce slurry or mix 50 g with sufficient tap water to create an 8-ounce slurry).

Administration

Flavoring agents (eg, chocolate syrup, concentrated fruit juice) or thickening agents (eg, bentonite, carboxymethylcellulose) can enhance charcoal's palatability. Check for the presence of bowel sounds before administration. IV antiemetics may be required to reduce the risk of vomiting. The activated charcoal container should be agitated thoroughly before administration. The container should be rinsed with a small quantity of water to insure that the patient has received all of the activated charcoal (Krenzelok, 1991).

Capsules and tablets should not be used for the treatment of poisoning.

Storage

Adsorbs gases from air, store in a closed container.

Drug Interactions

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. Consider therapy modification

Teriflunomide: Charcoal, Activated may decrease the serum concentration of Teriflunomide. Management: Unless using this combination to intentionally enhance teriflunomide elimination, consider an alternative to charcoal when possible. Separating drug administration is not likely to be effective at avoiding this interaction. Consider therapy modification

Adverse Reactions

Frequency not defined.

Gastrointestinal: Abdominal distention, appendicitis, constipation, dental discoloration (black; temporary), fecal discoloration (black), intestinal obstruction, mouth discoloration (black; temporary), vomiting

Ophthalmic: Corneal abrasion (with direct contact)

Respiratory: Aspiration, respiratory failure

Warnings/Precautions

Concerns related to adverse effects:

• Vomiting: Charcoal may cause vomiting; the risk appears to be greater when charcoal is administered with sorbitol (Chyka, 2005). IV antiemetics may be required to reduce the risk of vomiting or to control vomiting to facilitate administration (Vale, 1999).

Disease-related concerns:

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

Concurrent drug therapy issues:

• Ipecac: Ipecac should not be administered routinely in the management of poisoned patients (AACT, 2004b). In addition, use may delay the administration of or decrease the effectiveness of activated charcoal.

• Cathartics (eg, sorbitol, mannitol, magnesium sulfate): Coadministration of a cathartic is not recommended; cathartics have not been demonstrated to change patient outcome and have no role in the management of the poisoned patient. Cathartics subject the patient to the risk of developing significant fluid and electrolyte abnormalities (AACT, 2004a).

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors, 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.

• Capsules: Not recommended for use in the treatment of poisoning.

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP ["Inactive" 1997]; Zar, 2007).

• Sorbitol: Some products may contain sorbitol; coadministration of a cathartic, including sorbitol, is not recommended. Do not use products containing sorbitol in patients with a genetic intolerance to fructose or in patients who are dehydrated; may cause excessive diarrhea.

• Tablets: Not recommended for use in the treatment of poisoning.

Other warnings/precautions:

• Appropriate use: Not effective in the treatment of poisonings due to the ingestion of low molecular weight compounds such as cyanide, iron, ethanol, methanol, or lithium. Avoid use in hydrocarbon and caustic ingestions.

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

• Multidose administration: Based on experimental and clinical studies, multidose activated charcoal, in most acute poisonings, has not been shown to reduce morbidity or mortality (Vale, 1999). It may be considered if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, phenytoin, quinine, or theophylline, although no controlled studies have demonstrated clinical benefit.

Pregnancy Considerations

Activated charcoal is not absorbed systemically following oral administration. Use during pregnancy is not expected to result in significant exposure to the fetus. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey, 2003).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience dark stools (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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