Activated Charcoal in Medical Applications

Transcription

1 ) L. Activated Charcoal in Medical Applications DAVID O. COONEY University of Wyoming Laramie, Wyoming Marcel Dekker, Inc. New York* Basel Hong Kong

2 CONTENTS Foreword Preface 1 Introduction 1 I. DATA ON POISONING INCIDENTS IN THE USA 1 II. INITIAL APPROACHES TO THE TREATMENT OF POISONING 3 III. THE GROWING USE OF ACTIVATED CHARCOAL 5 IV. GENERAL REVIEW PAPERS 7 V. REFERENCES 7 2 Historical Background of Activated Charcoal 9 I. TERMINOLOGY 9 II. EARLY HISTORY 10 III. EVOLUTION OF METHODS FOR TESTING MEDICINAL CHARCOALS 12 IV. REFERENCES 16 3 Fundamentals of Activated Charcoal and the Adsorption Process 18 I. THE MANUFACTURE OF ACTIVATED CHARCOAL 18 A. Carbonization 19 B. Activation with Oxidizing Gases 19 II. THE PROPERTIES OF ACTIVATED CHARCOAL 20 A. Densities 22 B. Pore Volume and Pore-Size Distribution 22 C. Surface Area 24 D. Nature of the Charcoal Surface 25 III. THE NATURE OF THE ADSORPTION PROCESS 28 A. Effect of Temperature 28 B. Nature of the Solvent 28 C. Surface Area of the Charcoal 28 D. Pore Structure of the Charcoal 29 E. Nature of the Solute 29 F. ph of the Solution 31 G. Presence of Inorganic Salts 35 in v xi

3 xii Contents H. Competing Solutes 36 IV. DETERMINING ADSORPTION ISOTHERMS 37 A. The Langmuir Isotherm Equation 38 B. The Freundlich Isotherm Equation 41 C. Least-Squares Fitting of Data to Determine Isotherm Constants 43 D. Theoretical Aspects of Isotherm Equations 45 V. SUMMARY 46 VI. REFERENCES 47 4 Properties of Antidotal Charcoal 50 I. REQUIREMENTS OF THE U. S. PHARMACOPEIA 50 II. "SUPERACTIVE" CHARCOAL 53 III. CURRENTLY AVAILABLE USP CHARCOALS IN THE USA 55 IV. CURRENTLY AVAILABLE CHARCOAL PRODUCTS IN THE USA 56 V. OTHER CURRENTLY AVAILABLE CHARCOAL PRODUCTS 61 VI. THE "CONTAINER RESIDUE" ISSUE 64 VII. COMPARATIVE STUDIES OF ANTIDOTAL CHARCOALS 66 VIII. SUMMARY 70 IX. REFERENCES 71 5 The Nature of Drug Absorption, Distribution, and Elimination 73 I. THE EFFECT OF DRUG DOSAGE FORM 73 II. ROUTES OF DRUG ADMINISTRATION 75 III. THE ROLE OF ph IN DRUG ABSORPTION 75 IV. MECHANICAL ASPECTS OF GASTROINTESTINAL PHYSIOLOGY 77 V. ABSORPTION IN THE GASTROINTESTINAL TRACT 79 VI. DRUG FATE AFTER ABSORPTION 82 VII. GASTROINTESTINAL DIALYSIS AND INTERRUPTION OF THE ENTEROHEPATIC CYCLE 85 VIII. SUMMARY 88 IX. REFERENCES 89 6 Basic Details of Pharmacokinetic Modeling 91 I. INTRODUCTION 91 II. THE PHARMACOKINETICS OF INTRAVENOUSLY ADMINISTERED DRUGS 96 A. The One Compartment Open Model 98 B. The Two Compartment Open Model 103 HI. MODELS WITH FIRST-ORDER DRUG ABSORPTION 105 A. One Compartment Open Model 105 B. Two Compartment Open Model 106 IV. EXAMPLES OF PHARMACOKINETIC CALCULATIONS 106 A. Area Under the Curve 107 B. Elimination Half-life 107 C. Estimating t^ for Drug Absorption 107 D. Mean Residence Time 107 V. SUMMARY 108 VI. REFERENCES Methods for Treating Poisoning and Drug Overdose 110 I. GENERAL CHARACTERISTICS OF POISONED PATIENTS 110

4 Contents xiii II. GENERAL OVERDOSE MANAGEMENT STRATEGIES 110 III. ORAL DILUTION 113 IV. INDUCED EMESIS WITH SYRUP OF IPECAC 115 A. Toxicity of Ipecac 118 B. Other Ad verse Effects of Ipecac 120 C. Success of Ipecac in Producing Emesis 120 D. Comparison of Ipecac and Apomorphine in Producing Emesis 123 E. Effectiveness of Ipecac and Apomorphine in Recovering Stomach Contents 124 F. General Comments on the Use of Ipecac 126 V. GASTRIC LAVAGE 127 VI. COMPARISON OF IPECAC AND LAVAGE 130 VII. USE OF SALINE CATHARTICS OR SORBITOL 135 VIII. WHOLE-BOWEL IRRIGATION 138 IX. ALTERING DIURETIC PROCESSES 140 X. EXCHANGE TRANSFUSION 142 XL HEMODIALYSIS AND HEMOPERFUSION 142 XII. SUMMARY 147 XIII. REFERENCES The Design of Clinical Studies and Data Treatment 157 I. RANDOMIZED CROSS-OVER AND OTHER TYPES OF STUDIES 157 II. ASSESSMENT OF THE STATISTICAL SIGNIFICANCE OF DIFFERENCES IN TREATMENTS Some Basic Aspects of Antidotal Charcoal 163 I. CHARCOAL POWDER VERSUS TABLETED CHARCOAL 163 II. OPTIMAL DOSE OF ACTIVATED CHARCOAL 166 III. STABILITY OF THE DRUG/CHARCOAL COMPLEX 168 IV. STORAGE STABILITY OF CHARCOAL SUSPENSIONS 174 V. UNIVERSAL ANTIDOTE 175 VI. EFFECT OF PEPSIN ON IN VITRO ADSORPTION 179 VII. SUMMARY 180 VIII. REFERENCES The Classic Studies of Andersen 185 I. ANDERSEN'S IN VITRO ADSORPTION STUDIES 185 II. THE EFFECT OF ph 187 III. ADSORPTION FROM GASTROINTESTINAL CONTENTS 189 IV. FURTHER IN VIVO EXPERIMENTS 195 V. REFERENCES Effects of Activated Charcoal on Major Classes of Drugs and Chemicals 197 / I. COMMON HOUSEHOLD CHEMICALS 198 II. ALKALOIDS 198 HI. ASPIRIN AND OTHER SALICYLATES 201 A. In Vitro Studies 201 B. In Vivo Studies 201 IV. ACETAMINOPHEN AND INTERACTIONS WITH ACETYLCYSTEINE 204 A. In Vitro Studies 205 B. In Vivo Studies 205

5 xiv Contents C. Interactions with N-acetylcysteine 209 V. HYPNOTICS AND SEDATIVES 214 A. In Vitro Studies 214 B. In Vivo Studies 216 VI. TRICYCLIC ANTIDEPRESSANTS 220 A. Other In Vitro Studies 221 B. In Vivo Studies 222 VII. CARDIAC GLYCOSIDES 226 VIII. ORGANIC SOLVENTS 230 IX. ETHANOL 235 X. SUMMARY 238 XI. REFERENCES Effect of Charcoal on Other Classes of Drugs 245 I. ANTIHISTAMINES 247 A. Chlorpheniramine 247 B. Diphenhydramine 250 II. ANTI-INFECTIVES 250 A. Antibiotics 250 B. Antituberculosis Agents 251 C. Antimalarial Agents 253 D. Quinolones: Ciprofloxacin 256 E. Sulfones: Dapsone 256 F. Urinary Anti-Infectives: Trimethoprim 257 III. CARDIAC DRUGS 257 A. Anti-Arrhythmics 257 B. Beta-Blockers 262 C. Calcium Channel-Blockers: Diltiazem 262 IV. CNS AGENTS 263 A. B. C. D. E. Analgesics Anticonvulsants Anti-Inflammatory Agents Tranquilizers Other CNS Agents: Methamphetamine V. GASTROINTESTINAL DRUGS A. Cimetidine B. Propantheline C. Diphenoxylate D. Nizatidine VI. VII. /HI. ANTIDIABETIC SULFONYLUREAS RESPIRATORY RELAXANTS: THEOPHYLLINE A. In Vitro Studies B. Animal Studies C. Human Volunteer Studies D. Human Overdose Studies E. Conclusions About Theophylline ORGANIC SUBSTANCES A. Camphor B. Ethylene Glycol C. Isopropanol and Acetone D. Polybrominated Biphenyl E. Herbicides

6 Contents xv F. Insecticides 283 G. Pesticides 284 IX. OTHER SUBSTANCES 285 A. Allylpropynal and Sulfanilamide 285 B. Cyclosporin 285 C. Furosemide 285 D. Methotrexate 286 E. Cocaine 286 F. Phencyclidine 287 G. Miscellaneous Drugs 288 X. SUMMARY 288 XI. REFERENCES Effect of Administration Time, Food, and Gastric ph 295 I. EFFECT OF A DELAY IN ADMINISTRATION 295 A. Aspirin and Other Salicylates 296 B. Acetaminophen 299 C. Barbiturates 301 D. Tricyclic Antidepressants 303 E. Cardiac Glycosides 304 F. Theophylline 305 G. Propoxyphene 305 H. Other Drugs 306 II. EFFECT OF FOOD 310 III. EFFECT OF GASTRIC ph 313 IV. SUMMARY 314 V. REFERENCES Effect of Multiple Doses of Charcoal 318 I. ASPIRIN 318 II. ACETAMINOPHEN 321 III. PHENOBARBITAL 321 IV. DIGOXIN AND DIGITOXIN 323 A. Human Volunteer Studies with Subtoxic Doses 323 B. Overdose Case Reports 324 V. TRICYCLIC ANTIDEPRESSANTS 325 A. Human Volunteer Studies with Subtoxic Doses 326 B. Overdose Case Reports 327 VI. THEOPHYLLINE 327 A. Animal Studies 327 B. Human Volunteer Studies with Subtoxic Oral Doses 328 C. Human Volunteer Studies with Subtoxic IV Doses 328 D. Human Overdose Case Reports 332 VII. QUININE 334 VIII. ANTIBIOTICS 335 IX. PROPOXYPHENE 337 X. DAPSONE 337 XI. CARBAMAZEPINE 338 XII. PHENYTOIN 339 A. Human Studies with Subtoxic IV Doses 339 B. Human Overdose Reports 340

7 vi Contents XIII. XIV. XV. XVI. XVII. PIROXICAM OTHER DRUGS A. Glutethimide and Barbital B. Phenobarbital and Diazepam C. Meprobamate D. Diltiazem E. Nadolol and Sotalol F. Chlorpropamide G. Cyclosporin H. Phencyclidine I. Paroxetine J. Disopyramide K. Methotrexate LIMITATIONS ON MULTIPLE-DOSE CHARCOAL THERAPY SUMMARY REFERENCES 15 Ipecac, Cathartics, and Charcoal: Interactions and Comparative Efficacies 357 I. EFFECT OF CHARCOAL ON IPECAC 357 II. COMPARATIVE EFFECTIVENESS OF IPECAC AND CHARCOAL 359 HI. COMPARATIVE EFFECTIVENESS OF LAVAGE AND CHARCOAL 365 IV. COMPARATIVE EFFECTIVENESS OF WHOLE BOWEL IRRIGATION AND CHARCOAL 367 V. EFFECTS OF SORBITOL ON THE ACTION OF CHARCOAL 371 A. Some Preliminary Comments 372 B. Effects of Sorbitol on GI Transit Times 373 C. Dosage Recommendations for Sorbitol 374 D. Effect of Sorbitol on the Efficacy of Charcoal 375 E. Conclusions and Recommendations 382 VI. EFFECT OF SALINE CATHARTICS ON THE ACTION OF CHARCOAL 383 A. In Vitro Studies 383 B. In Vivo Studies 387 C. Summary and Conclusions 391 VII. SUMMARY 391 VIII. REFERENCES The Development Of Palatable Formulations I. PROVIDING LUBRICITY 398 II. PROVIDING FLAVOR 402 HI. OTHER APPROACHES TO PALATABILITY 414 IV. SUMMARY 414 V. REFERENCES Hazards Associated with Antidotal Charcoal Use 418 I. GENERAL TOXICITY OF CHARCOAL 418 II. ASPIRATION 419 III. PERFORATIONS 423 IV. BRONCHIOLITUS OBLITERANS 424 V. EMPYEMA 424

8 Contents xvii VI. INFECTIONS IN THE RESPIRATORY TRACT FROM NONSTERILE CHARCOAL 425 VII. ABDOMINAL DISTENSION FROM SORBITOL 425 VIII. HYPERNATREMIA AND HYPERMAGNESEMIA 426 IX. CONSTIPATING EFFECT OF CHARCOAL 431 X. OBSTRUCTIONS CAUSED BY CHARCOAL 432 XI. RECTAL ULCER WITH HEMORRHAGE 434 XII. CORNEAL ABRASIONS 434 XIII. "BLACK SMOKE SYNDROME" 435 XIV. SUMMARY 435 XV. REFERENCES Effect of Charcoal on Various Inorganic Substances 439 I. ARSENIC 440 II. BORIC ACID 440 III. CESIUM 441 IV. IRON 441 V. LITHIUM 442 VI. PHOSPHORUS 442 VII. POTASSIUM 443 VIII. CYANIDE 443 IX. THALLIUM 444 X. SUMMARY 444 XI. REFERENCES Effect of Charcoal on Endogenous Biochemicals 446 I. BILE SALTS 446 II. BILIRUBIN 447 III. EFFECT ON PRURITUS 450 IV. EFFECT ON ERYTHROPOIETIC PORPHYRIA 451 V. EFFECT ON UREMIC TOXINS 454 VI. HYPOLIPIDEMIC EFFECTS OF CHARCOAL 456 VII. EFFECTS IN LIVER DISEASE 460 VIII. PROLONGATION OF ANIMAL LIFESPAN 461 IX. SUMMARY 462 X. REFERENCES Use of Charcoal to Treat Poisoning in Animals 467 I. INCIDENCE OF ANIMAL POISONING AND GENERAL GUIDELINES FOR CHARCOAL USE 467 II. VETERINARY ACTIVATED CHARCOAL PRODUCTS 468 III. COMMON SOURCES OF ANIMAL POISONS AND TOXINS 469 IV. POISONING BY PLANTS 470 V. POISONING DUE TO HERBICIDES, PESTICIDES, AND INSECTICIDES 472 VI. FUNGAL TOXINS FROM GRAINS 478 VII. TOXINS FROM ALGAE 481 VIII. OTHER TOXINS 481 IX. POISONING OF HOUSEHOLD PETS 482 X. SUMMARY 483 XI. REFERENCES 483

9 xviii Contents 21 Reports from the Soviet Union 486 I. INTRODUCTION 486 II. ENTEROSORPTION STUDIES DESCRIBED BY NIKOLAEV 487 III. SOME OTHER STUDIES 488 IV. REFERENCES Resins and Clays as Sorbents 491 I. BASIC TYPES AND PROPERTIES OF RESINS USED AS ANTIDOTES 491 II. BASIC TYPES AND PROPERTIES OF CLAYS 493 III. STUDIES INVOLVING CLAYS 494 IV. STUDIES INVOLVING RESINS 497 A. General Studies of Ion Exchange Resins 497 B. General Studies of Cholestyramine and Colestipol 500 C. Effects of Cholestyramine and Colestipol in Cardiac Glycoside Overdoses 503 D. Effects of Cholestyramine and Colestipol on Other Drugs 507 E. Effects of Cholestyramine and Colestipol on Concomitant Drugs Taken Therapeutically 509 F. Effects of Resins on Various Endogenous Biochemicals 511 G. Use of Cholestyramine for Treating Hydrocarbon Toxicity 514 H. Effect of Cholestyramine and Colestipol on Bacterial Toxins and Antibiotics 515 I. Effect of Sodium Polystyrene Sulfonate on Inorganic Species 516 V. SUMMARY 517 VI. REFERENCES Other Medicinal Uses of Charcoal in Humans 525 I. EFFECT OF CHARCOAL ON SURFACE WOUNDS 525 II. EFFECT OF CHARCOAL ON VARIOUS SKIN PROBLEMS 527 HI. EFFECT ON GI TRACT BACTERIAL SEPSIS 528 IV. EFFECT ON INTESTINAL GAS 529 V. EFFECT ON DIARRHEA 533 VI. EFFECT ON PEPTIC ULCERS 534 VII. USE IN DEODORIZING OSTOMIES 534 VIII. USE IN THE TREATMENT OF ALCOHOLISM 535 IX. CHARCOAL AS A VEHICLE FOR PROLONGED-RELEASE MEDICATIONS 535 X. CHARCOAL INJECTED INTRAVENOUSLY 538 XI. SUMMARY 539 XII. REFERENCES Other Biochemical and Biological Uses of Charcoal 542 I. SNAKE VENOM ADSORPTION 542 II. VIRUS ADSORPTION 543 HI. BIOCHEMICAL FACTOR ADSORPTION 544 IV. BACTERIA ADSORPTION 544 V. BACTERIAL TOXIN ADSORPTION 545 VI. FUNGAL TOXIN ADSORPTION 546 VII. ADSORPTION OF ENZYMES AND OTHER PROTEINS 547 VIII. HORMONE ADSORPTION 548 IX. VITAMIN ADSORPTION 549

10 Contents xix X. ADSORPTION OF WHISKEY CONGENERS 549 XI. CATALYSIS OF REACTIONS BY ACTIVATED CHARCOAL 550 XII. MISCELLANEOUS COMPOUNDS ADSORBED BY CHARCOAL 551 XIII. CHARCOAL USE IN CONCENTRATING DRUGS FROM BIOLOGICAL FLUIDS 551 XIV. USE OF CHARCOAL IN THE ASSAY OF BIOCHEMICALS 552 XV. PROTECTION OF CROP PLANT SEEDLINGS FROM HERBICIDE DAMAGE 554 XVI. EFFECT OF CHARCOAL ON PLANT TISSUE CULTURES 558 XVII. EFFECT OF CHARCOAL ON BACTERIAL CULTURES 559 XVIII. EFFECTS OF CHARCOAL ON INSECTS 562 XIX. SUMMARY 563 XX. REFERENCES Summary 571 I. POSITIVE ASPECTS OF ACTIVATED CHARCOAL 571 II. SOME NEGATIVE ASPECTS OF ACTIVATED CHARCOAL 572 HI. UNSETTLED ISSUES 573 IV. RECOMMENDATIONS 574 V. REFERENCES 575 Index 577