The importance of paracetamol blood levels on the cost and management of patients with paracetamol overdose

Abstract

We aimed to evaluate the effect of serum paracetamol level measurement on cost and patient management by evaluating the patients with a history of paracetamol overdose in the emergency department. This study was performed by investigating the data of 175 adult patients admitted to the emergency service after ingestion of the paracetamol-containing drug. Patients were divided into main three groups according to the narrative of ingested amount, and ten subgroups according to the serum paracetamol level, antidote treatment and hospitalization. According to the patients’ narrative, the ingested paracetamol amount was toxic in 97 (55.4%) patients. Serum levels were non-toxic in 50 (28.6%), and toxic in only 4 (2.3%) patients. In intergroup cost analysis, the highest median cost per patient was in Group 4 ($ 332.9 [332.2 – 335.6]), and the lowest median cost per patient was in Group 3 ($ 98.0 [67.1 – 98.0]). When the patient groups in our study were evaluated in terms of cost per patient, there was a statistically significant difference between the groups (p <0.001). Antidote administration, hospitalization and duration of treatment were independent variables affecting cost in our study. One unit increase in antidote administration, hospitalization, and the length of treatment caused to increase in cost about 67.3 units, 56.1 units, 2.2 units, respectively (p<0.001). The treatment cost can be reduced by measuring serum paracetamol levels. For avoiding a potential missed diagnosis of paracetamol overdose the routine measurement of paracetamol level warrants to reduce the cost of the patients who had an ingestion history of unknown paracetamol amount, especially in cases with altered mental status and psychiatric disorder who had suspected/elusive medical anamnesis about drug ingestion.

Keywords

• Paracetamol
• Ingestion
• Level
• Management
• Cost
• Emergency

References

1. 1. Mowry JB, Spyker DA, Cantilena LR Jr, McMillan N, Ford M. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol (Phila). 2014 Dec;52(10):1032-283. doi: 10.3109/15563650.2014.987397.
2. 2. Sheen CL, Dillon JF, Bateman DN, Simpson KJ, Macdonald TM. Paracetamol toxicity: epidemiology, prevention and costs to the health-care system. QJM. 2002 Sep;95(9):609-19. doi: 10.1093/qjmed/95.9.609.
3. 3. Wightman, RS, Nelson, LS. Acetaminophen. In: Tintinalli, JE, editor-in-chief. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York: Mc Graw-Hill Comp.; 2020;1252-1259.
4. 4. Hodgman MJ, Garrard AR. A review of acetaminophen poisoning. Crit Care Clin. 2012 Oct;28(4):499-516. doi: 10.1016/j.ccc.2012.07.006.
5. 5. Yoon E, Babar A, Choudhary M, Kutner M, Pyrsopoulos N. Acetaminophen-Induced Hepatotoxicity: a Comprehensive Update. J Clin Transl Hepatol. 2016 Jun 28;4(2):131-42. doi: 10.14218/JCTH.2015.00052. Epub 2016 Jun 15.
6. 6. Montrief T, Koyfman A, Long B. Acute liver failure: A review for emergency physicians. Am J Emerg Med. 2019 Feb;37(2):329-337. doi: 10.1016/j.ajem.2018.10.032. Epub 2018 Oct 22.
7. 7. Ramachandran A, Jaeschke H. Mechanisms of acetaminophen hepatotoxicity and their translation to the human pathophysiology. J Clin Transl Res. 2017 Feb;3(Suppl 1):157-169. doi: 10.18053/jctres.03.2017S1.002. Epub 2017 Feb 12.
8. 8. Du K, Williams CD, McGill MR, Jaeschke H. Lower susceptibility of female mice to acetaminophen hepatotoxicity: Role of mitochondrial glutathione, oxidant stress and c-jun N-terminal kinase. Toxicol Appl Pharmacol. 2014 Nov 15;281(1):58-66. doi: 10.1016/j.taap.2014.09.002. Epub 2014 Sep 16.

9. 9. Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24.
10. 10. Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM; U.S. Acute Liver Failure Study Group. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17;137(12):947-54. doi: 10.7326/0003-4819-137-12-200212170-00007.
11. 11. Albalawi, MA, Albalawi, SA, Albalawi, THS, Almuhawwis, KS, Mansour, A. Evaluation of Recent Updates Regarding Acetaminophen-Induced Acute Liver Failure. Archives of Pharmacy Practice. 2019;1: 56.
12. 12. Litovitz TL, Bailey KM, Schmitz BF, Holm KC, Klein-Schwartz W. 1990 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1991 Sep;9(5):461-509. doi: 10.1016/0735-6757(91)90216-7.
13. 13. Sorodoc V, Jaba IM, Lionte C, Mungiu OC, Sorodoc L. Epidemiology of acute drug poisoning in a tertiary center from Iasi County, Romania. Hum Exp Toxicol. 2011 Dec;30(12):1896-903. doi: 10.1177/0960327111403172. Epub 2011 Mar 22.
14. 14. Myers RP, Shaheen AA, Li B, Dean S, Quan H. Impact of liver disease, alcohol abuse, and unintentional ingestions on the outcomes of acetaminophen overdose. Clin Gastroenterol Hepatol. 2008 Aug;6(8):918-25; quiz 837. doi: 10.1016/j.cgh.2008.02.053. Epub 2008 May 16.
15. 15. Dargan PI, Ladhani S, Jones AL. Measuring plasma paracetamol concentrations in all patients with drug overdose or altered consciousness: does it change outcome? Emerg Med J. 2001 May;18(3):178-82. doi: 10.1136/emj.18.3.178.
16. 16. Senarathna SM, Sri Ranganathan S, Buckley N, Fernandopulle R. A cost effectiveness analysis of the preferred antidotes for acute paracetamol poisoning patients in Sri Lanka. BMC Clin Pharmacol. 2012 Feb 22;12:6. doi: 10.1186/1472-6904-12-6.
17. 17. Gosselin S, Hoffman RS, Juurlink DN, Whyte I, Yarema M, Caro J. Treating acetaminophen overdose: thresholds, costs and uncertainties. Clin Toxicol (Phila). 2013 Mar;51(3):130-3. doi: 10.3109/15563650.2013.775292.