Comparison of the 20-Hour Intravenous and 72-Hour Oral Acetylcysteine Protocols for the Treatment of Acute Acetaminophen Poisoning

Yarema, Mark C.; Johnson, David W.; Berlin, Randall J.; Sivilotti, Marco L.A.; Nettel-Aguirre, Alberto; Brant, Rollin F.; Spyker, Daniel A.; Bailey, Benoit; Chalut, Dominic; Lee, Jacques S.; Plint, Amy C.; Purssell, Roy A.; Rutledge, Tim; Seviour, Catherine A.; Stiell, Ian G.; Thompson, Margaret; Tyberg, Jeffrey; Dart, Richard C.; Rumack, Barry H.

doi:10.1016/j.annemergmed.2009.05.010

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Volume 54, Issue 4 , Pages 606-614, October 2009

Comparison of the 20-Hour Intravenous and 72-Hour Oral Acetylcysteine Protocols for the Treatment of Acute Acetaminophen Poisoning

Presented at the North American Congress of Clinical Toxicology, October 2006, San Francisco, CA, and October 2007, New Orleans, LA; and the Canadian Association of Emergency Physicians, June 2007, Victoria, British Columbia, Canada, and June 2009, Calgary, Alberta, Canada.

Mark C. Yarema, MD
- Division of Emergency Medicine and Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
- Address for correspondence: Mark Yarema, MD, Department of Emergency Medicine, Foothills Medical Centre, C231, 1403 29th St NW, Calgary, Alberta, Canada T2N 2T9; 403-944-1596, Fax 403-944-2419
David W. Johnson, MD
- Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
Randall J. Berlin, MD
- Division of Emergency Medicine and Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
Marco L.A. Sivilotti, MD, MSc
- Departments of Emergency Medicine and Pharmacology and Toxicology, Queen's University, Kingston, Ontario, Canada
- Ontario Regional Poison Information Centre/Centre Anti-Poison de l'Ontario, Toronto, Ontario, Canada
Alberto Nettel-Aguirre, PhD, PStat
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
Rollin F. Brant, PhD
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
Daniel A. Spyker, MD, PhD
- Department of Biopharmaceutical Sciences, University of California–San Francisco, San Francisco, CA
Benoit Bailey, MD, MSc
- Division of Emergency Medicine, CHU Sainte Justine, Montréal, Quebec, Canada
Dominic Chalut, MD
- Department of Pediatrics, McGill University Health Centre, Montréal, Quebec, Canada
Jacques S. Lee, MD, MSc
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Amy C. Plint, MD, MSc
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
Roy A. Purssell, MD
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Drug and Poison Information Centre of British Columbia, Vancouver, British Columbia, Canada
Tim Rutledge, MD
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
Catherine A. Seviour, MD
- Department of Medicine (Emergency Medicine), Memorial University of Newfoundland, St. John's, Newfoundland, Canada
Ian G. Stiell, MD, MSc
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
Margaret Thompson, MD
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
- Ontario Regional Poison Information Centre/Centre Anti-Poison de l'Ontario, Toronto, Ontario, Canada
Jeffrey Tyberg, MD
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Richard C. Dart, MD, PhD
- Rocky Mountain Poison and Drug Center, Denver Hospital Health Authority, Denver, CO
Barry H. Rumack, MD
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO

Received 9 February 2009; received in revised form 7 April 2009; accepted 7 May 2009. published online 26 June 2009.

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Supervising editors: E. Martin Caravati, MD, MPH; Michael L. Callaham, MD

Dr. Caravati and Dr. Callaham were the supervising editors on this article. Dr. Dart did not participate in the editorial review or decision to publish this article.

Author contributions: RJB had the original idea for the study. MCY drafted the study protocol. DWJ, RJB, MLAS, and RFB revised the study protocol. MCY, DWJ, RJB, MLAS, and RAP obtained funding for the Canadian medical record review. BHR obtained funding for the United States National Multicenter Study. AN-A, RFB, and DAS performed the statistical analysis, and all authors contributed to the interpretation of the findings. MCY drafted the article, and all authors contributed substantially to its revision. All authors approved the final version to be published. MCY takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The authors disclose that unrestricted financial support for this study was received from Cumberland Pharmaceuticals, the Physicians of Ontario through the Physicians Services Incorporated Foundation, Calgary Health Region Adult Research Committee, Canadian Institutes of Health Research, Alberta Heritage Foundation for Medical Research, Canadian Association of Emergency Physicians, and the University of British Columbia Summer Student Research Program. Dr. Rumack has received honoraria and consulting fees from McNeil Consumer Products Company (Johnson & Johnson), which funded the United States National Multicenter Study on the effectiveness of oral acetylcysteine in the treatment of acute acetaminophen overdose. Dr. Dart is the Director of the Rocky Mountain Poison and Drug Center, which has received financial support from McNeil Consumer Products Company (Johnson & Johnson) and Cumberland Pharmaceuticals.

Reprints not available from the authors.

Publication date: Available online June 25, 2009.

PII: S0196-0644(09)00495-8

doi:10.1016/j.annemergmed.2009.05.010

Refers to article:

Is the Oral Acetylcysteine Protocol the Best Treatment for Late-Presenting Acetaminophen Poisoning? , 21 August 2009
G. Randall Bond
Annals of Emergency Medicine October 2009 (Vol. 54, Issue 4, Pages 615-617)
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