Articles You Might Have Missed
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ARTICLES YOU MIGHT HAVE MISSED
Articles You Might Have Missed Alexa Camarena-Michel 1
&
Grant Comstock 1 & Sasha Kaiser 1 & HoanVu Nguyen 1 & Christopher Pitotti 1 & John Rague 1
Received: 30 July 2020 / Revised: 13 August 2020 / Accepted: 14 August 2020 # American College of Medical Toxicology 2020
Keywords N-acetylcysteine . Carbon monoxide . Aluminum phosphide . Cannabis
Article #1: Pettie JM, Caparrotta TM, Hunter RW, et al. Safety and efficacy of the SNAP 12-h acetylcysteine regimen for the treatment of paracetamol overdose. EClinicalMedicine 2019; 11:11–17 Background: Standard protocols for treatment of paracetamol (acetaminophen, APAP) poisoning include administration of 300 mg/kg of n-acetylcysteine (NAC), via three different bag solutions, over a 21-h period. However, this treatment regimen is labor intensive, associated with dosing errors, and can result in adverse drug events (ADEs) such as anaphylactoid reactions. In 2015, a 12-h NAC protocol (Scottish and Newcastle anti-emetic pre-treatment for paracetamol poisoning study; the SNAP regimen) was instituted to administer equivalent total doses (300 mg/kg) of NAC. This regimen had previously been demonstrated to cause fewer ADEs compared with the 21-h protocol. Research Questions: What is the effectiveness of the 12-h SNAP regimen compared with the standard 21-h NAC regimen for the treatment of APAP poisoning? And, as hypothesized, did the 12-h SNAP regimen perform better in patients presenting > 8 h from ingestion? Methods: This was a mixed methods study comparing the efficacy of the SNAP and standard 21-h regimens at three hospitals (the Royal Infirmary of Edinburgh, St. Thomas’ Hospital and the Royal Victorian Infirmary) in the UK. The study was a prospective cohort study including patients admitted over a 4-year period (2013 to 2017) for APAP toxicity, 2 years before the introduction of the SNAP regimen and 2 years after. Patients received a total of 300 mg/kg of intravenous NAC according to either the standard 21-h protocol (150 mg/kg over 1 h, then 50 mg/kg over 4 h, and followed by 100 mg/kg over 16 h) or the SNAP protocol Supervising Editor: Daniel Brooks, MD * Alexa Camarena-Michel [email protected] 1
Rocky Mountain Poison and Drug Safety, Denver, CO, USA
(100 mg/kg over 2 h followed by 200 mg/kg over 10 h). The same 21-h and SNAP protocols were utilized at all three study sites, although stop criteria and patient monitoring differed between the Scottish site and two English sites. During the 21-h protocol, repeat blood tests were performed 1 h prior to NAC completion to ensure that liver function, creatinine, and INR values supported stopping NAC. At the end of the SNAP (12-h) protocol, liver function, creatinine, INR, and a repeat APAP level were checked to support stopping NAC. If the SNAP protocol was stopped within 24-h of the ingestions, these same blood tests were performed at the 24-h mark. The NAC treatments were continued (or restarted) for any of the following: ALT > two times the upper limit of normal or doubled
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