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Drug overview for ACTIDOSE (activated charcoal/sorbitol):
Generic name: ACTIVATED CHARCOAL/SORBITOL
Drug class:
Therapeutic class: Antidotes and other Reversal Agents
Activated charcoal, which is used clinically as an adsorbent and antidote based on its adsorptive property, is the residue from the destructive distillation of various organic materials that has been treated to increase its adsorptive power.
No enhanced Uses information available for this drug.
Generic name: ACTIVATED CHARCOAL/SORBITOL
Drug class:
Therapeutic class: Antidotes and other Reversal Agents
Activated charcoal, which is used clinically as an adsorbent and antidote based on its adsorptive property, is the residue from the destructive distillation of various organic materials that has been treated to increase its adsorptive power.
No enhanced Uses information available for this drug.
DRUG IMAGES
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The following indications for ACTIDOSE (activated charcoal/sorbitol) have been approved by the FDA:
Indications:
Unknown oral substance toxicity
Professional Synonyms:
Nonspecific toxicity from oral overdose
Indications:
Unknown oral substance toxicity
Professional Synonyms:
Nonspecific toxicity from oral overdose
The following dosing information is available for ACTIDOSE (activated charcoal/sorbitol):
The optimum dose of activated charcoal in the treatment of poisoning in pediatric patients has not been established. Some clinicians state that optimal adsorption appears to occur at a charcoal-to-toxin ratio of 10 to 1 or higher but that a fixed dose of 1 g/kg generally is recommended in children. A dose of 25-50 g or 0.5-1
g/kg of body weight given as a slurry in water has been recommended for children 1-12 years of age. Infants up to 1 year of age may receive 10-25 g or 0.5-1 g/kg.
Other clinicians suggest a dose of 15-30 g of activated charcoal in children with substantial overdoses of toxic substances when less than 1 hour has elapsed since ingestion. In children who have not swallowed the dose of activated charcoal within 20 minutes following ingestion of the toxic agent, some clinicians recommend that activated charcoal be administered through a nasogastric tube by personnel trained in the identification and treatment of complications of this procedure.
The usual dosage of activated charcoal used in multiple-dose therapy in children up to 13 years of age is 10-25 g initially, followed by 1-2 g/kg every 2-4 hours. An expert panel of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT) states that doses of 10-25 g may be used in children younger than 5 years of age because of their smaller gut lumen capacity and the usually smaller overdoses in these individuals. Multiple-dose therapy with activated charcoal generally should be continued until the patient recovers or until major symptoms of toxicity resolve. An IV antiemetic may be necessary to minimize the risk of vomiting during administration of multiple doses of charcoal even when given by nasogastric tube.
g/kg of body weight given as a slurry in water has been recommended for children 1-12 years of age. Infants up to 1 year of age may receive 10-25 g or 0.5-1 g/kg.
Other clinicians suggest a dose of 15-30 g of activated charcoal in children with substantial overdoses of toxic substances when less than 1 hour has elapsed since ingestion. In children who have not swallowed the dose of activated charcoal within 20 minutes following ingestion of the toxic agent, some clinicians recommend that activated charcoal be administered through a nasogastric tube by personnel trained in the identification and treatment of complications of this procedure.
The usual dosage of activated charcoal used in multiple-dose therapy in children up to 13 years of age is 10-25 g initially, followed by 1-2 g/kg every 2-4 hours. An expert panel of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT) states that doses of 10-25 g may be used in children younger than 5 years of age because of their smaller gut lumen capacity and the usually smaller overdoses in these individuals. Multiple-dose therapy with activated charcoal generally should be continued until the patient recovers or until major symptoms of toxicity resolve. An IV antiemetic may be necessary to minimize the risk of vomiting during administration of multiple doses of charcoal even when given by nasogastric tube.
Activated charcoal is administered orally or via nasogastric or orogastric tube. Activated charcoal powder can be administered as an extemporaneously prepared aqueous slurry or suspension and is commercially available as a suspension. Activated charcoal is most effective when administered early in the management of acute poisoning, preferably within 30-60 minutes of ingestion of the poison, although some benefit is possible with later administration in patients with gastric concretions or those who have ingested extended-release drugs or drugs that delay gastric emptying.
Continuous instillation of activated charcoal slurry into the duodenum via a small nasogastric tube may improve the retention of activated charcoal when an ingested agent produces protracted vomiting (e.g., theophylline). Tablets or granules of activated charcoal are less effective than the powdered form of the drug and should not be used in the treatment of poisonings. Many clinicians previously recommended that vomiting be induced with ipecac syrup before activated charcoal was administered.
However, because administration of ipecac syrup may delay the administration of activated charcoal and there is little evidence to demonstrate improved outcome with its use, most clinicians no longer recommend routine use of ipecac syrup in the emergency department or hospital setting. However, under rare circumstances, use of ipecac syrup in the home setting may be appropriate if not contraindicated and if recommended by a poison control center or other qualified clinician. (See Uses: Acute Poisoning, in Ipecac Syrup 56:20.) Although activated charcoal does not appear to diminish the emetic effects of ipecac syrup when given 10 minutes following the ipecac dose, vomiting should be completed before administration of activated charcoal.
(See Drug Interactions: Ipecac Syrup.) For extemporaneous preparation, activated charcoal powder should be mixed with sufficient tap water (e.g., 20-30 g in at least 240 mL) to form a slurry. Some clinicians state that more concentrated slurries generally should be avoided to minimize the risk of airway obstruction if aspiration occurs, to aid in dispersion of the charcoal, and possibly to increase palatability. Sorbitol may reduce the gritty sensation and improve the palatability of activated charcoal, and acts as a hyperosmotic laxative that may help prevent constipation associated with the drug.
Therefore, sorbitol has been used in the extemporaneous preparation of activated charcoal suspensions and is found in some commercial preparations. However, sorbitol should be administered only with single-dose activated charcoal or with the first dose of a multiple-dose regimen of the drug, and no more than 1 or 2 doses of sorbitol or another cathartic (if required) should be used in a 24-hour period because of the potential for dehydration, hypotension, and electrolyte disturbances (e.g., hypernatremia) associated with excessive catharsis. Sorbitol-containing preparations of activated charcoal should be used with caution in children and geriatric patients; hydration and electrolytes should be monitored with such use.
Also, if sorbitol is used with an initial dose of activated charcoal, a second cathartic generally should not be administered. Sorbitol content may vary between commercially available preparations of activated charcoal, and the label should be consulted to determine the amount of sorbitol contained in such products. The palatability of the activated charcoal slurry also can be improved by the addition of a thickening agent such as bentonite or carboxymethylcellulose.
Some evidence suggests that a small amount of a flavoring agent such as concentrated fruit juice or chocolate syrup may be added without substantially interfering with the adsorptive capacity of activated charcoal. However, some clinicians state that flavoring agents have been shown to decrease the adsorptive capacity of activated charcoal and generally should not be used. If chocolate syrup is used for flavoring, it should be added just prior to administration since the sweetness and flavor reportedly disappear after a few minutes of contact with activated charcoal.
Milk, ice cream, or sherbet should not be used as a vehicle for the administration of activated charcoal since the adsorptive capacity of activated charcoal was substantially decreased when ice cream (or sherbet) was mixed with activated charcoal in a 2.5:1 ratio by weight.
Continuous instillation of activated charcoal slurry into the duodenum via a small nasogastric tube may improve the retention of activated charcoal when an ingested agent produces protracted vomiting (e.g., theophylline). Tablets or granules of activated charcoal are less effective than the powdered form of the drug and should not be used in the treatment of poisonings. Many clinicians previously recommended that vomiting be induced with ipecac syrup before activated charcoal was administered.
However, because administration of ipecac syrup may delay the administration of activated charcoal and there is little evidence to demonstrate improved outcome with its use, most clinicians no longer recommend routine use of ipecac syrup in the emergency department or hospital setting. However, under rare circumstances, use of ipecac syrup in the home setting may be appropriate if not contraindicated and if recommended by a poison control center or other qualified clinician. (See Uses: Acute Poisoning, in Ipecac Syrup 56:20.) Although activated charcoal does not appear to diminish the emetic effects of ipecac syrup when given 10 minutes following the ipecac dose, vomiting should be completed before administration of activated charcoal.
(See Drug Interactions: Ipecac Syrup.) For extemporaneous preparation, activated charcoal powder should be mixed with sufficient tap water (e.g., 20-30 g in at least 240 mL) to form a slurry. Some clinicians state that more concentrated slurries generally should be avoided to minimize the risk of airway obstruction if aspiration occurs, to aid in dispersion of the charcoal, and possibly to increase palatability. Sorbitol may reduce the gritty sensation and improve the palatability of activated charcoal, and acts as a hyperosmotic laxative that may help prevent constipation associated with the drug.
Therefore, sorbitol has been used in the extemporaneous preparation of activated charcoal suspensions and is found in some commercial preparations. However, sorbitol should be administered only with single-dose activated charcoal or with the first dose of a multiple-dose regimen of the drug, and no more than 1 or 2 doses of sorbitol or another cathartic (if required) should be used in a 24-hour period because of the potential for dehydration, hypotension, and electrolyte disturbances (e.g., hypernatremia) associated with excessive catharsis. Sorbitol-containing preparations of activated charcoal should be used with caution in children and geriatric patients; hydration and electrolytes should be monitored with such use.
Also, if sorbitol is used with an initial dose of activated charcoal, a second cathartic generally should not be administered. Sorbitol content may vary between commercially available preparations of activated charcoal, and the label should be consulted to determine the amount of sorbitol contained in such products. The palatability of the activated charcoal slurry also can be improved by the addition of a thickening agent such as bentonite or carboxymethylcellulose.
Some evidence suggests that a small amount of a flavoring agent such as concentrated fruit juice or chocolate syrup may be added without substantially interfering with the adsorptive capacity of activated charcoal. However, some clinicians state that flavoring agents have been shown to decrease the adsorptive capacity of activated charcoal and generally should not be used. If chocolate syrup is used for flavoring, it should be added just prior to administration since the sweetness and flavor reportedly disappear after a few minutes of contact with activated charcoal.
Milk, ice cream, or sherbet should not be used as a vehicle for the administration of activated charcoal since the adsorptive capacity of activated charcoal was substantially decreased when ice cream (or sherbet) was mixed with activated charcoal in a 2.5:1 ratio by weight.
No dosing information available.
No generic dosing information available.
The following drug interaction information is available for ACTIDOSE (activated charcoal/sorbitol):
There are 0 contraindications.
There are 2 severe interactions.
These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.
| Drug Interaction | Drug Names |
|---|---|
| Polystyrene Sulfonate/Sorbitol SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Sorbitol may damage the intestinal mucosa, trigger vasospasms in the intestinal vasculature, and increase inflammation.(1) Polystyrene sulfonate crystals may deposit in these areas, resulting in further damage.(2,3) CLINICAL EFFECTS: Concurrent use of sorbitol and polystyrene sulfonate (either orally or rectally) may result in colonic necrosis, bleeding, ischemic colitis, and perforation of the gastrointestinal tract. Fatalities have been reported.(4) PREDISPOSING FACTORS: Predisposing factors may include a history of intestinal disease or surgery, hypovolemia, and/or renal insufficiency/failure. Premature infants may also be predisposed to the interaction.(4) PATIENT MANAGEMENT: The US manufacturer of sodium polystyrene sulfonate states that concurrent use with sorbitol (either orally or rectally) is not recommended.(4) In the event that sorbitol is used as a vehicle to administer polystyrene sulfonate rectally as an enema, particular attention should be given to administering a cleansing enema following the completion of the sodium polystyrene sulfonate enema.(4) Patients who have received concurrent polystyrene sulfonate and sorbitol should be monitored for signs of gastrointestinal complications and instructed to report abdominal pain and/or signs of gastrointestinal bleeding. If concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loss, including decreased hemoglobin, hematocrit, fecal occult blood, and/or decreased blood pressure and promptly evaluate patients with any symptoms. When applicable, perform agent-specific laboratory test (e.g. INR, aPTT) to monitor efficacy and safety of anticoagulation. Discontinue anticoagulation in patients with active pathologic bleeding. Instruct patients to report any signs and symptoms of bleeding, such as unusual bleeding from the gums or nose; unusual bruising; red or black, tarry stools; red, pink or dark brown urine; acute abdominal or joint pain and/or swelling. DISCUSSION: There have been numerous case reports of intestinal necrosis following the use of sodium polystyrene sulfonate and sorbitol.(1,5-13) In the majority of these cases, sorbitol was used as a vehicle for rectal administration of sodium polystyrene sulfonate(5-10); however, there have also been reports with oral administration (1,11,12) and in patients who received both oral and rectal sodium polystyrene with sorbitol.(13,14) Fatalities have been reported.(1,5,6) |
SODIUM POLYSTYRENE SULFONATE |
| Sorbitol/Lamivudine SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Sorbitol increases the osmotic pressure in the intestine, resulting in accelerated small intestinal transit time and decreased absorption and bioavailability of lamivudine. CLINICAL EFFECTS: Concurrent administration of sorbitol and lamivudine may result in decreased clinical efficacy of lamivudine.(1) Reduction in lamivudine exposure is sorbitol dose-dependent. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The manufacturer of lamivudine states that the concurrent use of lamivudine and sorbitol should be avoided.(1) Consider more frequent monitoring of HBV viral load when chronic coadministration cannot be avoided. DISCUSSION: In an open label, randomized sequence, 4-period, crossover trial in 16 healthy adults, coadministration of a single dose of lamivudine (300 mg) with sorbitol (3.2 grams) resulted in a dose-dependent decrease of lamivudine's area-under-the-curve (AUC(0-24), AUC infinity) and maximum concentration (Cmax) of 20%, 28%, and 28%. A single dose of lamivudine with sorbitol (10.2 grams) resulted in a decrease of lamivudine's AUC and Cmax of 39%, 52%, and 52%. A single dose of lamivudine with sorbitol (13.4 grams) resulted in a decrease of lamivudine's AUC and Cmax of 36%, 55%, and 55%.(1) |
ABACAVIR-LAMIVUDINE, CIMDUO, DELSTRIGO, DOVATO, EFAVIRENZ-LAMIVU-TENOFOV DISOP, EPIVIR, LAMIVUDINE, LAMIVUDINE HBV, LAMIVUDINE-ZIDOVUDINE, SYMFI, SYMFI LO, TRIUMEQ, TRIUMEQ PD |
There are 1 moderate interactions.
The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.
| Drug Interaction | Drug Names |
|---|---|
| Xanthine Derivatives/Charcoal SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Theophylline is absorbed by activated charcoal.(1) The absorption results in decreased theophylline absorption from the gastrointestinal tract, decreased enterohepatic recirculation, and increased theophylline clearance.(1-14) CLINICAL EFFECTS: Theophylline absorption is decreased and clearance is increased as charcoal absorbs the theophylline. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In a theophylline overdose the charcoal should be administered as soon as possible. Theophylline clearance may increase with continued administration. If the charcoal is not being given for theophylline overdose, a higher dose of theophylline should be given, or administration times should be separated. DISCUSSION: Activated charcoal is more effective than gastric lavage, emesis, or sorbitol catharsis and is considered first line therapy for sustained-release theophylline overdose.(15,16) Theophylline half-life has been reported to be decreased up to 52%, and clearance increased up to 96%. (5) Mean plasma level of a single dose of slow-release theophylline decreased by 39%.(2) Activated charcoal is also effective in treating aminophylline overdose.(17) |
AMINOPHYLLINE, DYPHYLLINE, ELIXOPHYLLIN, THEO-24, THEOPHYLLINE, THEOPHYLLINE ANHYDROUS, THEOPHYLLINE ER, THEOPHYLLINE ETHYLENEDIAMINE |
The following contraindication information is available for ACTIDOSE (activated charcoal/sorbitol):
Drug contraindication overview.
No enhanced Contraindications information available for this drug.
No enhanced Contraindications information available for this drug.
There are 2 contraindications.
Absolute contraindication.
| Contraindication List |
|---|
| Gastrointestinal obstruction |
| Gastrointestinal perforation |
There are 3 severe contraindications.
Adequate patient monitoring is recommended for safer drug use.
| Severe List |
|---|
| Absence of bowel sounds |
| Gastrointestinal hemorrhage |
| Hypovolemia |
There are 0 moderate contraindications.
The following adverse reaction information is available for ACTIDOSE (activated charcoal/sorbitol):
Adverse reaction overview.
No enhanced Common Adverse Effects information available for this drug.
No enhanced Common Adverse Effects information available for this drug.
There are 2 severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
| None. | None. |
| Rare/Very Rare |
|---|
|
Abdominal distension Abdominal pain with cramps |
There are 3 less severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Black stools Diarrhea Vomiting |
None. |
| Rare/Very Rare |
|---|
| None. |
The following precautions are available for ACTIDOSE (activated charcoal/sorbitol):
No enhanced Pediatric Use information available for this drug.
Contraindicated
Severe Precaution
Management or Monitoring Precaution
Contraindicated
| None |
Severe Precaution
| None |
Management or Monitoring Precaution
| None |
No enhanced Pregnancy information available for this drug.
No enhanced Lactation information available for this drug.
No enhanced Geriatric Use information available for this drug.
The following prioritized warning is available for ACTIDOSE (activated charcoal/sorbitol):
No warning message for this drug.
No warning message for this drug.
The following icd codes are available for ACTIDOSE (activated charcoal/sorbitol)'s list of indications:
| Unknown oral substance toxicity | |
| T65.91xA | Toxic effect of unspecified substance, accidental (unintentional), initial encounter |
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