Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study.

BACKGROUND: About 500 drug poisoning deaths involving paracetamol (acetaminophen) occur every year in England and Wales. To reduce the number of deaths, regulations were introduced in 1998 to restrict the sale of paracetamol. In this paper, we evaluate the impact of these regulations. METHODS: Mortality data for England and Wales were provided by the Office for National Statistics. Deaths were defined as due to compound paracetamol (paracetamol in combination with another analgesic, a low dose opioid or other ingredients) or paracetamol only, with or without alcohol or other drugs. The Department of Health provided data on all hospital admissions with a primary diagnosis of paracetamol poisoning. RESULTS: Mortality rates for paracetamol only were similar for males and females, and decreased from about 4.5 to 2.8 per million between 1997 and 1999 and again from about 3.1 to 2.2 per million between 2001 and 2002. These falls may be attributable to random variation in the rates. Deaths involving compound paracetamol, which were not subject to the 1998 regulations, remained relatively constant over the study period. There was evidence of a decreasing trend in paracetamol only mortality rates and this followed overall trends for other drug poisoning excluding opioids and drugs of misuse. Hospital admissions due to paracetamol poisoning increased from about 27 000 to 33 000 between 1995/1996 and 1997/1998 and then decreased to 25 000 in 2001/2002. There were almost 50 per cent more admissions for females than males, with the highest admission rates amongst females aged 15-24 years old. CONCLUSIONS: Between 1993 and 2002, mortality rates and hospital admissions due to paracetamol poisoning declined. However, the contribution of the 1998 regulations to this decline is not clear. Paracetamol poisoning continues to be an important public health issue in England and Wales and represents significant workload for the NHS in England

Restricting paracetamol in the United Kingdom to reduce poisoning: a systematic review

Background Paracetamol poisoning is implicated in about 150-200 poisoning deaths per year in England and Wales. We review previous studies assessing the effectiveness of regulations introduced in 1998 to restrict sales of paracetamol and reduce paracetamol poisoning. Methods We searched the following electronic databases: MEDLINE, EMBASE, CINHAL, HIMIC, COCH, APC, CENTRAL and DARE. English language publications between 1998 and 2003 were included. Studies were included if they took place in the United Kingdom and assessed changes in any aspect of paracetamol poisoning following the introduction of the 1998 regulations. Results Twelve studies were identified, which examined several different outcomes. Three studies examined admissions to liver transplant units; all reported reductions. Eight studies evaluated severity of paracetamol poisoning; three reported reductions but five did not. Five out of six studies reported reductions in hospital admissions. One study reported reduced mortality in England and Wales after 1 year while another found no difference in Scotland 2 years after the regulations were introduced. Two studies observed a significant reduction in over-the-counter sales. Studies suffered from several limitations including short follow-up periods, no case definition for paracetamol poisoning and lack of comparison groups. Conclusions The limitations of these studies makes it difficult to draw firm conclusions. They do, however, suggest that the 1998 regulations may have been associated with reduced admissions to liver units and liver transplants, reduced hospital attendance due to paracetamol poisoning and reduced sales of paracetamol. Further research is needed to fully evaluate the impact of the 1998 regulations. In the future, formal evaluation of the impact of similar interventions should be an integral part of policy formation

An open-label randomized clinical trial of prophylactic paracetamol coadministered with 7-valent pneumococcal conjugate vaccine and hexavalent diphtheria toxoid, tetanus toxoid, 3-component acellular pertussis, hepatitis B, inactivated poliovirus, and Haemophilus influenzae type b vaccine

BACKGROUND: In two clinical trials, low-grade fever was observed more frequently after coadministration than after separate administration of two recommended routine pediatric vaccines. Since fever is an important issue with vaccine tolerability, we performed this open-label study on the efficacy and safety of prophylactic use of paracetamol (acetaminophen, Benuron(R)) in children administered routine 7-valent pneumococcal conjugate vaccine (PCV-7) coadministered with hexavalent vaccine (diphtheria-tetanus-acellular pertussis-hepatitis B, polio, Haemophilus influenzae type b vaccine [DTPa-HBV-IPV/Hib]) in Germany. METHODS: Healthy infants (N = 301) who received a 3-dose infant series of PCV-7 and DTPa-HBV-IPV/Hib plus a toddler dose were randomly assigned 1:1 to prophylactic paracetamol (125 mg or 250 mg suppositories, based on body weight) at vaccination, and at 6--8 hour intervals thereafter, or a control group that received no paracetamol. Rectal temperature and local and other systemic reactions were measured for 4 days post vaccination; adverse events were collected throughout the study. RESULTS: In the intent-to-treat population, paracetamol reduced the incidence of fever >=38[degree sign]C, but this reduction was only significant for the infant series, with computed efficacy of 43.0% (95% confidence interval [CI]: 17.4, 61.2), and not significant after the toddler dose (efficacy 15.9%; 95% CI: -19.9, 41.3); results were similar in the per protocol (PP) population. Fever >39[degree sign]C was rare during the infant series, such that there were too few cases for assessment. After the toddler dose, paracetamol effectively reduced fever >39[degree sign]C, reaching statistical significance in the PP population only (efficacy 79%; 95% CI: 3.9, 97.7). Paracetamol also reduced reactogenicity, but there were few significant differences between groups after any dose. No vaccine-related serious adverse events were reported. CONCLUSIONS: Paracetamol effectively prevented fever and other reactions, mainly during the infant series. However, as events were generally mild and of no concern in either group our data support current recommendations to administer paracetamol to treat symptoms only and not for routine prophylaxis.Trial registration: NCT00294294

A look inside the association codeine-paracetamol: clinical pharmacology supports analgesic efficacy

Acute and chronic pain often requires a multimodal approach. Combination therapy reduces the number of individual daily administrations and improves patient's compliance with the prescribed analgesic treatment. Despite the association codeine/paracetamol is one of the most widely used central analgesic, the exact mechanism of action, particularly of paracetamol, is still object of pharmacological research. Recent findings showed that paracetamol may act through cerebral cyclo-oxygenase, descending opioidergic inhibitory pathways, serotonin pathway, and the endocannabinoid system; while codeine activity seems to related not only to its conversion to morphine, as previously known, but also by itself and through its metabolites, such as norcodeine (NORC) and codeine-6-glucuronide (C-6-G). The addition of codeine to paracetamol significantly improves the analgesic action and reduces the number needed to treat (NNT) from 5 to 2.3-3.1. Recent warnings about the risk of its metabolism related to CYP450 and its genetic variability in general population should be mainly considered when the association is used in paediatric patients undergoing tonsillectomy and/or adenoidectomy procedures for obstructive sleep apnoea syndrome (OSAS). In adults, the association codeine/paracetamol has been shown to be effective and safe in different settings: acute pain, trauma patients, and chronic nociceptive pain

Frequent use of paracetamol and risk of allergic disease among women in an Ethiopian population

Introduction The hypothesis that paracetamol might increase the risk of asthma and other allergic diseases have gained support from a range of independent studies. However, in studies based in developed countries, the possibility that paracetamol and asthma are associated through aspirin avoidance is difficult to exclude. Objectives To explore this hypothesis among women in a developing country, where we have previously reported aspirin avoidance to be rare. Methods In 2005/6 a population based cohort of 1065 pregnant women was established in Butajira, Ethiopia and baseline demographic data collected. At 3 years post birth, an interview-based questionnaire administered to 945 (94%) of these women collected data on asthma, eczema, and hay fever in the past 12 month, frequency of paracetamol use and potential confounders. Allergen skin tests to Dermatophagoides pteronyssinus and cockroach were also performed. The independent effects of paracetamol use on allergic outcomes were determined using multiple logistic regression analysis. Findings The prevalence of asthma, eczema and hay fever was 1.7%, 0.9% and 3.8% respectively; of any one of these conditions 5.5%, and of allergen sensitization 7.8%. Paracetamol use in the past month was reported by 29%, and associations of borderline significance were seen for eczema (adjusted OR (95% CI) = 8.51 (1.68 to 43.19) for 1–3 tablets and 2.19 (0.36 to 13.38) for ≥4 tablets, compared to no tablets in the past month; overall p = 0.055) and for ‘any allergic condition’ (adjusted OR (95% CI) = 2.73 (1.22 to 6.11) for 1–3 tablets and 1.35 (0.67 to 2.70) for ≥4 tablets compared to 0 in the past month; overall p = 0.071). Conclusions This study provides further cross-sectional evidence that paracetamol use increases the risk of allergic disease

Photolysis of in-situ electrogenerated hydrogen peroxide for the degradation of emerging pollutants

This study investigates the degradation of paracetamol, an emerging contaminant widely used as pain and fever reliever, by means of hydrogen peroxide either alone or in combination with UV-C photolysis. In particular, we provide a comparison between the performance of both commercial and electrogenerated H2O2 whose production has been achieved by galvanostatic electrolysis in undivided reactor with a gas diffusion cathode. The performance of the treatments has been assessed in terms of both pollutant decay and mineralization. The influence of the H2O2 to paracetamol molar ratio is discussed. The results show that the electrogenerated hydrogen peroxide, when activated by UV-C irradiation, results in faster degradation and mineralization of paracetamol. However, under the conditions adopted, complete depletion of the total organic carbon (TOC) has never been attained

Investigating the removal of some pharmaceutical compounds in hospital wastewater treatment plants operating in Saudi Arabia

The concentrations of 12 pharmaceutical compounds (atenolol, erythromycin, cyclophosphamide, paracetamol, bezafibrate, carbamazepine, ciprofloxacin, caffeine, clarithromycin, lidocaine, sulfamethoxazole and Nacetylsulfamethoxazol (NACS)) were investigated in the influents and effluents of two hospital wastewater treatment plants (HWWTPs) in Saudi Arabia. The majority of the target analytes were detected in the influent samples apart from bezafibrate, cyclophosphamide, and erythromycin. Caffeine and paracetamol were detected in the influent at particularly high concentrations up to 75 and 12 ug/L, respectively. High removal efficiencies of the pharmaceutical compounds were observed in both HWWTPs, with greater than 90 % removal on average. Paracetamol, sulfamethoxazole, NACS, ciprofloxacin, and caffeine were eliminated by between >95 and >99 % on average. Atenolol, carbamazepine, and clarithromycin were eliminated by >86 % on average. Of particular interest were the high removal efficiencies of carbamazepine and antibiotics that were achieved by the HWWTPs; these compounds have been reported to be relatively recalcitrant to biological treatment and are generally only partially removed. Elevated temperatures and high levels of sunlight were considered to be the main factors that enhanced the removal of these compounds

Effect of Durian Fruit Juice (Durio Zibethinus Murr.) to Pharmacokinetic Profile of Paracetamol on Wistar Male Rats (Rattus Norvegicus L.)

Paracetamol is widely used as analgesic and antipyretic agent in treatment of pain and fever. Paracetamol has interaction with carbohydrates and alcohol. Durian is the fruit native of Indonesia, that contain carbohydrates and alcohol. The aims of this research were to study the influence of durian fruit juice to the absorption and elimination kinetics of paracetamol and to know the dose of durian fruit juice that influence the absorption and elimination kinetics of paracetamol. The study was conducted using 16 rats, divided into 4 groups (n=4 per group). Each group was treated the following treatment : control paracetamol (paracetamol 9 mg/200 gBW), dose 1 group (paracetamol 9 mg/200 gBW and 0.675 g/200 gBW of durian fruit juice), dose 2 group (paracetamol 9 mg/200 gBW and 1.350 g/200 gBW of durian fruit juice) and dose 3 group (paracetamol 9 mg/200 gBW and 2.700 g/200 gBW of durian fruit juice). Blood sampling is done from the vein of rat's tail at minutes 10, 20, 30, 40, 60, 90, 120, 180, 240, 300 and 360. The quantitation of paracetamol in plasma was determined by UV spectrophotometer at 243 nm. Result showed that durian fruit juice changed the absorption kinetics of paracetamol, durian fruit juice decreased Ka, Cpmaks and increased Tmaks parameter of paracetamol. Durian fruit juice also changed the elimination kinetics of paracetamol, its decreased Vd, Ke, Cl and increased the value of AUC and T1/2 paracetamol. All doses of durian fruit juice can influence the absorption and elimination kinetics of paracetamol includes Ka, Cpmaks, Tmaks, Vd, Cl, Ke, T1/2 and AUC parameters on wistar male rats (Rattus norvegicus L.)

An evaluation of thermodynamic models for the prediction of drug and drug-like molecule solubility in organic solvents

Prediction of solubility of active pharmaceutical ingredients (API) in different solvents is one of the main issue for crystallization process design. Experimental determination is not always possible because of the small amount of product available in the early stages of a drug development. Thus, one interesting perspective is the use of thermodynamic models, which are usually employed for predicting the activity coefficients in case of Vapour–Liquid equilibria or Liquid–Liquid equilibria (VLE or LLE). The choice of the best thermodynamic model for Solid–Liquid equilibria (SLE) is not an easy task as most of them are not meant particularly for this. In this paper, several models are tested for the solubility prediction of five drugs or drug-like molecules: Ibuprofen, Acetaminophen, Benzoic acid, Salicylic acid and 4-aminobenzoic acid, and another molecule, anthracene, a rather simple molecule. The performance of predictive (UNIFAC, UNIFAC mod., COSMO-SAC) and semi-predictive (NRTL-SAC) models are compared and discussed according to the functional groups of the molecules and the selected solvents. Moreover, the model errors caused by solid state property uncertainties are taken into account. These errors are indeed not negligible when accurate quantitative predictions want to be performed. It was found that UNIFAC models give the best results and could be an useful method for rapid solubility estimations of an API in various solvents. This model achieves the order of magnitude of the experimental solubility and can predict in which solvents the drug will be very soluble, soluble or not soluble. In addition, predictions obtained with NRTL-SAC model are also in good agreement with the experiments, but in that case the relevance of the results is strongly dependent on the model parameters regressed from solubility data in single and mixed solvents. However, this is a very interesting model for quick estimations like UNIFAC models. Finally, COSMO-SAC needs more developments to increase its accuracy especially when hydrogen bonding is involved. In that case, the predicted solubility is always overestimated from two to three orders of magnitude. Considering the use of the most accurate equilibrium equation involving the ΔCp term, no benefits were found for drug predictions as the models are still too inaccurate. However, in function of the molecules and their solid thermodynamic properties, the ΔCp term can be neglected and will not have a great impact on the results