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The Role of Cathartics in the Management of the Poisoned Patient

LeAnne Kamis, PharmD; Anthony Burda, RPh, DABAT; Michael Wahl, MD, FACEP
Illinois Poison Center, Chicago, IL

Introduction
The Illinois Poison Center (IPC) would like to inform physicians of its current
policies on administering cathartics with activated charcoal (AC).
Background
Specialists at the Illinois Poison Center (IPC) are consulted on a variety of
toxicologic exposures in the emergency room setting, including choosing optimal
measures for gastrointestinal (GI) decontamination. The question often arises of
whether to administer AC with or without sorbitol. Position statements published jointly
by the American Academy of Clinical Toxicology (AACT) and the European Association
of Poisons Centres and Clinical Toxicologists (EAPCCT) state that there are no definite
indications for the use of cathartics in the management of the poisoned patient.
Because of this, the IPC no longer routinely recommends the administration of sorbitol,
magnesium citrate or any other cathartic alone or in combination with AC.
What is the rationale for the use of cathartics?
Historically, cathartics were administered in the treatment of poisonings with the
goal of decreasing GI absorption of a poison by speeding the poisons or the poison-AC
complexs transit through the GI tract. Additionally, sorbitol acts as an artificial sweetener,
imparting a more palatable, less gritty taste to AC. Also, since it was believed that AC
was constipating, a laxative cathartic was administered with each dose of AC.
What studies support or refute the efficacy of cathartics?

Seven in vitro studies conducted in the 1980s demonstrated that the addition of
magnesium citrate, magnesium sulfate, sodium sulfate, sorbitol or mannitol improved the
adsorptive capacity of AC products. Five animal studies have demonstrated improved
survival rates or lowered peaks and/or areas under the curve (AUC) when cathartics
were administered with AC to various study animals after ingesting aspirin,
chlorpheniramine, chloroquine and T2 mycotoxin. However, several limitations were
found in these studies, including:

Whether the statistically significant difference in absorption between AC in


combination with a cathartic and AC alone would be significant in a clinical
setting;

Whether there was adequate study power in order to accurately determine if


there actually was a difference in absorption between AC alone and AC plus a
cathartic; and

Whether the conditions present in the experiments would accurately reflect true
clinical situations with regard to time of AC plus sorbitol administration postingestion and physiologic and/or biochemical conditions in the subjects.
In five human volunteer studies, where subjects were given aspirin,

acetaminophen, lithium or theophylline and were treated with a cathartic alone, there
was no statistically significant difference in the AUC or urine recovery of drug and
metabolites when compared to untreated control subjects. When human volunteers were
given aspirin or theophylline and treated with a combination of AC and sorbitol, two
studies demonstrated a significant reduction in the AUC or urinary elimination of drug
and metabolites when compared to subjects treated with AC alone. However, additional
volunteer studies showed no difference between the groups.
Finally, and most importantly, no published clinical studies exist demonstrating
any improved patient outcomes or reduction in the bioavailability of drugs following the
administration of a cathartic with or without AC.
What are the indications for the use of cathartics in the poisoned patient?

Based on available published data, the AACT and EAPCCT concluded that there
are no definite indications for the use of cathartics in the management of the poisoned
patient. Additionally, in 1999, these organizations published a position paper on the use
of multiple-dose activated charcoal, useful in the enhanced elimination of some drugs
(e.g., theophylline, phenobarbital, carbamazepine), which stated that the need for
concurrent administration of cathartics remains unproven and is not recommended.
What are some of the complications and contraindications associated with
cathartic use?
Some untoward effects of single-dose cathartic use include nausea, abdominal
cramps, vomiting and transient hypotension; whereas multiple doses may cause
dehydration, electrolyte imbalance, hypernatremia in patients receiving sodiumcontaining cathartics, and hypermagnesemia in patients receiving a magnesiumcontaining cathartic.
Cathartics should never be used in the presence of absent bowel sounds, recent
abdominal trauma, recent bowel surgery, intestinal obstruction, intestinal perforation,
ingestion of a corrosive substance, volume depletion, hypotension or significant
electrolyte imbalance. Cathartics should be avoided in the very young (less than one
year old) and the very old. Avoid magnesium-containing cathartics in the presence of
renal failure, renal insufficiency or heart block.
What are the IPCs current recommendations with respect to the use of cathartics
and how can pharmacists assist in disseminating this information?
Since administration of a cathartic to a poisoned patient may cause unwanted
gastric distension, nausea and vomiting, has no proven benefit, and is not necessary
since AC is not constipating, the IPC rarely recommends the routine administration of a
cathartic to a poisoned patient in the emergency department. Occasionally, when

multiple-dose charcoal is ordered, a cathartic may be considered only with the first dose
of AC but not with subsequent doses of AC.
Administration of sorbitol with each dose of AC in a multiple-dose regimen has
been associated with serious adverse effects from dehydration to electrolyte imbalance.
Physicians serving on pharmacy and therapeutics committees should be aware
that AC is available as products premixed in either water or sorbitol slurries and are not
interchangeable. Physicians can play an important role in educating other hospital
medical and nursing staff on the appropriate selection of AC products. Poison center
specialists, along with medical toxicology consultants, are available 24 hours a day, 7
days a week and can be reached at 1-800-222-1222 with questions regarding
appropriate GI decontamination measures, antidotal therapy, as well as other treatment
approaches in the management of the poisoned patient.
For more information on how physicians can help promote poison safety in their
communities and workplace, contact Vickie Dance, Public Education Manager, IPC, at
312-906-6125, or visit the IPC Web site at www.IllinoisPoisonCenter.org.

References
1. Barceloux D, McGuigan M, Hartigan-Go K. American Academy of Clinical
Toxicology, European Association of Poisons Centres and Clinical Toxicologists;
Position Statement: Cathartics. Clin Toxicol 1997; 35(7), 743-752.
2. Vale JA, Krenzelok EP, Barceloux GD. American Academy of Clinical Toxicology,
European Association of Poisons Centres and Clinical Toxicologists; Position
Statement and Practice Guidelines on the Use of Multi-Dose Activated Charcoal
in the Treatment of Acute Poisoning. Clin Toxicol 1999; 37(6), 731-751.
3. Chyka PA, Seger D, Krenzelok EP, Vale JA. American Academy of Clinical
Toxicology, European Association of Poisons Centres and Clinical Toxicologists;
Position Paper: Single-Dose Activated Charcoal. Clin Toxicol 2005; 43:61-87.

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