Activated Charcoal

Approved Indications:

• Acute Oral Poisoning and Overdose: Treatment of acute poisonings and overdoses involving substances that are adsorbed by charcoal to prevent systemic absorption. Optimal when administered within 1 hour of ingestion.
• Gastrointestinal Decontamination: Use in emergency medicine for rapid adsorption of toxins in the GI tract.

Clinically Accepted Off-label Uses:

• Multiple-Dose Activated Charcoal (MDAC): Enhances elimination of some drugs and toxins undergoing enterohepatic or enteroenteric recirculation (e.g., carbamazepine, phenobarbital, theophylline).
• Chronic Kidney Disease Adjunct: To reduce accumulation of uremic toxins in patients with CKD (limited and variable evidence).
• Hyperphosphatemia Management: Binding phosphate in patients with renal impairment (off-label use).
• Symptomatic Relief of Gas and Bloating: Occasionally used for reducing intestinal gas in functional gastrointestinal disorders.

Disease Stage/Severity Considerations:

• Most effective when administered early post-ingestion, ideally within 60 minutes.
• Ineffective or contraindicated for substances not adsorbed by charcoal, such as metals, alcohols, acids, or alkalis.

Adults:

• Single dose: 25 to 100 grams orally or via nasogastric tube.
• Multiple-dose regimen: 25 to 50 grams every 4 to 6 hours for selected poisonings requiring enhanced elimination.

Pediatrics:

• Single dose: Approximately 1 gram/kg orally or via nasogastric tube (maximum 50 grams).
• Multiple doses as clinically indicated.

Elderly:

• Same as adult dosing, with caution due to risk of aspiration and comorbidities.

Renal and Hepatic Impairment:

• No dosage adjustments necessary; monitor clinical status closely.

Route of Administration:

• Oral or via nasogastric tube.
• Administer with water to avoid esophageal obstruction.

Duration:

• Single dose for most poisonings.
• Multiple doses continued as needed depending on toxin kinetics and clinical judgment.

Activated charcoal acts by adsorbing toxins and drugs within the gastrointestinal tract through a highly porous surface with large surface area, physically binding molecules and preventing their absorption into the bloodstream. This adsorption decreases systemic bioavailability of the toxin, facilitating elimination via feces. In multiple-dose regimens, activated charcoal interrupts enterohepatic and enteroenteric recirculation of some drugs, enhancing their clearance and reducing toxicity.

• Absorption: Not absorbed systemically; remains within the GI lumen.
• Distribution: Confined to gastrointestinal tract.
• Metabolism: Not metabolized.
• Excretion: Excreted in feces with adsorbed substances.
• Onset: Immediate binding upon contact in the GI tract.
• Half-life: Not applicable, as it is not absorbed or metabolized.

• Pregnancy: FDA Category C. No adequate human studies; animal studies do not indicate teratogenicity. Use only if clearly needed, typically in cases of maternal poisoning.
• Lactation: Minimal systemic absorption; unlikely to pass into breast milk. Considered safe during breastfeeding but use only if indicated.
• Data Limitations: Limited controlled data; caution advised.

• Primary Class: Gastrointestinal Adsorbent
• Subclass: Activated Carbon Preparation

• Known hypersensitivity to activated charcoal or excipients.
• Unprotected airway or high aspiration risk without adequate airway protection.
• Ingestion of corrosive substances (strong acids or alkalis).
• Ingestion of petroleum distillates or hydrocarbons.
• Known or suspected gastrointestinal obstruction or ileus.

• Aspiration Risk: Significant risk of aspiration pneumonitis, especially in patients with impaired consciousness; airway protection (intubation) recommended when indicated.
• Gastrointestinal Complications: Risk of bowel obstruction or perforation; monitor for abdominal pain and distension.
• Electrolyte and Fluid Imbalances: Particularly with multiple-dose regimens; monitor hydration status.
• Clinical Monitoring: Observe for vomiting, respiratory distress, or signs of bowel obstruction.
• Black Box Warnings: None officially, but aspiration pneumonitis is a serious known risk.

Common:

• Gastrointestinal: Nausea, vomiting, constipation, diarrhea, black stools, mild abdominal discomfort or bloating.

Serious and Rare:

• Aspiration pneumonitis (life-threatening if occurs).
• Bowel obstruction or intestinal perforation.
• Electrolyte disturbances from prolonged use.
• Allergic reactions are very rare.

Timing & Dose-Dependence:

• GI side effects usually occur shortly after administration.
• Serious complications are uncommon but increase with improper use or underlying patient risk factors.

• Adsorbs many orally administered drugs, reducing their absorption and efficacy.
• Avoid simultaneous administration with other oral medications; separate dosing by at least 2 hours.
• Food can decrease adsorption capacity.
• No significant interaction with alcohol.
• No known effects on CYP450 enzyme systems.

• Guidelines consistently recommend administration within 1 hour post-ingestion for maximal efficacy.
• Multiple-dose activated charcoal recommended for specific poisonings with prolonged absorption or enterohepatic circulation.
• Emphasis on airway protection and monitoring to reduce aspiration-related complications.
• No new FDA or EMA approved indications; recommendations remain stable.

• Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C.
• Protect from moisture and light.
• Keep container tightly closed.
• Do not freeze.
• Shake oral suspensions well before use.
• No reconstitution required unless specified by manufacturer.