Irish Journal of Medical Science

, Volume 181, Issue 3, pp 439–443 | Cite as

Paracetamol overdose: the liver unit perspective

  • M. Iqbal
  • W. J. Cash
  • S. Sarwar
  • P. A. McCormick
Brief Report


Liver failure resulting from deliberate or accidental paracetamol overdose continues to be an important reason for referral to liver transplant centres. Severe hepatic dysfunction often appears 72–96 h after overdose. Liver injury can be prevented by timely administration of the specific antidote, N-acetylcysteine. Unfortunately, administration of N-acetylcysteine is frequently delayed due to late presentation or late administration. While N-acetylcysteine works best if given within 8 h of overdose, it is beneficial at any time period and should always be given if there is concern about significant overdose, irrespective of interval from time of ingestion. Early discussion with liver transplant unit is suggested if there is any doubt or evidence of liver failure.


Paracetamol N-Acetylcysteine Liver failure Liver transplant 



We acknowledge the help of Yvonne McGarry (transplant Co-coordinator) Liver unit, for providing the data regarding the patients with paracetamol overdose. There was no financial incentive or input into this article.

Conflict of interest



  1. 1.
    Fagan E, Wannan G (1996) Reducing paracetamol overdoses. BMJ 313:1417–1418PubMedCrossRefGoogle Scholar
  2. 2.
    Larson AM, Polson J, Fontana RJ et al (2005) Acetaminophen-induced acute liver failure: results of a United States Multicenter, prospective study. Hepatology 42:1364–1372PubMedCrossRefGoogle Scholar
  3. 3.
    National Suicide Research Foundation (2005) National Parasuicide Registry Ireland: annual report, 2004. CorkGoogle Scholar
  4. 4.
    Hawkins LC, Edwards JN, Dargan PI (2007) Impact of restricting paracetamol pack sizes on paracetamol poisoning in the United Kingdom: a review of the literature. Drug Saf 30(6):465–479 (review)PubMedCrossRefGoogle Scholar
  5. 5.
    Morgan O, Majeeed A (2005) Restricting paracetamol in the United Kingdom to reduce poisoning: a systematic review. J Public Health 27:12–18CrossRefGoogle Scholar
  6. 6.
    Bronstein AC, Spyker DA, Cantilena LR, Green J, Rumack BH, Heard SE (2007) 2006 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clin Toxicol 45:815–917CrossRefGoogle Scholar
  7. 7.
    Girre C, Hispard E, Palombo S, N’Guyen C, Dally S (1993) Increased metabolism of acetaminophen in chronically alcoholic patients. Alcohol Clin Exp Res 17(1):170–173PubMedCrossRefGoogle Scholar
  8. 8.
    Waring WS, Stephen AF, Malkowska AM, Robinson OD (2008) Acute ethanol co ingestion confers a lower risk of hepatotoxicity after deliberate acetaminophen overdose. Acad Emerg Med 15(1):54–58PubMedCrossRefGoogle Scholar
  9. 9.
    McClements BM, Hyland M, Callender TL et al (1990) Management of paracetamol poisoning complicated by enzyme induction due to alcohol or drugs. Lancet 335:1526 (letter)PubMedCrossRefGoogle Scholar
  10. 10.
    Nolan CM, Sandblom RE, Thummel KE et al (1994) Hepatotoxicity associated with acetaminophen usage in patients receiving multiple drug therapy for tuberculosis. Chest 105(2):408–411PubMedCrossRefGoogle Scholar
  11. 11.
    Turvill JL, Burroughs AK, Moore KP (2000) Change in occurrence of paracetamol overdose in UK after introduction of blister packs. Lancet 355:2048–2049CrossRefGoogle Scholar
  12. 12.
    Hawton K, Townsend E, Deeks J et al (2001) Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. Br Med J 322(7296):1203–1207CrossRefGoogle Scholar
  13. 13.
    Bateman DN (2009) Limiting paracetamol pack size: has it worked in the UK? Clin Toxicol (Phila) 47(6):536–541CrossRefGoogle Scholar
  14. 14.
    Donohue E, Walsh N, Tracey JA (2006) Pack-size legislation reduces severity of paracetamol overdoses in Ireland. Ir J Med Sci 175:40–42CrossRefGoogle Scholar
  15. 15.
    Ní Mhaoláin AM, Davoren M, Kelly BD et al (2009) Paracetamol availability in pharmacy and non-pharmacy outlets in Dublin, Ireland. Ir J Med Sci 178(1):79–82PubMedCrossRefGoogle Scholar
  16. 16.
    Waring WS, Robinson OD, Stephen AF, Dow MA, Pettie JM (2008) Does the patient history predict hepatotoxicity after acute paracetamol overdose? QJM 101(2):121–125PubMedCrossRefGoogle Scholar
  17. 17.
    Rumack BH, Matthew H (1975) Acetaminophen poisoning and toxicity. Pediatrics 55(6):871–876PubMedGoogle Scholar
  18. 18.
    Smilkstein MJ, Knapp GL, Kulig KW, Rumack BH (1988) Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med 319:1557–1562PubMedCrossRefGoogle Scholar
  19. 19.
    White SJ, Rumack BH (2005) The acetaminophen toxicity equations: “solutions” for acetaminophen toxicity based on the Rumack–Matthew nomogram. Ann Emerg Med 45(5):563–564PubMedCrossRefGoogle Scholar
  20. 20.
    McCormick PA, Casey P, Barry P, Laffoy M, Treacy J (2000) Delays in administration of acetylcysteine in paracetamol overdose. Ir Med J 93(3):77–78PubMedGoogle Scholar
  21. 21.
    Boobis AR, Fawthrop DJ, Davis DS (1989) Mechanisms of cell deaths. Trends Pharmacol Sci 10:275–280PubMedCrossRefGoogle Scholar
  22. 22.
    Tee LBG, Boobis AR, Huggett AC, Davies DS (1986) Reversal of acetaminophen toxicity in isolated hamster hepatocytes by dithiothreitol. Toxicol Appl Pharmacol 83:294–314PubMedCrossRefGoogle Scholar
  23. 23.
    Keays R, Harrison PM, Wendon JA et al (1991) Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial. BMJ 303:1026–1029PubMedCrossRefGoogle Scholar
  24. 24.
    Prescott LF, Park J, Ballantyne A, Adriaenssens P, Proudfoot AT (1977) Treatment of paracetamol (acetaminophen) poisoning with N-acetylcysteine. Lancet 2:432–434PubMedCrossRefGoogle Scholar
  25. 25.
    Prescott LF, Illingworth RN, Critchley JAJH, Stewart MJ, Adam RD, Proudfoot AT (1979) Intravenous N-acetylcysteine: the treatment of choice for paracetamol poisoning Br Med J 2(6198):1097–1100Google Scholar
  26. 26.
    Smilkstein MJ, Bronskin AC, Linden C, Augenstein WL, Kulig KW, Rumack BH (1991) Acetaminophen overdose: a 48-h intravenous N-acetylcysteine treatment protocol. Ann Emerg Med 20:1058–1063PubMedCrossRefGoogle Scholar
  27. 27.
    Parker D, White J, Paten D, Routledge P(1990) Safety of late acetylcysteine treatment in paracetamol poisoning. Hum Exp Toxicol 9:25–27Google Scholar
  28. 28.
    Harrison PM, Keays R, Bray GP et al (1990) Improved outcome of paracetamol-induced fulminant hepatic failure by late administration of acetylcysteine. Lancet 335:1572–1573PubMedCrossRefGoogle Scholar
  29. 29.
    Buckley N, Eddleston M (2005) Paracetamol (acetaminophen) poisoning. Clin Evid (14):1738–1744Google Scholar
  30. 30.
    O’Grady J, Alexander G, Hayllar K, Williams R (1989) Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 97(2):439–445PubMedGoogle Scholar
  31. 31.
    Makin A, Williams R (1994) The current management of paracetamol over dosage. Br J Clin Pharmacol 48:144–148Google Scholar
  32. 32.
    Bernal W, Wendon J, Rela M, Heaton N, Williams R (1998) Use and outcome of liver transplantation in acetaminophen-induced acute liver failure. Hepatology 27:1050–1055PubMedCrossRefGoogle Scholar

Copyright information

© Royal Academy of Medicine in Ireland 2011

Authors and Affiliations

  • M. Iqbal
    • 1
  • W. J. Cash
    • 1
  • S. Sarwar
    • 1
  • P. A. McCormick
    • 1
  1. 1.Liver UnitSt. Vincent’s University HospitalDublin 4Ireland

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