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Intoxication par le paracétamol : quoi de neuf ?

Acetaminophen poisoning: What is new?

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Médecine Intensive Réanimation

Résumé

Le paracétamol est à l’origine de l’une des intoxications les plus fréquentes dans le monde, source persistante de décès. Les objectifs de cette revue sont de faire le point, d’une part, sur les mécanismes et facteurs prédictifs de toxicité du paracétamol et, d’autre part, sur les travaux récents visant à optimiser la prise en charge des intoxications. Le paracétamol en surdose est responsable d’une hépatite cytolytique menant à une nécrose hépatocytaire dose-dépendante. Selon les recommandations françaises, le traitement antidotique par N-acétylcystéine (NAC) est décidé selon la paracétamolémie interprétée à l’aide d’un nomogramme en fonction du délai écoulé depuis l’exposition avec, pour seuil de traitement, une ligne partant de 150 mg/l à h4. Afin d’en simplifier l’administration et d’en réduire les effets secondaires, des variantes du schéma d’administration classique de la NAC ont été étudiées. Les indications et modalités d’administration de la NAC restent en effet toujours un sujet de débat passionnant, à la recherche du juste équilibre entre nécessité de traiter les patients à risque d’hépatotoxicité et souhait de minimiser les coûts et les effets secondaires. De nouveaux biomarqueurs issus de la recherche sur les mécanismes de toxicité du paracétamol ont été proposés pour identifier plus précocement les patients à risque de dommage hépatique : ils devraient bientôt être disponibles en routine.

Abstract

Acetaminophen is one of the most common causes of poisoning worldwide often leading to fatalities. The objectives of this paper were to: 1) review the mechanisms and predictive factors of acetaminophen poisoning; and 2) present the most recent clinical studies aiming at improving its management. Acetaminophen overdose is responsible for a dosedependent toxic hepatitis resulting in liver necrosis. According to the French guidelines, treatment with N-acetylcysteine (NAC) should be decided based on the interpretation of plasma acetaminophen concentration in relation to the time of ingestion using a nomogram with a line starting at 150 mg/l at h4 as threshold for treatment. New protocols of NAC infusion have been studied to simplify its administration and limit its potential side effects. Indications and modalities of NAC administration remain a matter of intense debate. Investigations aim at reaching the best equilibrium between the necessity to treat all patients at risk of liver toxicity and the wish to minimize the treatment costs and side effects. New biomarkers assessed in studies focused at understanding the mechanisms of acetaminophen-related toxicity have been suggested to identify poisoned patients who are at risk of liver toxicity and allow their treatment on time. These new prognosticators should be soon available at the bedside.

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  1. Réanimation médicale et toxicologique, hôpital Lariboisière, Inserm UMRS1144, université Paris-Diderot, 2, rue Ambroise-Paré, F-75475, Paris, France

    B. Mégarbane

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Mégarbane, B. Intoxication par le paracétamol : quoi de neuf ?. Méd. Intensive Réa 26, 383–395 (2017). https://doi.org/10.1007/s13546-017-1300-1

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