Charcoal

Pharmacologic Category

Antidote

Dosing: Adult

Acute poisoning: Oral, NG: Note: Some products may contain sorbitol; coadministration of a cathartic, including sorbitol, is not recommended due to the potential risk of severe dehydration and electrolyte imbalance. Some clinicians still recommend dosing activated charcoal in a 10:1 (charcoal:poison) ratio for optimal efficacy (Gude 2010); however, the amount of poison ingested is commonly unknown, which makes this approach challenging and often impractical and could result in the administration of an inordinate amount of activated charcoal (Chyka 2005).

Single dose (Chyka 2005): 25 to 100 g

Multidose: Initial dose: 50 to 100 g followed by 25 to 50 g every 4 hours

Intracranial hemorrhage associated with oral non-vitamin K antagonist anticoagulants (off-label use): Oral, enteral: 50 g within 2 hours of ingestion of an oral direct thrombin inhibitor (dabigatran) or an oral direct factor Xa inhibitor (eg, apixaban, edoxaban, or rivaroxaban). Concomitant agents are also recommended in certain patients (ie, 4-factor prothrombin complex concentrate [PCC] or activated PCC [aPCC] for direct factor Xa inhibitor reversal or idarucizumab for dabigatran reversal) (NCS/SCCM [Frontera 2016]).

* See Dosage and Administration in AHFS Essentials for additional information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Acute poisoning: Oral, NG:

Note: Some products may contain sorbitol; coadministration of a cathartic, including sorbitol, is not recommended due to the potential risk of severe dehydration and electrolyte imbalance. Some clinicians still recommend dosing activated charcoal in a 10:1 (charcoal:poison) ratio for optimal efficacy (Gude 2010); however, the amount of poison ingested is commonly unknown, which makes this approach challenging and often impractical and could result in the administration of an inordinate amount of activated charcoal (Chyka 2005).

Single dose: Charcoal in water:

Age-directed dosing: Note: Although dosing by body weight in children (0.5 to 1 g/kg) is recommended by several resources, there are no data or scientific rationale to support this recommendation (Chyka 2005).

Infants <1 year:

Manufacturer's labeling (Actidose-Aqua): 1 g/kg.

AACT recommendation (Chyka 2005): 10 to 25 g.

Children 1 to 12 years:

Manufacturer's labeling:

Actidose-Aqua: 25 to 50 g.

Kerr Insta-Char (Aqueous): Weight ≥16 kg: 1 to 2 g/kg or 15 to 30 g.

AACT recommendation (Chyka 2005): 25 to 50 g.

Adolescents:

Manufacturer's labeling:

Actidose-Aqua: 50 to 100 g.

Kerr Insta-Char (Aqueous): Weight ≥ 32 kg: 1 to 2 g/kg or 50 to 100 g.

AACT recommendation (Chyka 2005): 25 to 100 g.

Single dose: Charcoal with sorbitol; Note: Use of oral charcoal with sorbitol as part of a multiple dose activated charcoal regimen is not recommended (AACT [Vale 1999]); however, a single dose may be used to produce catharsis (AACT 2004):

Infants <1 year: Not recommended.

Children 1 to 12 years (Actidose with Sorbitol):

Weight 16 to <32 kg: 25 g.

Weight ≥ 32 kg: 25 to 50 g.

Adolescents:

Actidose with Sorbitol: 50 g.

Kerr Insta-Char in Sorbitol: Weight ≥32 kg: 1 to 2 g/kg or 50 to 100 g.

Multiple dose: Charcoal in water (doses are repeated until clinical observations of toxicity subside and serum drug concentrations have returned to a subtherapeutic range or until the development of absent bowel sounds or ileus); Note: Reserve for life threatening ingestions of carbamazepine, dapsone, phenobarbital, quinine, or theophylline (AACT 1999).

Manufacturer's labeling (Actidose-Aqua):

Infants <1 year: 1 g/kg every 4 to 6 hours.

Children 1 to 12 years: 25 to 50 g every 4 to 6 hours.

Adolescents: 50 to 100 g every 4 to 6 hours.

Use: Labeled Indications

Acute poisoning: Suspension: Activated charcoal is a nonabsorbable adsorbent that may be considered in the management of poisonings when GI decontamination of drugs or chemicals is indicated (eg, presentation to a treatment facility within 1 hour of ingestion of substances associated with a high degree of morbidity and/or mortality). Activated charcoal is generally an effective adsorbent of drugs and chemicals with a molecular weight range of 100 to 1,000 daltons. Activated charcoal may occasionally be considered >1 hour postingestion (Chyka 2005), especially when substances with known delayed absorption (eg, sustained-release preparations, salicylates) have been ingested (ACMT 2015; Ghosh 2014; Livshits 2015). Contact a poison control center to determine whether the use of activated charcoal is advised in these patients.

Multidose activated charcoal (MDAC) may be considered to enhance drug elimination if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline (Vale 1999).

* See Uses in AHFS Essentials for additional information.

Use: Off-Label: Adult

Intracranial hemorrhage associated with oral non-vitamin K antagonist anticoagulantsLevel of Evidence [G]

Based on the Neurocritical Care Society and the Society of Critical Care Medicine guideline for reversal of antithrombotics in intracranial hemorrhage, activated charcoal is suggested for intubated intracranial hemorrhage patients presenting within 2 hours of ingestion of an oral direct factor Xa inhibitor (eg, apixaban, edoxaban, rivaroxaban) or an oral direct thrombin inhibitor (dabigatran); use is suggested in patients with enteral access and/or alert patients with low aspiration risk. Concomitant agents are also recommended in certain patients (ie, 4-factor prothrombin complex concentrate [PCC] or activated PCC [aPCC] for direct factor Xa inhibitor reversal or idarucizumab for dabigatran reversal).

Level of Evidence Definitions

Level of Evidence Scale

Clinical Practice Guidelines

Life-Threatening Hemorrhage:

NCS/SCCM, “Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage,” 2016

Poisonings:

American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT), “Position Paper: Single-Dose Activated Charcoal,” 2005

American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT), “Position Statement and Practice Guidelines on the Use of Multi-Dose Activated Charcoal in the Treatment of Acute Poisoning,” 1999

Administration: Oral

Flavored beverages (eg, cola, chocolate milk, concentrated fruit juice) can enhance charcoal's palatability; however, the addition of some flavoring agents (eg, chocolate syrup, milk, ice cream, sherbet, marmalade) are known to reduce the adsorptive capacity and, consequently, the efficacy of activated charcoal. If possible, avoid these adjunctive agents in preference to activated charcoal-water slurries. Nevertheless, these flavoring agents do not completely compromise the effectiveness of activated charcoal and may be necessary in some circumstances to enhance compliance (Cooney 1995; Dagnone 2002). Check for presence of bowel sounds before administration. IV antiemetics may be required to reduce the risk of vomiting. The activated charcoal container should be agitated thoroughly before administration. The container should be rinsed with a small quantity of water to insure that the patient has received all of the activated charcoal (Krenzelok 1991).

Capsules and tablets should not be used for the treatment of poisoning.

Administration: Pediatric

Oral: Administer as soon as possible after ingestion, preferably within 1 hour for greatest effect. Shake well before use. Flavored beverages (eg, cola, chocolate milk, concentrated fruit juice) can enhance charcoal's palatability; however, the addition of some flavoring agents (eg, chocolate syrup, milk, ice cream, sherbet, marmalade) are known to reduce the adsorptive capacity and, consequently, the efficacy of activated charcoal. If possible, avoid these adjunctive agents in preference to activated charcoal-water slurries. Nevertheless, these flavoring agents do not completely compromise the effectiveness of activated charcoal and may be necessary in some circumstances (eg, administration in pediatric patients) to enhance compliance (Cooney 1995; Dagnone 2002). Manufacturer's labeling for Actidose Aqua and Actidose with sorbitol recommends avoiding adding chemicals, syrups, or dairy products. Check for presence of bowel sounds before administration. Antiemetics (IV) may be required to reduce the risk of vomiting. The container should be rinsed with a small quantity of water to ensure that the patient has received all of the activated charcoal (Krenzelok 1991).

Capsules and tablets should not be used for the treatment of poisoning

Instruct patient to drink slowly, rapid administration may increase frequency of vomiting; if patient has persistent vomiting, multiple doses may be administered as a continuous enteral infusion

Storage/Stability

Adsorbs gases from air, store in a closed container.

Preparation for Administration: Adult

Powder: Dilute with at least 8 mL of water per 1 g of charcoal, or mix in a charcoal to water ratio of 1:4 to 1:8; mix vigorously to form a slurry (eg, mix 25 g with sufficient tap water to create a 4-ounce slurry or mix 50 g with sufficient tap water to create an 8-ounce slurry).

Preparation for Administration: Pediatric

Oral: Powder: Dilute with at least 8 mL of water per 1 g of charcoal or mix in a charcoal to water ratio of 1:4 to 1:8; mix vigorously to form a slurry (eg, mix 25 g with sufficient tap water to create a 4-ounce slurry or mix 50 g with sufficient tap water to create an 8-ounce slurry).

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

• It is used to treat some poisonings.

• It is used to ease too much gas in the stomach.

Frequently reported side effects of this drug

• Dark stools

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• A significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Medication Safety Issues

Sound-alike/look-alike issues:

Contraindications

There are no absolute contraindications listed within the manufacturer’s labeling.

Note: The American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) consider the following to be contraindications to the use of charcoal (Chyka 2005; Vale 1999): Presence of intestinal obstruction or GI tract not anatomically intact; patients at risk of GI hemorrhage or perforation; patients with an unprotected airway (eg, CNS depression without intubation); if use would increase the risk and severity of aspiration

Warnings/Precautions

Concerns related to adverse effects:

• Vomiting: Charcoal may cause vomiting; the risk appears to be greater when charcoal is administered with sorbitol; the influence of the rate and volume of activated charcoal administration, ingested substance(s), and/or comorbid conditions on the risk of vomiting is unknown (Chyka 2005). IV antiemetics may be required to reduce the risk of vomiting or to control vomiting to facilitate administration (AACT 1999).

Disease-related concerns:

• Decreased peristalsis: Use with caution in patients with decreased peristalsis.

Concurrent drug therapy issues:

• Ipecac: Ipecac should not be administered routinely in the management of poisoned patients (AACT 2004b). In addition, use may delay the administration of or decrease the effectiveness of activated charcoal.

• Cathartics (eg, sorbitol, mannitol, magnesium sulfate): Coadministration of a cathartic is not recommended; cathartics have not been demonstrated to change patient outcome and have no role in the management of the poisoned patient. Cathartics subject the patient to the risk of developing significant fluid and electrolyte abnormalities (AACT 2004a).

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.

• Capsules: Not recommended for use in the treatment of poisoning.

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP ["Inactive" 1997]; Zar 2007).

• Sorbitol: Some products may contain sorbitol; coadministration of a cathartic, including sorbitol, is not recommended. Do not use products containing sorbitol in patients with a genetic intolerance to fructose or in patients who are dehydrated; may cause excessive diarrhea.

• Tablets: Not recommended for use in the treatment of poisoning.

Other warnings/precautions:

• Appropriate use: Not effective in the treatment of poisonings due to the ingestion of low molecular weight compounds such as cyanide, iron, ethanol, methanol, or lithium. Avoid use in hydrocarbon and caustic ingestions.

• Efficacy: Most effective when administered within 30 to 60 minutes of ingestion. The gritty and unpalatable consistency of activated charcoal can create compliance issues in a noncomatose patient and, therefore, impact efficacy.

• Multidose administration: Based on experimental and clinical studies, multidose activated charcoal (MDAC), in most acute poisonings, has not been shown to reduce morbidity or mortality (Vale 1999). It may be considered if a patient has ingested a life-threatening amount of carbamazepine, dapsone, phenobarbital, phenytoin, quinine, or theophylline, although no controlled studies have demonstrated clinical benefit. MDAC may reduce the half-life and length of hospital stay in patients with severe phenytoin intoxication (Chan 2015).

* See Cautions in AHFS Essentials for additional information.

Warnings: Additional Pediatric Considerations

Excessive amounts of activated charcoal with sorbitol may cause hypernatremic dehydration in pediatric patients (Farley 1986); use is not recommended in infants <1 year of age. Aspiration may cause tracheal obstruction in infants but usually not a major problem in adults. Aspiration pneumonitis, bronchiolitis obliterans, and ARDS have been reported following aspiration of charcoal; however, these problems may be due to the aspiration of gastric contents and not charcoal per se.

Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP 1997; Shehab 2009).

Some products contain fructose or sorbitol and should not be administered to patients with a rare autosomal recessive genetic intolerance to fructose.

Pregnancy Considerations

Activated charcoal is not absorbed systemically following oral administration. Use during pregnancy is not expected to result in significant exposure to the fetus. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003).

Breast-Feeding Considerations

Activated charcoal is not absorbed systemically following oral administration. Breast-feeding is not expected to result in significant exposure to a nursing child.

Adverse Reactions

Frequency not defined.

Gastrointestinal: Abdominal distention, appendicitis, constipation, dental discoloration (black; temporary), fecal discoloration (black), intestinal obstruction, mouth discoloration (black; temporary), vomiting

Ophthalmic: Corneal abrasion (with direct contact)

Respiratory: Aspiration, respiratory failure

* See Cautions in AHFS Essentials for additional information.

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Leflunomide: Charcoal, Activated may decrease serum concentrations of the active metabolite(s) of Leflunomide. Management: Unless using this combination to intentionally enhance leflunomide elimination, consider an alternative to charcoal when possible. Separating drug administration is not likely to be effective at avoiding this interaction. Risk D: Consider therapy modification

Teriflunomide: Charcoal, Activated may decrease the serum concentration of Teriflunomide. Management: Unless using this combination to intentionally enhance teriflunomide elimination, consider an alternative to charcoal when possible. Separating drug administration is not likely to be effective at avoiding this interaction. Risk D: Consider therapy modification

Food Interactions

The addition of some flavoring agents (eg, milk, ice cream, sherbet, marmalade) are known to reduce the adsorptive capacity, and therefore the efficacy, of activated charcoal and should be avoided in preference to activated charcoal-water slurries; nevertheless, these flavoring agents do not completely compromise the effectiveness of activated charcoal and may be necessary in some circumstances (eg, administration in pediatric patients) to enhance compliance (Cooney 1995; Dagnone 2002).

Advanced Practitioners Physical Assessment/Monitoring

Assess for active bowel sounds prior to administration and during therapy in patients receiving multiple-dose activated charcoal.

Nursing Physical Assessment/Monitoring

Monitor for active bowel sounds prior to administration and during therapy in patients receiving multiple-dose activated charcoal. Educate patient on the importance of fluids.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Liquid, Oral:

Actidose with Sorbitol: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [sweet flavor]

Actidose-Aqua: 15 g/72 mL (72 mL); 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [sweet flavor]

Kerr Insta-Char: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [contains fd&c red #40, methylparaben sodium, propylene glycol, propylparaben sodium, sodium benzoate; cherry flavor]

Kerr Insta-Char: 50 g/240 mL (240 mL) [contains propylene glycol]

Kerr Insta-Char in Sorbitol: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [contains fd&c red #40, methylparaben sodium, propylene glycol, propylparaben sodium, sodium benzoate; cherry flavor]

Suspension, Oral:

Char-Flo with Sorbitol: 25 g (120 mL)

Suspension Reconstituted, Oral:

EZ Char: 25 g (1 ea) [contains bentonite]

Generic: 25 g (28 g)

Anatomic Therapeutic Chemical (ATC) Classification

• A07BA01

Generic Available (US)

May be product dependent

Pricing: US

Liquid (Actidose with Sorbitol Oral)

25 g/120 mL (per mL): $0.14

50 g/240 ml (per mL): $0.10

Liquid (Kerr Insta-Char in Sorbitol Oral)

25 g/120 mL (per mL): $0.25

50 g/240 ml (per mL): $0.17

Liquid (Kerr Insta-Char Oral)

25 g/120 mL (per mL): $0.25

50 g/240 ml (per mL): $0.17

Suspension (Char-Flo with Sorbitol Oral)

25-48 g/120 mL (per mL): $0.05

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Adsorbs toxic substances, thus inhibiting GI absorption and preventing or limiting systemic toxicity. Administration of multiple doses of charcoal may interrupt enteroenteric, enterohepatic, and enterogastric circulation of some drugs; may also adsorb any unabsorbed drug which remains in the gastrointestinal tract.

Pharmacodynamics/Kinetics

Note: In studies using adult human volunteers: Mean reduction in drug absorption following a single dose of ≥50 g activated charcoal (AACT [Chyka 2005]):

Given within 30 minutes after ingestion: 47.3% reduction

Given at 60 minutes after ingestion: 40.07% reduction

Given at 120 minutes after ingestion: 16.5% reduction

Given at 180 minutes after ingestion: 21.13% reduction

Given at 240 minutes after ingestion: 32.5% reduction

Absorption: Not absorbed from the GI tract

Excretion: Feces (as charcoal)

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

No significant effects or complications reported

Effects on Bleeding

No information available to require special precautions

Index Terms

Activated Carbon; Activated Charcoal; Adsorbent Charcoal; Liquid Antidote; Medicinal Carbon; Medicinal Charcoal

References

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Brand Names: International

Acticarb (AE); Allocholum (UA); Antipois (VN); Bekarbon (ID); Biocarbon (AT, MT, MY); Ca-R-Bon (TH); Carbo Medicinalis (PL); Carbobel Mono (BE); Carbomint (VN); Carbomix (DK, FR, MT, SE, TR, TW); Carbon Natural (UY); Carbosorb (CZ, NZ); Carbosorb X (AU, NZ); Carbosorb XS (AU, NZ); Carbotox (SK); Carbotural (MX); Charbogir (BE); Charcodote (GB, KR, SG); Charcotrace (AU, KR); Deltacarbon (TH); JL Bragg's Medicinal Charcoal (HK); Karbosorb (HU); Koal (BD); Kremezin (TW); Mamograf (AR); Neocarbon (BR); Norit (BE, IL); RCOL (IN); Sorbex (UA); Ultra Carbon (AE, CY); Ultracarbon (MY, SG, TR); Yo'Come Penney (TW)

Last Updated 2/20/20