BUPROPION

BUPROPION Also explore Side-Effects

0.0 OVERVIEW

0.1 LIFE SUPPORT

A. This overview assumes that basic life support measures have been instituted.

0.2 CLINICAL EFFECTS

0.2.1 SUMMARY OF EXPOSURE

A. Bupropion is a pharmacologically unique antidepressant, with structural similarities to amphetamines and diethylpropion. It acts by selectively inhibiting neuronal reuptake of dopamine, norepinephrine, and serotonin. It also has moderate anticholinergic activity.
B. Tremors and seizures are the most likely effects in acute overdose, occurring within 1 to 4 hours following ingestion, with the exception of sustained-release preparations, which have been reported to result in delayed seizures. Sinus tachycardia is common in overdose.
C. Toxicity may be delayed after ingestion of sustained release products.

0.2.5 CARDIOVASCULAR

A. Tachycardia is common after overdose. Intraventricular conduction delays have rarely been reported after large ingestions. Cardiovascular toxicity of bupropion is limited.

0.2.7 NEUROLOGIC

A. Seizures are the most likely effect to occur in overdose. In therapeutic doses, tremors occurred following 400 to 600 mg/day, and seizures after daily doses of 600 to 900 mg.
B. Agitation and excitement are also common effects. Perceptual alterations, including vivid dreaming and visual hallucinations have been described with doses of greater than 450 mg/day.
C. Paresthesias, lightheadedness, lethargy and confusion are common after overdose; coma is rare.

0.2.8 GASTROINTESTINAL

A. Nausea and vomiting are common after overdose.

0.2.9 HEPATIC

A. Hepatocellular hypertrophy and hyperplasia have been reported in animals. Induction of liver enzymes has also been observed.

0.2.17 METABOLISM

A. Increased serum levels of homovanillic acid may be seen, especially when psychosis is present.

0.3 LABORATORY/MONITORING

A. Obtain serum electrolytes. Cardiac monitoring may be necessary. Monitor for seizures and mental status changes.

0.4 TREATMENT OVERVIEW

0.4.2 ORAL/PARENTERAL EXPOSURE

A. EMESIS - Emesis may be spontaneous. Ipecac induced emesis is not advisable due to potential rapid onset of seizures.
B. ACTIVATED CHARCOAL: Administer charcoal as slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
C. GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in Trendelenburg and left lateral decubitus position or by endotracheal intubation. Control any seizures first.

1. CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.

D. SEIZURES: Administer a benzodiazepine IV; DIAZEPAM (ADULT: 5 to 10 mg, repeat every 10 to 15 min as needed. CHILD: 0.2 to 0.5 mg/kg, repeat every 5 min as needed) or LORAZEPAM (ADULT: 4 to 8 mg; CHILD: 0.05 to 0.1 mg/kg).

1. Consider phenobarbital if seizures recur after diazepam 30 mg (adults) or 10 mg (children > 5 years).
2. Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, hypoxia.

0.5 RANGE OF TOXICITY

A. Therapeutic adult doses are 300 to 450 mg/day. Seizures have been reported with doses of 600 to 900 mg. Overdoses of 9 grams in adults, resulting in seizures, have been survived.
B. In 12 of 13 overdoses reported during clinical trials, patients ingested 850 to 4200 mg and recovered without significant sequelae.

1.0 SUBSTANCES INCLUDED/SYNONYMS

1.1 THERAPEUTIC/TOXIC CLASS

A. Bupropion is a structurally unique, monocyclic antidepressant. It acts by selectively inhibiting neuronal reuptake of dopamine, norepinephrine, and serotonin. It also has moderate anticholinergic activity. The chemical structure of this propiophenone is similar to amphetamine and diethylpropion, although its pharmacologic effects and adverse effects are distinctive.

1.2 SPECIFIC SUBSTANCES

o Amfebutamone

o Bupropion

o BW-323

o 2-tert-butylamino-3-chlorpropiophenone

1.6 AVAILABLE FORMS/SOURCES

A. FORMS

1. Bupropion is available (Wellbutrin(R)) by Burroughs Wellcome in 75 and 100 mg tablets. Bupropion was voluntarily withdrawn from marketing due to the potential for seizures in 1986, and re-introduced in July, 1989.
2. Bupropion is also available as a sustained-release 150 mg tablet (Zyban(R)) (Weiner et al, 1998).

B. USES

1. Bupropion is an antidepressant and is approved as an aid in smoking cessation (Sigg, 1999) and in the treatment of bulimia (Ayers & Tobias, 2001). Due to its dopamine stimulating effect, bupropion may offer an advantage in the elderly with depression and dementia (Trappler & Miyashiro, 2000). Bupropion has also been suggested as therapy for children with attention deficit hyperactive disorder (ADHD) (Ayers & Tobias, 2001).

3.0 CLINICAL EFFECTS

3.1 SUMMARY OF EXPOSURE

A. Bupropion is a pharmacologically unique antidepressant, with structural similarities to amphetamines and diethylpropion. It acts by selectively inhibiting neuronal reuptake of dopamine, norepinephrine, and serotonin. It also has moderate anticholinergic activity.
B. Tremors and seizures are the most likely effects in acute overdose, occurring within 1 to 4 hours following ingestion, with the exception of sustained-release preparations, which have been reported to result in delayed seizures. Sinus tachycardia is common in overdose.
C. Toxicity may be delayed after ingestion of sustained release products.

3.3 VITAL SIGNS

3.3.3 TEMPERATURE

A. HYPERTHERMIA - Mild hyperthermia (101 F) developed in an 18-year-old woman who became combative after ingesting 9,000 milligrams of bupropion (Storrow, 1994).

3.5 CARDIOVASCULAR

3.5.1 SUMMARY

A. Tachycardia is common after overdose. Intraventricular conduction delays have rarely been reported after large ingestions. Cardiovascular toxicity of bupropion is limited.

3.5.2 CLINICAL EFFECTS

A. TACHYCARDIA

1. INCIDENCE - Sinus tachycardia was reported in 25 of 58 patients (52%) after overdose with bupropion only (Spiller et al, 1994). None of these patients developed other dysrhythmias or hemodynamic compromise. Cardiovascular overdose effects include primarily tachycardia and rarely hypotension (Ayers & Tobias, 2001).
2. CASE REPORT - Sinus tachycardia, lasting 48 hours, was reported in a woman who also developed seizures following a 9000 mg overdose (Storrow, 1994).
3. CASE REPORTS - Tachycardia has been reported in 3 patients following overdoses of 3000 mg, 4500 mg, and 4350 mg, respectively, of sustained release bupropion. Symptoms resolved in all patients following aggressive benzodiazepine therapy (Weiner et al, 1998).

B. ARRHYTHMIA

1. CASE REPORT - Abnormal junctional rhythm was reported in one patient during clinical trials, but a cause-effect relationship was not established (Wenger and Stern, 1983).

C. ECG ABNORMAL

1. Intraventricular conduction delays and sinus tachycardia have been reported following large overdose (Paris & Saucier, 1998; Shrier et al, 2000; Fresh et al, 1999).
2. CASE REPORT - Paris & Saucier (1998) reported sinus tachycardia and intraventricular conduction delays in a 32-year-old male following a 9 gram ingestion of bupropion. Initial ECG revealed supraventricular tachycardia (123 bpm) and QRS and QTc interval prolongation, 135 msec and 485 msec, respectively. Conduction delays resolved within 48 hours.
3. CASE REPORT - Four hours following the ingestion of 1500 mg of sustained-release bupropion, an ECG revealed intraventricular conduction delay, with ventricular rate of 150 beats/min, QRS of 100 ms, and a QTc interval of 600 ms in a 16-year-old female. Slow but consistent resolution of tachycardia and prolonged QT interval was reported on serial ECGs over the next 12 hours. Complete resolution occurred with no treatment (Shrier et al, 2000).
4. CASE REPORT - A 36-year-old female was reported on ECG to have a QRS of 166 ms (QTc 587 ms) with a left bundle branch block pattern 12 hours following ingestion of 4.5 grams bupropion. Her serum bupropion level was 0.44 mg/L (therapeutic, 0.025-0.2 mg/L) at 16 hours post- ingestion. Progressive normalization of QRS width and rate was shown on serial ECGs (Fresh et al, 1999).
5. CASE REPORT - One 22-year-old patient who ingested 2000 to 2200 mg developed hypokalemia and nonspecific ST-T changes, but no QRS prolongation or other cardiac abnormalities (Wenger and Stern, 1983). No changes in PR interval and QRS duration were seen in patients treated with bupropion.

D. HYPOTENSION

1. Orthostatic hypotension or dizziness may occur at therapeutic doses; two patients who fell backward did not have symptoms suggesting orthostatic hypotension, but had other signs of Parkinsonism (Szuba & Leuchter, 1992).
2. Spiller et al (1994) found no cases of hypotension in a retrospective case series of 58 bupropion overdoses.

3.5.3 ANIMAL EFFECTS

A. BUNDLE BRANCH BLOCK

1. Animal experiments have shown changes in PR interval and QRS duration at concentrations 10 to 100 times that required for amitriptyline or imipramine (Wenger et al, 1983).

3.7 NEUROLOGIC

3.7.1 SUMMARY

A. Seizures are the most likely effect to occur in overdose. In therapeutic doses, tremors occurred following 400 to 600 mg/day, and seizures after daily doses of 600 to 900 mg.
B. Agitation and excitement are also common effects. Perceptual alterations, including vivid dreaming and visual hallucinations have been described with doses of greater than 450 mg/day.
C. Paresthesias, lightheadedness, lethargy and confusion are common after overdose; coma is rare.

3.7.2 CLINICAL EFFECTS

A. SEIZURES

1. ADVERSE EFFECTS

a. Patients with no prior seizure history have developed seizures after daily doses of 600 to 900 mg. In one study, 2 of 4 patients receiving 800 mg or more daily developed seizures after 2 to 4 doses (Van Wyck Fleet et al, 1983).
b. Seizures occurred within 1 to 4 hours following the dose.
c. INCIDENCE - A review of manufacturer's records on 37 cases of seizures during bupropion therapy revealed an overall incidence of seizures of 0.8%. When patients receiving more than 450 mg/day were excluded, the incidence decreased to 0.35%, which increased to 0.48% after 2 years of therapy (Davidson, 1989).
d. Predisposing factors (diet, family history, abnormal baseline EEG, head injury, chronic ethanol use, possible withdrawal, other drugs that lower seizure threshold) are present in many patients who develop seizures on therapeutic doses (Johnston et al, 1991).

2. ACUTE TOXICITY

a. INCIDENCE - In one study, 12 of 58 patients (21%) with bupropion only overdose developed seizures (Spiller et al, 1994). The manufacturer reports seizures occurring in approximately one third of all overdose cases (Prod Info Wellbutrin(R), 1999). In most cases, seizures are of short duration and may not require ongoing treatment (Ayers & Tobias, 2001).

(1) ONSET - Seizure activity developed within 1 to 8 hours post-ingestion (reviewed in Ayers & Tobia, 2001).

b. CASE REPORT - Grand mal seizures developed in an 18-year-old woman after ingesting 9,000 milligrams of bupropion (Storrow, 1994), and in a 39-year-old woman who ingested 1000 to 2000 milligrams (Gittelman & Kirby, 1993).
c. CASE REPORT - Another patient who ingested 9000 mg of bupropion and 800 mg of tranylcypromine experienced a grand mal seizure and recovered without further sequelae.
d. In 5 overdose reports of ingestion of 900 to 3000 mg, seizures were not noted, however, some or all of these had concurrently ingested benzodiazepines (Van Wyck Fleet et al, 1983).
e. CASE REPORT - A grand mal seizure was reported in a 32-year-old male following the ingestion of 9 grams of bupropion. The seizure resolved after 3 minutes with no intervention (Paris & Saucier, 1998).
f. CASE REPORT - Following the ingestion of up to 3000 mg of bupropion in a suicide attempt, a 14-year-old male was reported to have 2 tonic-clonic seizures, the first approximately 6 hours post-ingestion. The seizures were of short duration (up to 45 seconds) and required no pharmacological intervention (Ayers & Tobias, 2001).
g. DELAYED SEIZURES - Have been reported following overdoses of sustained-release bupropion. Two patients, ingesting 30 tablets of bupropion SR 150 mg (and co-ingestants), each, developed seizures 9.75 hours and 10 hours post-ingestion, respectively. The seizures resolved spontaneously with no treatment (Harmon et al, 1998).
h. RECURRENT SEIZURES/SUSTAINED-RELEASE - Sigg (1999) reported recurrent seizures separated by 10 hours in a patient following a maximum ingestion of 4.5 grams of sustained-release bupropion. The first seizure occurred at approximately 4 hours after ingestion. This patient did not receive any form of gastrointestinal decontamination.
i. Three cases of overdose with sustained-release bupropion, with no coingestants, have been presented. All 3 patients developed symptoms of central nervous system excitation, including tachycardia, tremors, anxiety, and nervousness within 4 hours of ingestion. In all 3 cases, benzodiazepines were administered promptly, with resolution of symptoms between 8 and 12 hours of the overdoses (Weiner et al, 1998).

B. CNS DEPRESSION

1. Paresthesias, lightheadedness, slurred speech, lethargy and confusion are common; coma has been reported in mixed overdoses, but is rare after single ingestions of bupropion (Wenger and Stern, 1983; Spiller et al, 1994; Storrow, 1994; Ayers & Tobias, 2001).

C. TREMOR

1. INCIDENCE - Tremor was reported in 14 of 58 overdose (24%) cases (Spiller et al, 1994).

a. Tremor is a common effect in higher therapeutic doses (400 to 600 mg/day), occurring in 8 of 16 patients in one study (Dufresne et al, 1985).

D. HALLUCINATION

1. Vivid dreaming, visual hallucination, and altered time sense were described in patients receiving high doses (greater than 450 mg/day) (Becker & Difresne, 1982). Hallucinations developed in 4 of 58 overdose cases (Spiller et al, 1994). Visual hallucinations were reported in a 14-year-old following the ingestion of up to 3000 mg of bupropion (Ayers & Tobias, 2001).
2. Organic mental disorders (including 1 case of auditory hallucinations) were reported in 3 patients with bipolar mood disorder taking bupropion (Ames et al, 1992).

E. AGITATION

1. Agitation and excitement are common adverse effects during treatment. Paris & Saucier (1998) reported an adult with agitation, combativeness, and prolonged delirium after a 9 gram overdose. A brief episode of agitation and combativeness 18 hours post-ingestion (up to 3000 mg bupropion) was reported in a 14-year-old (Ayers & Tobias, 2001).

F. EXTRAPYRAMIDAL DISORDER

1. A parkinsonian syndrome was reported in 2 patients, manifesting as falling backwards (Szuba & Leuchter, 1992).

G. CATATONIC REACTION

1. CASE REPORT - Catatonia is reported in a 19-year-old male on the fifth day of bupropion therapy (75 mg 3 times daily). Increased muscle tone, mutism, posturing, and unresponsiveness were noted. Bupropion therapy was stopped and electroconvulsive treatments were begun (Jackson et al, 1992).

3.8 GASTROINTESTINAL

3.8.1 SUMMARY

A. Nausea and vomiting are common after overdose.

3.8.2 CLINICAL EFFECTS

A. VOMITING

1. INCIDENCE - Vomiting occurred in 2 of 5 patients who overdosed on 900 to 3000 mg. Vomiting developed in 8 of 58 overdose cases (14%) in another study (Spiller et al, 1994). Two episodes of vomiting were reported within 5 hours of ingestion of up to 3000 mg bupropion in a 14-year-old (Ayers & Tobias, 2001).
2. Overdose of sustained-release bupropion has resulted in vomiting within 4 hours of ingestion (Weiner et al, 1998).

3.9 HEPATIC

3.9.1 SUMMARY

A. Hepatocellular hypertrophy and hyperplasia have been reported in animals. Induction of liver enzymes has also been observed.

3.9.3 ANIMAL EFFECTS

A. HEPATOCELLULAR DAMAGE

1. Hepatotoxicity consisting of hepatocellular hypertrophy and focal nodular hyperplasia was observed in rats after chronic administration. In addition, there was an increase in liver weight in both rats and dogs, apparently related to hepatic enzyme induction (Tucker, 1983).

3.10 GENITOURINARY

3.10.2 CLINICAL EFFECTS

A. PRIAPISM

1. Clitoral priapism of 24-hour duration is reported in a 50-year-old female two days after starting bupropion therapy (100 mg twice daily) (Levenson, 1995).

3.12 FLUID-ELECTROLYTE

3.12.2 CLINICAL EFFECTS

A. HYPOKALEMIA

1. Mild hypokalemia has occasionally been reported in overdose (Spiller et al, 1994).

3.13 HEMATOLOGIC

3.13.2 CLINICAL EFFECTS

A. EOSINOPHILIA

1. CASE REPORT - A case of eosinophilia is described in a 72-year-old female with no other pre-disposing causes five days after initiation of bupropion therapy. The eosinophil count peaked at 0.60 fraction of 1.00 with the count returning to normal after drug cessation (Malesker et al, 1995).

3.15 MUSCULOSKELETAL

3.15.2 CLINICAL EFFECTS

A. RHABDOMYOLYSIS

1. CHRONIC TOXICITY

a. CASE REPORT - An asymptomatic 49-year-old male had a creatine kinase (CK) level of 18,394 u/L found during routine blood analysis (David & Esquenazi, 1999). The patient was taking bupropion 150 mg twice daily for 5 months along with glipizide and metformin. Following intravenous hydration and drug cessation CK returned to normal within 8 days.

3.17 METABOLISM

3.17.1 SUMMARY

A. Increased serum levels of homovanillic acid may be seen, especially when psychosis is present.

3.17.2 CLINICAL EFFECTS

A. ALTERED NEUROTRANSMITTER LEVEL

1. Increases in plasma concentrations of the dopamine metabolite homovanillic acid were found in patients who experienced psychoses in association with bupropion treatment, but not in those who obtained good clinical responses from the drug. Disruptions in dopaminergic pathways may underlie this form of toxicity (Golden et al, 1988).

3.18 PSYCHIATRIC

3.18.2 CLINICAL EFFECTS

A. PSYCHOSIS

1. Acute psychosis was described in 4 depressed patients with no prior history of psychosis who were receiving bupropion.
2. In one patient psychotic symptoms (auditory hallucinations, severe agitation, time disorientation) occurred 3 weeks after a dose increase to 500 mg/day.
3. In another patient visual hallucinations began 4 days after a dose increase to 300 mg/day, and subsided when the dose was reduced to 225 mg/day.
4. In the other two patients, hallucinations occurred after 300 mg/day and 100 mg/day and were not apparently dose-related (Golden et al, 1985).
5. Nightmares have been described in patients on therapeutic doses of bupropion (Balon, 1996).
6. In another study, elevated plasma homovanillic acid levels were found in patients experiencing psychoses with bupropion, suggesting an alteration in dopamine metabolism in these individuals (Golden et al, 1988).
7. Repetitive and compulsive behavior was exhibited in a child being given bupropion for ADHD. The compulsive behavior abated on discontinuation of bupropion, although his hyperactivity returned (Jacobsen et al, 1994).

3.20 REPRODUCTIVE

3.20.3 EFFECTS IN PREGNANCY

A. PREGNANCY CATEGORY

§ BUPROPION B

§ Reference: Briggs et al, 1998.

3.20.4 EFFECTS DURING BREAST-FEEDING

A. BREAST MILK

1. Bupropion and its metabolites are excreted into human breast milk. Peak milk concentration of bupropion, following a 100 mg dose, was 0.189 mcg/mL, and was reached in 2 hours (Briggs et al, 1998).

3.23 OTHER

3.23.2 CLINICAL EFFECTS

A. DRUG DEPENDENCE

1. CONCLUSION - It would appear that bupropion has little CNS activity which would characterize it as an amphetamine or drug with significant abuse potential.
2. HUMAN STUDIES - However, the potential for drug abuse seen in animals has not been replicated in human studies (Peck, 1979; Griffith et al, 1983; Miller & Griffith, 1983).

a. CASE SERIES - In 14 male volunteers with a history of mixed substance abuse, placebo, bupropion (100 mg, 200 mg and 400 mg single doses) and dextroamphetamine (15, 30 mg single doses) were compared (Miller & Griffith, 1983).

(1) A single dose of 400 mg bupropion produced a modest elevation over placebo responses on the morphine-benzedrine subscale of the Addiction Research Center Index (ARCI) and a score intermediate between placebo and amphetamine on the Liking Scale of the ARCI.
(2) These scales measure general feelings of euphoria and drug desirability. On the Benzedrine and amphetamine subscales, both of which measure specific psychostimulant subjective effects, there was little overlap between bupropion and amphetamine in any of the items comparing these scales.

B. DRUG INTERACTION

1. CARBAMAZEPINE and VALPROATE - Popli & Tanquary (1994) reported bupropion drug interactions with carbamazepine and valproate sodium. Three patients taking doses of 525 to 600 mg/day were reported to have bupropion levels of 0 up to 21 ng/mL, with no seizure activity.
2. AMANTADINE - Six nursing home patients on long term bupropion therapy developed confusion, agitation, gross motor tremors, ataxia, dizziness, and vertigo within one week of beginning amantadine therapy. Effects resolved within 72 hours of discontinuing amantadine and bupropion. The authors proposed the drug interaction resulted from a synergistic central dopamine effect (Trappler & Miyashiro, 2000).

3.23.3 ANIMAL EFFECTS

A. DRUG DEPENDENCE

1. Because of the structural similarity of bupropion to amphetamine, its abuse potential has been studied. At high doses in rats, bupropion substitutes for psychostimulants in drug discrimination tests (Jones, 1980).

4.0 LABORATORY/MONITORING

4.1 MONITORING PARAMETERS/LEVELS

4.1.1 SUMMARY

A. Obtain serum electrolytes. Cardiac monitoring may be necessary. Monitor for seizures and mental status changes.

4.1.2 SERUM/BLOOD

A. BLOOD/SERUM CHEMISTRY

1. Obtain serum electrolytes.

4.1.4 OTHER

A. MONITORING

1. Cardiac monitoring may be necessary.

5.0 ABSTRACTS

5.1 CASE REPORTS

A. ROUTE OF EXPOSURE

1. ORAL: Van Wyck Fleet et al (1983) summarized cases of overdose/suicide attempts with bupropion. In 5 female patients ingesting 900 to 3000 mg bupropion in a single dose, vomiting occurred in 2 patients; however, there were no reports of cardiac abnormalites, unconsciousness, or seizures.

6.0 TREATMENT

6.1 LIFE SUPPORT

A. Support respiratory and cardiovascular function.

6.3 PATIENT DISPOSITION

6.3.1 DISPOSITION/ORAL EXPOSURE

6.3.1.5 OBSERVATION CRITERIA/ORAL

A. In cases of substantial poisoning with sustained-release bupropion preparations, monitor the patient for 8 to 12 hours for signs of delayed CNS excitation, including seizures.

6.4 MONITORING

A. Obtain serum electrolytes. Cardiac monitoring may be necessary. Monitor for seizures and mental status changes.

6.5 ORAL EXPOSURE

6.5.1 PREVENTION OF ABSORPTION/PREHOSPITAL

A. EMESIS/NOT RECOMMENDED -

1. Emesis may be spontaneous. Induced-emesis is not advisable due to rapid onset of seizures.

B. ACTIVATED CHARCOAL -

1. PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION

a. Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion.

(1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should be administered by medical or paramedical personnel capable of airway management to prevent aspiration in the event of spontaneous emesis.

2. CHARCOAL DOSE

a. Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years; and 1 gram/kilogram in infants up to 1 year old (USP DI, 2000; Chyka & Seger, 1997).

(1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (Barceloux et al, 1997).

b. ADVERSE EFFECTS/CONTRAINDICATIONS

(1) Complications: emesis, aspiration (Chyka & Seger, 1997). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
(2) Contraindications: unprotected airway, gastrointestinal tract not anatomically intact, therapy may increase the risk or severity of aspiration; ingestion of most hydrocarbons (Chyka & Seger, 1997).

6.5.2 PREVENTION OF ABSORPTION