Charcoal, Activated (Monograph)

Brand names: Actidose, Adsorba, CharcoAid G, Charcoal Plus DS, CharcoCaps, ... show all 8 brands EZ-Char, Insta-Char, Liqui-Char
Drug class: Antacids and Adsorbents
VA class: GA900
CAS number: 16291-96-6

Medically reviewed by Drugs.com on Aug 15, 2023. Written by ASHP.

Introduction

Adsorbent and antidote;^a destructive distillation residue of organic materials with small particle size, treated to increase adsorptive power.^{106 a}

Uses for Charcoal, Activated

Poisonings

May be used for treatment (GI decontamination)¹⁰⁴ in most oral poisonings^{101 102 103 105 106 107 108 110 112 116 a} except those involving corrosive agents (e.g., strong acids or alkalis) or substances for which its absorptive capacity is too low to be clinically useful (e.g., iron salts, lithium, boric acid, arsenic, malathion, or organic solvents such as methanol, ethanol, or ethylene glycol).^{102 103 105 107 108 110 112 113 116}

Most commonly used agent for GI decontamination in poisoned patients;¹³² however, routine administration in poisoned patients is not recommended by American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists (AACT/EAPCCT).¹¹³ Controlled studies demonstrating reduced morbidity and mortality generally are lacking.^{101 113} (See General: Poisonings, under Dosage and Administration.)

Hemoperfusion

Hemoperfusion through columns of activated charcoal to remove endogenous or exogenous toxins in uremia, hepatic failure, or acute toxicity associated with overdose of certain drugs.^{102 a}

GI Disorders

Adsorption of intestinal gases in the treatment of flatulence, intestinal distention, and dyspepsia;^{102 a} FDA classified as lacking substantial evidence of efficacy as antiflatulent or digestive aid.¹⁰⁷

Has been used alone or combined with kaolin in the management of diarrhea, but value has not been established.^a

Wounds and Ulcers

Has been used in dressings for suppurating wounds or ulcers to decrease odor and promote healing.^{102 a}

Related/similar drugs

simethicone, Mylanta, GoLYTELY, GaviLyte-G, Gas-X, Activated Charcoal, aluminum hydroxide / magnesium hydroxide / simethicone

Charcoal, Activated Dosage and Administration

General

Poisonings

• Most effective when administered early, preferably within 30–60 minutes of poison ingestion.^{101 102 103 104 105 113}

• Multiple-dose regimens may be considered for drugs that undergo enterohepatic or enteroenteric circulation, those with a small volume of distribution, those that are not extensively protein bound, and those with a low endogenous clearance.^{102 104 107} Also may be considered for life-threatening ingestions of phenobarbital, carbamazepine, quinine, dapsone, theophylline, paraquat, or Amanita phalloides.^{103 105 110 114}

• Tablets or granules of activated charcoal are less effective than powder and should not be used in the treatment of poisonings.^a

• If help from a poison control center (800-222-1222), emergency medical facility (911), or other qualified health professional cannot be obtained quickly by medically unsupervised individuals attempting to manage acute poisoning, follow directions on the container of activated charcoal.^{100 103 107 117}

Administration

Oral Administration

Administer activated charcoal powder orally¹⁰⁷ or via nasogastric or orogastric tube^{113 129} as extemporaneously prepared slurry or suspension or commercially available suspension.^{101 102 107}

Continuous nasogastric infusion or division of the total dose into smaller amounts given more frequently may improve tolerance of large doses.¹²⁹

If an antiemetic is required to successfully administer high dosages, a serotonin type 3 ( 5-HT₃) receptor antagonist (e.g., ondansetron) or metoclopramide may be preferred.¹²⁹

Sorbitol may be administered with single-dose activated charcoal or with first dose of multiple-dose regimen for palatability and laxative action; additional suspending and flavoring agents generally not recommended.^{107 102 103 a}

Reconstitution

Extemporaneously, mix powder with sufficient tap water (e.g., 20–30 g in at least 240 mL) to form a slurry.¹⁰⁰

Dosage

Pediatric Patients

Poisonings

Oral

Adults

Poisonings

Oral

Single dose: 25–100 g^{102 103 104 105 107 108 110 113} or 0.5–1 g /kg;¹²⁹ for massive ingestion of a highly toxic substance or if limited adsorption of a lethal substance may provide substantial clinical benefit, 1.5–2 g/kg may be given.¹²⁹

Multiple doses: 50–100 g, then 12.5 g every hour, 25 g every 2 hours, or 50 g every 4 hours.^{102 105 107 114} Alternatively, 0.5–1 g/kg every 4–6 hours for lower-risk ingestions and larger doses (e.g., 1–1.5 g/kg per hour) for more serious ingestions (e.g., life-threatening ingestion of extended-release theophylline).¹²⁹ Continue multiple-dose therapy until patient recovers or major toxicity resolves.^{105 107}

GI Disorders

Oral

0.6–5 g as a single dose^a or 0.975–3.9 g 3 times daily after meals.^a

Cautions for Charcoal, Activated

Contraindications

• Before endoscopy after ingestion of corrosive agents,¹⁰⁵ unless necessary to adsorb another ingested toxin; may obscure endoscopic evaluation of gastroesophageal lesions.^{103 107 113 a}

• Patients with an unprotected airway, a GI tract that is not anatomically intact, and where risk or severity of aspiration may be increased (e.g., hydrocarbon ingestions).^{107 113 114}

• Multiple-dose regimen in presence of ileus or bowel obstruction.^{103 107 114}

Warnings/Precautions

Warnings

Petroleum Distillates Ingestion

Do not use for ingestion of petroleum distillates (e.g., gasoline, kerosene);¹⁰³ limited efficacy, and toxicity other than aspiration is rare.^{105 107 100 103 113}

Sorbitol and Cathartics

Sorbitol, present in many commercial preparations, should be administered only with a single dose of activated charcoal or the first dose of multiple-dose activated charcoal; no more than 1 or 2 doses of sorbitol or another cathartic (if required) should be used in a 24-hour period because of potential for dehydration, hypotension, electrolyte disturbances (e.g., hypernatremia) associated with excessive catharsis.^{103 107 129}

If sorbitol is used with an initial dose of activated charcoal, a second cathartic generally should not be administered.¹⁰⁷

Use sorbitol with caution in children and geriatric patients; monitor hydration and electrolytes.^{103 107}

General Precautions

GI Effects

May cause vomiting,¹⁰² constipation,¹⁰² diarrhea,¹⁰² and GI obstruction^{102 114} or fecal impaction¹⁰² in dehydrated patients.^{102 103 108 114}

Generally should not be used when decreased peristalsis present (reduced or absent bowel sounds); if risk of GI obstruction, perforation, or hemorrhage exists; if surgery has occurred recently; or if electrolyte imbalance or volume depletion exists.^{103 107 113}

Pulmonary Effects

Aspiration of activated charcoal may lead to more severe complications than aspiration of gastric contents alone.^{101 102} Aspiration from vomiting or misdirected nasogastric catheter has resulted in granulomatous reactions, bronchiolitis obliterans, tissue reaction to suspension agents (sorbitol, povidone), increased lung permeability, and rarely, death.^{101 102 104 111 114 130}

Take measures to reduce the risk of aspiration (e.g., placement of a cuffed endotracheal tube in patients with impaired laryngeal reflexes).^{102 107 113}

Use of Fixed Combination

When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

Common Adverse Effects

Vomiting, diarrhea, constipation, black stools.¹⁰³

Drug Interactions

May decrease absorption of and therapeutic response to other orally administered drugs.^{102 106 107 a} Drugs other than those used for GI decontamination or antidotes for ingested toxins should not be given within 2 hours of activated charcoal; if necessary, concomitant drug therapy can be given parenterally.^{102 107}

Specific Drugs

Charcoal, Activated Pharmacokinetics

Absorption

Bioavailability

Not absorbed from the GI tract.^a

Elimination

Metabolism

Does not undergo metabolism.^a

Elimination Route

Excreted in feces.^a

Stability

Storage

Oral

Well-closed glass or metal containers.^a

Actions

• Nonspecific adsorbent; inhibits GI absorption of various drugs and chemicals.^a

• Broader spectrum of adsorptive activity than other adsorbents (attapulgite, Arizona montmorillonite, evaporated milk).^a

• Inadequate adsorption of alcohols (e.g., ethanol, methanol, ethylene glycol), iron salts, lithium, corrosive agents (e.g. strong acids and alkalis), boric acid, arsenic, malathion, or organic solvents for clinical use in GI decontamination.^{101 105}

• Adsorbs enzymes, vitamins, amino acids, minerals, and other nutrients from the GI tract; of no importance when used in the management of acute poisoning.^a

• Effectiveness of activated charcoal in the lower GI tract is questionable.¹⁰⁷

Advice to Patients

• Importance of calling poison control center (800-222-1222), physician, or emergency department before administration.¹⁰⁷

• Shake liquid well, drink, then rinse container with water, shake again, and drink to get full dose.¹⁰⁷

• Administer only after vomiting has ceased.¹⁰⁷

• Importance of not mixing with milk, ice cream, or sherbet.¹⁰⁷

• Importance of taking oral drugs not used for poisoning at least 2 hours before or after administration of activated charcoal.¹⁰⁷

• Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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