A Randomised Controlled Trial of Multiple Dose Activated Charcoal in Acute Self-Poisoning

Objective: The case-fatality for intentional self-poisoning to the rural developing world is 10-50 fold higher than industrialised countries, due mostly to the use of highly toxic pesticides and plants. We aimed to determine whether routine therapy with multiple dose activated charcoal to interrupt enterovascular or enterohepatic circulations offers benefit, compared to no charcoal, to such an environment. The RCT was registered as ISRCTN02920054. Methods: We conducted an open-label parallel group randomised controlled trial of six 50 g doses at four hourly intervals vs no charcoal vs a stogie 50 g dose of activated charcoal to three Sri Lankan hospitals. Mortality was the primary outcome. Results: 4632 patients were randomised to receive no charcoal (1554), a single dose of charcoal (1545), or six doses of charcoal (1533); outcomes were available for 4629. 2338 (50.5%) had ingested pesticides whilst 1647 (35.6%) had ingested yellow oleander seeds. Mortality did not differ significantly between the groups. 97 of 1531 (6.3%) participants to the multiple dose group died, compared with 105 of 1554 (6.8%) to the no charcoal group (adjusted odds ratio [OR] 0.96, 95% confidence interval [CI] 0.70-1.33). 439 patients were admitted within two hours of poison ingestion and allocated to either MDAC (n=214) or SDAC (n=225). Comparing these 439 patients with 225 who were admitted within two hours of poison ingestion and allocated to no charcoal, there was no evidence of benefit on deaths of early charcoal admtoistration (34/439 vs 15/225; OR 1.18 [exact 95% CI 0.61-2.38]; test of interaction P=0.5). In addition, there was no evidence of an interaction between early charcoal administration and any of the secondary outcomes. No significant differences were noted for patients who took particular poisons, or were more severely ill on admission. Conclusion: We found no benefit from routine administration of multiple dose activated charcoal, nor from early administration of charcoal, for patients poisoned by plants or pesticides to resource-poor rural developing world district hospitals. We cannot recommend the routine use of activated charcoal in rural Asia-Pacific; while further studies of early charcoal administration may be useful, effective affordable treatments are urgently required.