Version May 2024
Acute poisoning: Oral, NG: Note: Some products may contain sorbitol; routine 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]).
Refer to adult dosing.
(For additional information see "Activated charcoal: Pediatric drug information")
Acute poisoning:
Note: Some products may contain sorbitol; routine 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 (AACT/EAPCCT [Chyka 2005]).
Single dose: Charcoal in water:
Note: Although dosing by body weight in infants and children (0.5 to 1 g/kg) is recommended by several resources, there are no data or scientific rationale to support this recommendation (AACT/EAPCCT [Chyka 2005]).
Infants <1 year:
AACT recommendation: Oral, NG: 10 to 25 g (AACT/EAPCCT [Chyka 2005]).
Manufacturer's labeling (Actidose-Aqua): Oral, NG: 1 g/kg.
Children 1 to 12 years:
AACT recommendation: Oral, NG: 25 to 50 g (AACT/EAPCCT [Chyka 2005]).
Manufacturer's labeling:
Actidose-Aqua: Oral, NG: 25 to 50 g.
Kerr Insta-Char (Aqueous): Weight ≥16 kg: Oral, NG: 15 to 30 g or 1 to 2 g/kg.
Adolescents:
AACT recommendation: Oral, NG: 25 to 100 g (AACT/EAPCCT [Chyka 2005]).
Manufacturer's labeling:
Actidose-Aqua: Oral, NG: 50 to 100 g.
Kerr Insta-Char (Aqueous): Weight ≥32 kg: Oral, NG: 50 to 100 g or 1 to 2 g/kg.
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 2004a; AACT [Vale 1999]).
Children weighing ≥16 kg:
Actidose with Sorbitol:
Weight 16 to <32 kg: Oral, NG: 25 g.
Weight ≥32 kg: Oral, NG: 25 to 50 g.
Adolescents:
Actidose with Sorbitol: Oral, NG: 50 g.
Kerr Insta-Char in Sorbitol: Weight ≥32 kg: Oral, NG: 50 to 100 g or 1 to 2 g/kg.
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 2004a).
Manufacturer's labeling (Actidose-Aqua):
Infants <1 year: Oral, NG: 1 g/kg every 4 to 6 hours.
Children 1 to 12 years: Oral, NG: 25 to 50 g every 4 to 6 hours.
Adolescents: Oral, NG: 50 to 100 g every 4 to 6 hours.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. 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
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
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:
• Cathartics (eg, sorbitol, mannitol, magnesium sulfate): Some products may contain sorbitol. In general, routine coadministration of a cathartic is not recommended; however, if cathartics are used, their use should be limited to a single dose to minimize adverse effects. Cathartics have not been demonstrated to change patient outcome and may subject the patient to an increased 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).
• 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).
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.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Liquid, Oral:
Actidose-Aqua: 15 g/72 mL (72 mL [DSC]) [sweet flavor]
Actidose-Aqua: 15 g/72 mL (72 mL) [contains propylene glycol]
Actidose-Aqua: 25 g/120 mL (120 mL [DSC])
Actidose-Aqua: 25 g/120 mL (120 mL) [contains propylene glycol; sweet flavor]
Actidose-Aqua: 50 g/240 mL (240 mL [DSC])
Actidose-Aqua: 50 g/240 mL (240 mL) [contains propylene glycol; sweet flavor]
Kerr Insta-Char: 25 g/120 mL (120 mL); 50 g/240 mL (240 mL) [contains fd&c red #40 (allura red ac dye), methylparaben sodium, propylene glycol, propylparaben sodium, sodium benzoate; cherry flavor]
Kerr Insta-Char: 50 g/240 mL (240 mL) [contains propylene glycol]
Suspension, Oral:
Actidose with Sorbitol: 25 g (120 mL [DSC], 240 mL [DSC])
Actidose with Sorbitol: 25 g (120 mL [DSC], 240 mL [DSC]) [sweet flavor]
Actidose with Sorbitol: 25 g (120 mL, 240 mL) [contains propylene glycol; sweet flavor]
Char-Flo with Sorbitol: 25 g (120 mL)
Kerr Insta-Char in Sorbitol: 25 g (120 mL, 240 mL) [contains fd&c red #40 (allura red ac dye), methylparaben sodium, propylene glycol, propylparaben sodium, sodium benzoate; cherry flavor]
Suspension Reconstituted, Oral:
EZ Char: 25 g (1 ea)
Generic: 28 g (28 g)
May be product dependent
Liquid (Actidose-Aqua Oral)
15 g/72 mL (per mL): $0.15
25 g/120 mL (per mL): $0.14
50 g/240 ml (per mL): $0.10
Liquid (Kerr Insta-Char Oral)
25 g/120 mL (per mL): $0.25
50 g/240 ml (per mL): $0.17
Suspension (Actidose with Sorbitol Oral)
25 g/120 mL (per mL): $0.14
50 g/240 ml (per mL): $0.10
Suspension (Char-Flo with Sorbitol Oral)
25-48 g/120 mL (per mL): $0.05
Suspension (Kerr Insta-Char in Sorbitol Oral)
25 g/120 mL (per mL): $0.25
50 g/240 ml (per mL): $0.17
Suspension (reconstituted) (Charcoal Activated Oral)
28 g (per gram): $1.01
Suspension (reconstituted) (EZ Char Oral)
25 g (per each): $17.65
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.
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 the 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 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.
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
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).
Intracranial hemorrhage associated with oral non-vitamin K antagonist anticoagulants
Actidose may be confused with Actos
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Acetylcysteine: Charcoal, Activated may decrease the serum concentration of Acetylcysteine. Risk C: Monitor therapy
AmLODIPine: Charcoal, Activated may decrease the serum concentration of AmLODIPine. Risk C: Monitor therapy
Chloroquine: Charcoal, Activated may decrease the serum concentration of Chloroquine. Risk C: Monitor therapy
FLUoxetine: Charcoal, Activated may decrease serum concentrations of the active metabolite(s) of FLUoxetine. Charcoal, Activated may decrease the serum concentration of FLUoxetine. Risk C: Monitor therapy
Leflunomide: Charcoal, Activated may decrease serum concentrations of the active metabolite(s) of Leflunomide. Specifically, concentrations of teriflunomide may decrease. Management: Unless using this combination to intentionally enhance teriflunomide elimination, consider an alternative to charcoal whenever possible. Separating drug administration is not likely to be effective at avoiding this interaction. Risk D: Consider therapy modification
Moxifloxacin (Systemic): Charcoal, Activated may decrease the serum concentration of Moxifloxacin (Systemic). Risk C: Monitor therapy
PHENobarbital: Charcoal, Activated may decrease the serum concentration of PHENobarbital. Risk C: Monitor therapy
Propranolol: Charcoal, Activated may diminish the therapeutic effect of Propranolol. Risk C: Monitor therapy
RifAMPin: Charcoal, Activated may decrease the absorption of RifAMPin. Risk C: Monitor therapy
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
Unithiol: Charcoal, Activated may diminish the therapeutic effect of Unithiol. Risk X: Avoid combination
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).
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).
Activated charcoal is not absorbed systemically following oral administration. Breast-feeding is not expected to result in significant exposure to a nursing child.
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.
Note: In studies using adult human volunteers: Mean reduction in drug absorption following a single dose of ≥50 g activated charcoal (AACT/EAPCCT [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)
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