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Issue 15: October 2016
Drugs and Therapeutics Backgrounder
Inadvertent Acetaminophen Overdoses in Adult Hospitalized Patients
BOTTOM LINE
 Acetaminophen is the leading cause of acute liver failure in Canada
 Patients should never receive inadvertent overdoses of acetaminophen while in hospital
 The maximum cumulative dose of acetaminophen from all sources is 4 g per day for adult
patients
 Consider limiting the cumulative dose of acetaminophen to 3 g per day in patients at risk of
acetaminophen induced liver toxicity
Acetaminophen is one of the most commonly used drugs in hospitalized patients and is generally considered safe
and effective.
Health Canada reports that up to 20% of acetaminophen overdoses in Canada are unintentional. Some experts
have recommended a maximal daily dose of acetaminophen of 2.6 g per day since acute liver failure can occur at
therapeutically recommended doses of acetaminophen (less than 4 g per day).
Although medication administration is controlled in the hospital setting, studies show that inadvertent overdosing of
acetaminophen, greater than the recommended maximum dosage, occurs in up to 6% of hospitalized patients.
Strategies to Improve Acetaminophen Safety
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Risk factors that contribute to inadvertent
Limit the number of products containing
acetaminophen overdoses in hospital
acetaminophen that are prescribed.
o Prescribe only one product containing
 Regular around-the-clock dosing plus as-needed (PRN)
acetaminophen.
dosing (i.e., multiple acetaminophen orders)
 Use of multiple acetaminophen containing products,
The 4 g daily dose limit in adults equals:
such as opioid-acetaminophen combination products
o 12 tablets for the 300/325mg products.
 Medication products that contain more than 500 mg of
o 8 tablets for the 500 mg product.
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®
acetaminophen (e.g., Tylenol Arthritis, Tylenol Extra
Become familiar with combination pain
Strength)
relievers that contain acetaminophen.
 Patients in critical care and surgical units
o Prescribe single-ingredient opioid
alternatives when appropriate (see
table on reverse).
Use the minimally effective acetaminophen dose reduction in patients at risk of acetaminophen toxicity.
o Patients who are aged 65 years and older, who have chronic liver disease, who regularly consume
alcohol (3 or more alcoholic drinks daily), or who take maximal daily doses of acetaminophen for
chronic pain, may be at greater risk of experiencing liver toxicity from acetaminophen.
Note the total amount of acetaminophen from all sources and routes given within the previous 24 hours.
Work with your team to create systems that alert staff about dose limits and that track daily cumulative
dosing of acetaminophen.
Inform all patients who are prescribed acetaminophen at discharge about the risks of liver toxicity due to
unintentional acetaminophen overdose and how to correctly identify products containing acetaminophen.
Prepared by: Joseph Blais, Clinical Pharmacist, University of Alberta Hospital
Reviewed by: Humeira Dhanji, Clinical Nurse Specialist, Acute Pain Service, Foothills Medical Centre
Dr. Dean Karvellas, Associate Professor of Medicine, Division of Gastroenterology and Critical Care Medicine, University of Alberta
Medication Quality and Safety Team, Pharmacy Services
© 2016 Alberta Health Services, Drug Utilization & Stewardship, Pharmacy Services. All rights reserved. Permissions contact: [email protected]. This information is intended for general
information only. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as
to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health
Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use.
Issue 15: October 2016
Drugs and Therapeutics Backgrounder
Alberta Health Services Formulary Products Containing Acetaminophen
Acetaminophen is available in various dosage forms including tablets, oral solutions, and suppositories.
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N.B. Many non-formulary products, used by patients outside of hospital, contain acetaminophen. Examples include Tylenol
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Arthritis, Tylenol No. 1, Tylenol with Codeine No. 4, Robaxacet , and numerous other non-prescription cough and cold
products. Thoroughly review all medications for acetaminophen content if a patient requests to use their own medication(s)
while in hospital.
Table: AHS Drug Formulary combination acetaminophen products intended for adult use
Product Name
®
Percocet
Active Ingredients
Strength
Acetaminophen
Oxycodone
325 mg/tab
5 mg/tab
®
Acetaminophen*
Codeine
Caffeine
300 mg/tab
15 mg/tab
15 mg/tab
®
Acetaminophen*
Codeine
Caffeine
300 mg/tab
30 mg/tab
15 mg/tab
Acetaminophen
Tramadol
325 mg/tab
37.5 mg/tab
Tylenol with Codeine
No. 2
Tylenol with Codeine
No. 3
Tramacet
®#
Single-ingredient opioid formulary alternatives
Oxycodone immediate release tablets
 5 mg
 10 mg
 20 mg
Codeine immediate release tablets
 15 mg
 30 mg
Codeine syrup
Codeine immediate release tablets
 15 mg
 30 mg
Codeine syrup
No formulary alternative.
Tramadol products are available upon hospital discharge for
outpatients.
#Formulary restricted to the treatment of postoperative pain in patients 18 years of age or older; OR continuation of therapy for patients initiated on
acetaminophen-tramadol prior to admission to an AHS inpatient facility
*Atasol® brand contains 325 mg of acetaminophen per tablet
References
1. Civan, Jesse M, Victor Navarro, Steven K Herrine, Jeffrey M Riggio, Paul Adams, and Simona Rossi. 2014. “Patterns of Acetaminophen Use Exceeding 4
Grams Daily in a Hospitalized Population at a Tertiary Care Center.” Gastroenterology & Hepatology 10 (1). Millenium Medical Publishing: 27–34.
http://www.ncbi.nlm.nih.gov/pubmed/24799836.
2. Government of Canada, Health Canada, Health Products and Food Branch, Health Products and Food Branch Marketed Health Products Directorate. 2015.
“Summary Safety Review - Acetaminophen - Liver Injury.” Accessed August 24, 2016. http://www.hc-sc.gc.ca/dhp-mps/medeff/reviews-examens/acetaminoeng.php.
3. National Council for Prescription Drug Programs. 2016. “NCPDP Recommendations for Dose Accumulation Monitoring in the Inpatient Setting:
Acetaminophen Case Model, Version 1.0.” American Journal of Health-System Pharmacy 73 (15). American Society of Health-System Pharmacists: 1144–65.
doi:10.2146/ajhp160215.
4. Zhou, Li, Saverio M. Maviglia, Lisa M. Mahoney, Frank Chang, E. John Orav, Joseph Plasek, Laura J. Boulware, et al. 2012. “Supratherapeutic Dosing of
Acetaminophen Among Hospitalized Patients.” Archives of Internal Medicine 172 (22). American Medical Association: 1721.
doi:10.1001/2013.jamainternmed.438.
Prepared by: Joseph Blais, Clinical Pharmacist, University of Alberta Hospital
Reviewed by: Humeira Dhanji, Clinical Nurse Specialist, Acute Pain Service, Foothills Medical Centre
Dr. Dean Karvellas, Associate Professor of Medicine, Division of Gastroenterology and Critical Care Medicine, University of Alberta
Medication Quality and Safety Team, Pharmacy Services
© 2016 Alberta Health Services, Drug Utilization & Stewardship, Pharmacy Services. All rights reserved. Permissions contact: [email protected]. This information is intended for general
information only. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as
to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health
Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use.