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Recommendations from the Clinical Toxicology Recommendations Collaborative on the administration of activated charcoal in acute oral overdose

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Hoegberg, Lotte C. G., Gosselin, Sophie, Buckley, Nicholas A., Wood, David M., Shepherd, Greene, Hanley, James, Bates, Nicola, St-Onge, Maude, Caravati, E. Martin, Smith, Silas W., Shadnia, Shahin, Gudjonsdottir, Gudborg, Jiranantakan, Thanjira, Johnson, Jami, Olson, Kent R., Bédry, Régis, Eyer, Florian, Tse, Man Li, Chan, Wui Ling, Stolbach, Andrew, Lang, Eddy, Hoffman, Robert S.·2026·Clinical Toxicology
DOI 10.1080/15563650.2025.2609807
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Abstract

Introduction The Clinical Toxicology Recommendations Collaborative was established by three international clinical toxicology societies and tasked to produce recommendations on the management of poisonings. The Activated Charcoal in Clinical Toxicology Workgroup (the Workgroup) was formed to provide recommendations on the administration of activated charcoal for gastrointestinal decontamination and enhanced elimination in poisoning.Methods Based on a systematic review of the literature, 43 poisons or poison categories were selected for appraisal. Voting statements were drafted using a predetermined format. Strength of consensus was measured using the Disagreement Index as defined by the RAND/University of California at Los Angeles Appropriateness Method. A two-round modified Delphi method was used to reach expert consensus.Results The Workgroup concluded that there is no role for activated charcoal in poisoning from arsenic, caesium, copper, ethanol, methanol, ethylene glycol, iron, lead, lithium, and metformin. Activated charcoal is appropriate after ingestion of antidysrhythmics (types I and III not discussed specifically), beta-adrenergic antagonists, bupropion, calcium-channel blockers, carbamazepine, cardiac glycosides, chloroquine, cocaine, colchicine, cyanide, dapsone, diphenhydramine, disopyramide, factor Xa inhibitors, ibuprofen, isoniazid, lamotrigine, methotrexate, moclobemide, opioids, organophosphorus insecticides, paracetamol (acetaminophen), paraquat, phenobarbital, phenytoin, quinidine and quinine, salicylates, selective serotonin reuptake inhibitors, sulfonylureas, thallium, theophylline, tricyclic antidepressants, valproic acid, venlafaxine, and warfarin. An additional dose of activated charcoal to complete gastrointestinal decontamination is appropriate after ingestion of carbamazepine, paracetamol, paraquat, phenobarbital, salicylates, thallium, theophylline, valproic acid and verapamil. The maximum time post-ingestion for which activated charcoal administration is recommended differs for each poison and different formulations. According to an individualized risk assessment, activated charcoal is appropriate up to 6 h post-ingestion for many poisons. If ongoing absorption is suspected, which may occur, for example, with pharmacobezoar formation, certain modified-release preparations, or when drug burden exceeds the limits of solubility, then activated charcoal can be administered beyond 6 h post-ingestion for gastrointestinal decontamination. Multiple-dose activated charcoal for enhanced elimination is appropriate in poisoning with carbamazepine, cardiac glycosides, colchicine, dapsone, phenobarbital, phenytoin, thallium and theophylline.Use of endotracheal intubation to facilitate the administration of activated charcoal in patients who are conscious Before deciding to perform endotracheal intubation to assist with the administration of activated charcoal, every clinician needs to weigh the potential complications and adverse effects of this procedure against the toxicity expected to be prevented by the administration of activated charcoal. This is a challenging decision, and a local poison centre and/or a bedside toxicology consultation can assist with this decision. Endotracheal intubation is not a benign procedure and is associated with a high rate of various adverse events, such as new haemodynamic instability, severe hypoxaemia, and cardiac arrest, which seem more common in children. In three studies that evaluated the risks of endotracheal intubation in over 2,200 poisoned patients, the rates of hypotension were between 1.5% and 11.8%, desaturation between 3.4% and 7.1%, and cardiac arrest in 0.4%. The risk of aspiration following administration of activated charcoal after endotracheal intubation is reported to be low (1-4%). Therefore, the decision to endotracheally intubate a patient to administer activated charcoal needs to carefully assess the patient’s other comorbidities and the expected toxicity of the ingestion, which needs to be clinically significant to outweigh the risk of endotracheal intubation. Endotracheal intubation may also be considered if another treatment, such as haemodialysis or extracorporeal circulation, might be required or for transportation to another institution for ongoing clinical care. In these situations, for which endotracheal intubation has been performed for another indication, the risk-benefit will change in favour of activated charcoal administration. The following good practice statements were adopted to address the use of endotracheal intubation to facilitate the administration of activated charcoal.Endotracheal intubation should not be performed solely for the purpose of administration of activated charcoal in patients not anticipated to develop clinically significant complications of poisoning.In patients in whom endotracheal intubation is clinically indicated (e.g., compromised or unprotected airway, respiratory failure, significantly dimi

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Authors
Hoegberg, L. C. G., Gosselin, S., Buckley, N. A., Wood, D. M., Shepherd, G., Hanley, J., Bates, N., St-Onge, M., Caravati, E. M., Smith, S. W., Shadnia, S., Gudjonsdottir, G., Jiranantakan, T., Johnson, J., Olson, K. R., Bédry, R., Eyer, F., Tse, M. L., Chan, W. L., Stolbach, A., Lang, E., & Hoffman, R. S.
Affiliations
  • Department of Clinical Pharmacology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg
  • Université de Sherbrooke (CA)
  • The University of Sydney (AU)
  • King's College London (GB)
  • University of North Carolina at Chapel Hill (US)
  • Ochsner Medical Center (US)
  • Veterinary Poisons Information Service
  • Université Laval (CA)
  • University of Utah (US)
  • New York University (US)
  • Shahid Beheshti University of Medical Sciences (IR)
  • Faculty of Pharmaceutical Sciences, University of Iceland
  • University of Oklahoma (US)
  • California Poison Control System, University of California
  • Hôpital Pellegrin (FR)
  • Division of Clinical Toxicology and Poison Control Centre Munich, Department of Internal Medicine II, TUM School of Medicine, Technical University of Munich
  • Hospital Authority (HK)
  • Emergency Department, Khoo Teck Puat Hospital
  • Johns Hopkins University (US)
  • University of Calgary (CA)
Corresponding author
Gosselin, Sophie
ORCID
Venue
Clinical Toxicology
Publisher
Informa UK Limited
Published
2026-03-30
Volume
64
Issue
6
Pages
419-475
ISSN
  • 0009-9309 (ISSN-L)
  • 1556-3650
  • 1556-9519
DOI
10.1080/15563650.2025.2609807
OpenAlex
W7143471711
Cited by
7
References
426
Citations by year
2026: 7
FWCI
47.79
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Toxicology (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Emergency Medicine › Poisoning and overdose treatments
  • Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Plant-based Medicinal Research
  • Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Forensic Toxicology and Drug Analysis
Keywords
activated carbon, gastrointestinal decontamination, expert consensus recommendations, time to administration, pharmacobezoar, modified-release formulation, medication burden, paracetamol, salicylates, thallium, carbamazepine, phenobarbital, valproic acid, theophylline
MeSH terms
Systematic Reviews as Topic, Administration, Oral, Antidotes, Charcoal, Humans, Poisoning, Practice Guidelines as Topic, Drug Overdose

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