Paracetamol Management and Safety
Published: 03 April 2022
Published: 03 April 2022
Paracetamol is the most commonly used medicine in Australia (Healthdirect 2019).
It’s also the most frequently overdosed medicine, the most common reason for calling poisons centres, the top cause of acute liver failure in Western countries, and was responsible for over 95,000 hospitalisations and 200 deaths in Australia between 2007-08 and 2016-17 (Cairns 2019; Cairns et al. 2019).
While paracetamol is considered safe and effective if used as directed, taking more than the recommended dose or overdosing, can be dangerous and in severe cases, fatal (Healthdirect 2019).
With paracetamol being such a widespread and frequently-used medicine, it’s crucial for healthcare professionals to be able to understand the potential dangers of paracetamol misuse and recognise and respond to the signs of overdose safely.
Paracetamol, also known as acetaminophen, is an analgesic medicine used to reduce fever and manage mild to moderate acute or chronic pain. It’s a first-line treatment recommended for pain that can’t be managed using non-pharmacological methods (e.g. rest, ice or heat packs) (Healthdirect 2020; NPS MedicineWise 2019).
Paracetamol is typically preferred to non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen when treating mild to moderate pain as it has less adverse effects (AMH 2022).
Paracetamol may be used to manage a variety of ailments. Examples include:
(Healthdirect 2020)
Paracetamol comes in a variety of forms, including:
(ADF 2021)
According to the Therapeutic Goods Administration (2019):
Recommended dose | Maximum amount in one 24-hour period | |
Adults and children over 12 years | 500 mg to 1 g every four to six hours as required | 4 g |
Children aged 1 month to 12 years | 15 mg per kilogram of the child’s body weight, every four to six hours as required | Four doses |
When administering paracetamol:
(TGA 2019)
According to the Guidelines for the Management of Paracetamol Poisoning in Australia and New Zealand, paracetamol overdose in adults is characterised by either:
(Chiew et al. 2019)
Paracetamol has potentially hepatotoxic properties - that is, it’s capable of causing liver injury or damage (Paniagua & Amariles 2017). This is due to a toxic metabolite known as N-acetyl-p-benzoquinone imine (NAPQI), which forms after paracetamol is administered and can cause damage to liver cells. NAPQI can be detoxified by a substance called glutathione in the liver, however, excessive amounts of paracetamol use up the glutathione stores, allowing NAPQI to accumulate and cause liver damage (Long 2020; Willacy & Tidy 2020).
This can lead to liver failure, which is potentially fatal (Willacy & Tidy 2020).
Read: Acute Management of Poisoning
Paracetamol overdose may be intentional or accidental (Cairns 2019).
Intentional poisoning, wherein an individual knowingly takes an excessive amount of paracetamol as a form of self-harm, accounts for most (about three-quarters) of paracetamol overdose cases (Cairns 2019).
Accidental overdose may occur for a variety of reasons but is often associated with children finding and ingesting paracetamol being kept in the home (NPS MedicineWise 2019). Other causes of accidental overdose include:
(Cairns 2019; NPS MedicineWise 2019)
Both intentional and accidental paracetamol overdose may be associated with the way in which paracetamol is sold. In Australia, paracetamol can be purchased outside of pharmacies (e.g. in supermarkets). If bought from a pharmacy, paracetamol can be purchased in packs of 100 over the counter without requiring consultation with a pharmacist. There’s also no legal restriction on how many packs of paracetamol someone can purchase at once (NPS MedicineWise 2019).
On the other hand, in the UK, where in 1998 paracetamol was legislated to have a maximum pack size of 32 tablets in pharmacies and 16 tablets in non-pharmacies, deaths from paracetamol overdose have reduced by about 43% (Hawton et al. 2013).
Another contributing factor is the narrow margin between paracetamol’s maximum daily dose and the amount needed to cause overdose (Better Health Channel 2021).
As long as it’s used at the recommended dose, paracetamol is safe for:
(Healthdirect 2020)
People who should seek advice before taking paracetamol include:
(Healthdirect 2020)
Certain medicines may not be safe to take alongside paracetamol as there is the potential for unpredictable reactions. These medicines include:
(NHS Inform 2021; Healthdirect 2020)
Note: Adults can take paracetamol alongside other analgesics that do not contain paracetamol, including ibuprofen, aspirin and codeine (NHS 2019).
Symptoms of paracetamol overdose often don’t appear until two to three days after the paracetamol was ingested. They might include:
(Better Health Channel 2021)
Note: Side effects of paracetamol are different to overdose symptoms and may include:
(ADF 2021; NHS Inform 2021)
Paracetamol overdose is a medical emergency. If someone you are caring for is displaying signs of paracetamol overdose, call 000 for an ambulance immediately. If someone has taken more than the recommended dose of paracetamol, even if they appear well and are displaying no symptoms, treatment must be commenced as soon as possible (Better Health Channel 2021; Healthdirect 2019).
If in doubt, always contact the national Poisons Information Centre on 131 126.
If the patient is in a critical state, they may require resuscitation, stabilisation and admission to the intensive care unit (Willacy & Tidy 2020).
Specific management of paracetamol overdose will depend on a number of factors, including:
(Long 2020)
As a very general rule:
(Chiew 2019; Better Health Channel 2022; PCH 2021)
Note: This is a very basic overview of treatment for paracetamol overdose. For comprehensive information and advice, refer to the Guidelines for the Management of Paracetamol Poisoning in Australia and New Zealand.
In order to reduce the risk of paracetamol overdose as much as possible:
(NPS MedicineWise 2019)
On a legislative level, paracetamol overdose may be reduced by restricting the sale of paracetamol by non-pharmacy retailers, as well as decreasing paracetamol package sizes (NPS MedicineWise 2019).
Paracetamol is extremely useful due to its availability, efficacy and safety when used according to directions. However, while paracetamol is easy to purchase and widely accessible, it’s important not to wrongly assume that there are no risks associated with this medicine.
Paracetamol overdose has caused thousands of hospitalisations and hundreds of deaths in Australia. In order to ensure paracetamol is used safely, it’s crucial to always follow the instructions on the packaging.
Question 1 of 3
Finish the sentence. Most cases of paracetamol overdose are …