Paracetamol is one of the most widely used over-the-counter analgesic and antipyretic drugs, considered safe at therapeutic doses. However, it is also one of the leading causes of drug-induced liver injury worldwide.
Why it’s dangerous:
• At high doses, the liver’s normal metabolism (glucuronidation and sulfation) becomes saturated.
• More drug gets metabolized via the CYP450 pathway into NAPQI (N-acetyl-p-benzoquinone imine): a toxic metabolite.
• Normally, glutathione neutralizes NAPQI. But in overdose, glutathione stores are depleted → leading to hepatocellular necrosis and acute liver failure.
Toxic dose:
→ Adults: >150 mg/kg (or >7.5 g in a single ingestion)
→ Children: >200 mg/kg.
Clinical features (stages):
1. 0–24 hrs: Nausea, vomiting, malaise, diaphoresis.
2. 24–72 hrs: Right upper quadrant pain, rising liver enzymes.
3. 72–96 hrs: Peak liver injury, jaundice, coagulopathy, encephalopathy.
4. >5 days: Recovery (if survived) or death.
Management:
N-acetylcysteine (NAC): The antidote; replenishes glutathione. Most effective if given within 8–10 hours of ingestion.
Activated charcoal: If patient presents within 1–2 hours.
Liver transplant: In severe acute liver failure (King’s College criteria).
Why it matters:
→ Easy accessibility of paracetamol makes accidental and intentional overdoses common.
→ Many people are unaware of “hidden paracetamol” in combination drugs (cold remedies, painkillers).
→ Public awareness and strict regulation on maximum pack size (as done in some countries) can reduce poisoning cases.
Do you think restricting OTC paracetamol pack sizes (like in the UK) could be an effective public health measure in countries like India, or should the focus be more on awareness and antidote availability?
MBH/AB