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Three Part Question

[In overdose with aspirin or other non steroidals] is [gastric lavage better than charcoal or nothing] at [reducing toxicity]?

Clinical Scenario

A 53 year old widow attends the emergency department having taken 20 aspirin and 20 ibuprofen one and a half hours previously. You remember that non-steroidals slow gastric emptying and wonder whether gastric lavage would be of use in toxicity reduction.

Search Strategy

Medline 1966-05/04 using the OVID interface.
[{exp gastric lavage OR gastirc lavage.mp OR exp gastric emptying OR gastric emptying.mp OR exp irrigation OR lavage.mp OR empt$.mp OR irrigat$.af OR washout.af OR wash-out.af} AND {exp poisoning OR exp overdose OR exp suicide OR exp Self-Injurious Behavior/ OR poiso$.af OR overdos$.af OR suicid$.af OR (deliberate adj5 self adj5 harm).af OR dsh.af} AND {exp aspirin OR exp anti-inflammatory agents, non-steroidal OR salic$.af OR nsaid.mp OR ketoprofen.af OR diclofenac.af OR aceclofenac.af OR acemetacin.af OR azapropazone.af OR celecoxib.af OR dexketoprofen.af OR diflunisal.af OR etodolac.af OR fenbrufen.af OR fenoprofen.af OR flurbiprofen.af OR indometacin.af OR indomethacin.af OR ketoprofen.af OR mefenamic acid.af OR meloxicam.af OR nabumetone.af OR naproxen.af OR phenylbutazone.af OR piroxicam.mp OR exp piroxicam OR rofecoxib.af OR sulindac.af OR tenoxicam.af OR tiaprofenic acid.af}] LIMIT to Human AND English language.

Search Outcome

Altogether 72 papers found 71 of which failed to answer the three part question. A further reference was found after scanning of references. The 2 papers are shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Danel V et al, 1988, UK	12 healthy volunteers given 1.5g aspirin acting as own controls treated with nothing, charcoal and lavage	Prospective controlled study	Salicylate recovered in urine over 24h	Control 13.3% lavage 8.8% charcoal 7.0%	Statistical significance not assessed Dose fairly small Number of patients small
Lapatto-Reiniluoto O et al, 1999, Finland	9 healthy volunteers as own controls given 400mg ibuprofen. Treated with water (control), charcoal or charcoal followed by lavage	Prospective controlled trial	AUC plasma ibuprofen as % of control	Control 100% charcoal alone 70% (p<0.05) charcoal + lavage 51% (p<0.05) No statiscal significance between control groups	Small numbers Therapeutic ibuprofen dose

Comment(s)

There are no large scale trials performed in this area, however those that exist show that at best lavage is no better if not slightly worse than charcoal at reducing salicylate toxicity. Lavage although better than nothing has an element of risk involved in its practice and charcoal must therefore be treatment of choice.

Editor Comment

Search repeated on 8/11/03. No new papers found. For UK position statement on gastric lavage see http://www.spib.axl.co.uk/toxbaseindex.htm

Clinical Bottom Line

Gastic lavage is no better than charcoal alone at reducing toxicity following aspirin or NSAID overdose.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Danel V, Henry JA, Gluckman E. Activated charcoal,emesis and gastric lavage in aspirin overdose. BMJ 1988;296:1507.
2. Lapatto-Reinoluoto O, Kivisto T, Neuvonen PJ. Effect of activated charcoal alone or given after gastric lavage in reducing the absorption of diazepam, ibuprofen and citalopram. Br J Clin Pharmacol 1999;48:148-53.