Fomepizole Therapy for Acetaminophen-Induced Liver Failure in an Infant

Acetaminophen overdose is common in the pediatric population. N-acetylcysteine (NAC) is effective at preventing liver injury in most patients when started shortly after the overdose. Delays to therapy increase risk of hepatotoxicity and liver failure that may necessitate organ transplant. Animal stu...

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Bibliographic Details
Published in:Pediatrics (Evanston) 2023-10, Vol.152 (4)
Main Authors: Pepin, Lesley, Matsler, Nikolaus, Fontes, Andrew, Heard, Kennon, Flaherty, Brian F., Monte, Andrew A.
Format: Article
Language:English
Subjects:
Acetaminophen
Acetylcysteine
Analgesics
Antidotes
Case reports
Cell death
Clinical trials
Hepatotoxicity
Liver
Liver failure
Metabolic pathways
Overdose
Oxidative stress
Pediatrics
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Summary:Acetaminophen overdose is common in the pediatric population. N-acetylcysteine (NAC) is effective at preventing liver injury in most patients when started shortly after the overdose. Delays to therapy increase risk of hepatotoxicity and liver failure that may necessitate organ transplant. Animal studies have demonstrated fomepizole may provide added benefit in acetaminophen overdose because of its ability to block the metabolic pathway that produces the toxic acetaminophen metabolite and downstream inhibition of oxidative stress pathways that lead to cell death. Several adult case reports describe use of fomepizole in patients at higher risk for poor outcomes despite NAC. We describe a case of a 7-month-old female who presented in acute liver failure with persistently elevated acetaminophen concentration secondary to repeated supratherapeutic doses of acetaminophen to manage fever. Fomepizole and NAC antidotes were used in the management of the patient. She fully recovered despite demonstrating multiple markers of poor outcome on initial presentation. Although randomized trials are lacking, this case suggests that fomepizole may safely provide additional benefit in pediatric patients at risk for severe acetaminophen toxicity.
ISSN:0031-4005
1098-4275
DOI:10.1542/peds.2022-061033