Agreement: I Agree Body: Dear Editor Paracetamol (Acetaminophen) is an effective, mild analgesic, antipyretic agent and probably the most widely used drug in the world because of its low cost and easy availability. The most important complication of a major overdose of paracetamol is paracetamol induced liver disease(PILD) and Acute renal failure in very small proportion, but only a small minority of patients are at risk. Some 25 years ago before effective antidotal therapy became generally available, less than 10% of patients referred to the hospital with paracetamol poisoning developed severe liver damage and hepatic failure (1). While in older children it is usually intentional and suicidal, in younger children it is accidental(2). Acute paracetamol poisoning is a straightforward problem. Paracetamol is one of the agents frequently used for suicide. Activated charcoal seems the best choice to reduce absorption. In India, paracetamol is available in various strengths and preparations such as suspension, drops, tablets, injections, and suppositories as well as in combination with other analgesics. There is very little data on accidental PILD in India . Parental anxiety about high fever and febrile seizures leads them to use paracetamol even when not indicated. Availability as an over-the-counter medication allows indiscriminate use in practice. PILD is a treatable medical emergency and this makes early diagnosis very crucial. There are few laboratories in a vast country like India involved in diagnosis. In an Indian study, 13% of all poisonings in children were attributed to paracetamol(3). Medication errors are a serious problem in children, both in the hospital setting and in ambulatory practice. However there is greater awareness about medication safety today. Massive paracetamol overdoses have been reported occasionally in the literature, with variable outcomes. Patient do not develop acute liver failure despite a massive overdose and a long delay between ingestion and antidote administration. The pharmacogenetics of paracetamol metabolism of the patient might play a role in the favorable prognosis. Furthermore, there is a need to shed light on the ease of accessibility to large amounts of over-the-counter medications for the general public in India. Since diagnosis through laboratory tests remain a challenge preventive strategy should out do the curative one and , public health measures that restrict the availability of paracetamol, such as reducing non-prescription pack sizes, are needed to stanch such cases of massive paracetamol overdoses. As remedial measures for prevention, healthcare givers advocate paracetamol use only “as necessary” rather than round the clock. This needs parental education that fever in a child is not a cause for panic and that febrile seizures are not as common as they think. Color coding of different strengths and labeling the dose in bold letters on bottles containing drops are suggestions endorsed by care givers. Others advocate a ban on paracetamol drops and strengths above 250 mg/5 ml. The acetaminophen hepatotoxicity working group of the Food and Drug Administration has recommended improved packaging to facilitate delivery of an appropriate dose as a practical intervention(4). A better suggestion is that paracetamol preparations for children be removed as an over-the-counter medication. The research results indicate a need to address an issue of great importance, both preventable by simple measures as well as treatable if diagnosed early. Prospective studies are required to assess the exact extent and severity of paracetamol poisoning . references: 1. Patnakar MS, Bhagwat VR et al; , Paracetamol poisoning : A case report, IJSR ;2014, 10(3); 72-75 2. Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with acetaminophen: hepatoxicity after multiple doses in children. J Pediatr 1998;132(1):22–27. 3. Lakshmi M, Radhika R. Analysis of acetaminophen toxicity in children in a tertiary care setting. Indian J Trauma Emerg Pediatr 2013;5:5–8 4.The Acetaminophen Hepatotoxicity Working Group, Centre for Drug Evaluation and Research, Food and Drug Administration. Recommendations for FDA Interventions to Decrease the Occurrence of Acetaminophen Hepatotoxicity. Rockville, MD, United States; 2008. [accessed 2020 May 17]. Available from: www.fda.gov/ohrms/dockets/ac/09/briefing/2009-4429b1-02-FDA.pdf No competing Interests: Yes The following competing Interests: Electronic Publication Date: Thursday, September 24, 2026 - 06:44 AI use: No, I have not used AI Highwire Comment Subject: Management of paracetamol (acetaminophen) toxicity Workflow State: Released Full Title: Re: Management of paracetamol (acetaminophen) toxicity Highwire Comment Response to: Management of paracetamol (acetaminophen) toxicity Check this box if you would like your letter to appear anonymously:: Last Name: Singh First name and middle initial: Prabhakar Email: Prabhakar.singh@aiims.edu Address: Associate Professor, SAIF, Department of Anatomy, AIIMS, New Delhi India Occupation: Associate Professor, SAIF, Department of Anatomy Other Authors: Nishat Ahmad, Professor and Program Director, WAPSI Affiliation: AIIMS, New Delhi India BMJ: Additional Article Info: Rapid response