PM returned from a wrestling duel. PM weighs in at 104 lb. and is 17-years old.

Question

PM returned from a wrestling duel. PM weighs in at 104 lb. and is 17-years old. He is spending some time at home when he remarks, "My allergies are killing me." PM goes into the bathroom and comes out with a bottle of Benadryl Maximum Strength Severe Allergy and Sinus This is just what I need," says PM. "It says here that I shouldn't take more than 8 of these a day. OK, I'll take 8 that should take care of these allergies." Six days later, PM's mom walks into his room saying, "What's the matter? Why aren't up and getting ready for school?" PM replies, "I don't feel well. I've been throwing up and have had diarrhea all night." Hey, you look yellow - like really yellow!" screams PM's mom. "I'm going to take you to the emergency room now! When they arrive at the emergency room, the physician examines PM and asks about any recent medications he has been taking. PM tells the doctor that he was having problems with allergies and has been taking 8 tablets of Benadryl Maximum Strength Severe Allergy and Sinus every day for the past six days and no other medications The physician is very concerned and immediately orders some laboratory work. What is possibly the root cause of these signs and symptoms (etiology)? Could one of the active ingredients cause these, or was it the combination? What is the drug metabolism involved, and is it the ingested ingredient or the metabolite that is causing illness? There are a few possible dosing factors involved, which of these factors could be causing signs and symptoms compared to the combination of factors? How do these root causes lead to illness (pathophysiology)? How is this situation treated (pharmacology/therapy)? Be sure to discuss these altogether and any assumptions made in the conclusion.

Explanation / Answer

Benadryl maximum strength severe allergy sinus headache caplets have the following molecules as active ingredients –

Acetaminophen ( which acts as a pain reliever)
Diphenhydramine (which acts as a anti-histamine)
Pseudoephedrine (which acts as a nasal decongestant)

As per the label warnings, it is specifically written not to use more than the recommended dosage, and to consult a physician before starting the medication. The active ingredients in the drug usually cause drowsiness, and slightly dizzy feeling. Overdosing on the drug can lead to liver failure1.

At 17 years old, and 104 lbs, PM is young and underweight. Hence the criteria that maximum of 8 caplets can be taken per day would not be applicable in this case. It can therefore be assumed that PM was already overdosing on the caplets, when he was consuming 8 caplets every 24 hours. Moreover, from the information given, it would seem that PM consumed all the 8 tablets in a single dose, and did not spread them out to multiple doses over a period of time.

This would mean that there has been extreme pressure on PM’s liver to filter out the drug from his system. The drug which has most likely caused this is Acetaminophen, which is known to cause liver damage in higher doses. It has most likely lead to hepatic injury. Nausea, vomiting, and diarrhoea are the symptoms.

Now, old RBC’s travel to the liver to be broken down and bilirubin is formed as a result of this breakdown. A functional liver would convert the yellow bilirubin into urobilinogen and excreted through faeces and urine. When the liver is unable to function properly, bilirubin accumulates in the blood stream, and the person develops jaundice (as seen in the case of PM).

The laboratory tests ordered by the doctor would reveal the level of acetaminophen toxicity in PM’s body. The treatment would encompass emptying the stomach by gastric lavage method, or by using antidotes against acetaminophen like N-acetylcysteine (NAC). Additionally, activated charcoal can be administered to bind any drug remaining in the gastrointestinal tract.

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