A Cochrane review included 10 small and low-methodological quality randomised trials, one quasi-randomised study, and 48 observational studies. Activated charcoal, gastric lavage, and ipecac were able to reduce the absorption of paracetamol but the clinical benefit was unclear. Of these, activated charcoal seemed to have the best risk-benefit ratio. N-acetylcysteine seemed preferable to placebo/supportive treatment, dimercaprol and cysteamine, but N-acetylcysteine's superiority to methionine was unproven. N-acetylcysteine may reduce mortality in patients with fulminant hepatic failure (Peto OR 0.26, 95% CI 0.09 to 0.94, one trial). It is not clear which N-acetylcysteine treatment protocol offers the best efficacy. No strong evidence supports other interventions for paracetamol overdose. Liver transplantation has the potential to be life-saving in fulminant hepatic failure, but refinement of selection criteria for liver transplantation and evaluation of the long-term outcome are required.
Comment: The quality of evidence is downgraded by potential reporting bias (only few small trials reported).