Acetaminophen Use Concomitant with Long-Lasting Flucloxacillin Therapy: A Dangerous Combination

  • Luuk René van den Bersselaar Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
  • Judith Maria Dimphena van den Brule Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
  • Johannes Gerardus van der Hoeven Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands

Keywords

5-oxoproline, acetaminophen, flucloxacillin, anion gap, metabolic acidosis

Abstract

Acetaminophen and flucloxacillin both interfere with the ?-glutamyl cycle. Long-lasting concomitant use of flucloxacillin and acetaminophen can lead to 5-oxoproline accumulation and severe high anion gap metabolic acidosis. Females and patients with sepsis, impaired kidney and/or liver function, malnutrition, advanced age, congenital 5-oxoprolinase deficiency and supratherapeutic acetaminophen and flucloxacillin dosage are associated with increased risk. Therefore, a critical attitude towards the prescription of acetaminophen concomitant with flucloxacillin in these patients is needed.
We present the case of a 79-year-old woman with severe 5-oxoprolinaemia after long-lasting treatment with flucloxacillin and acetaminophen, explaining the toxicological mechanism and risk factors, and we make recommendations for acetaminophen use in patients with long-lasting flucloxacillin treatment.

VIEW THE ENTIRE ARTICLE

References

  • Gotland N, Uhre ML, Mejer N, Skov R, Petersen A, Larsen AR, et al. Long-term mortality and causes of death associated with Staphylococcus aureus bacteremia. A matched cohort study. J Infect 2016;73(4):346–357.

  • Donker T, Bosch T, Ypma RJ, Haenen AP, van Ballegooijen WM, Heck ME, et al. Monitoring the spread of meticillin-resistant Staphylococcus aureus in The Netherlands from a reference laboratory perspective. J Hosp Infect 2016;93(4):366–374.

  • Berbee JK, Lammers LA, Krediet CTP, Fischer JC, Kemper EM. Metabolic acidosis caused by concomitant use of paracetamol (acetaminophen) and flucloxacillin? A case report and a retrospective study. Eur J Clin Pharmacol 2017;73(11):1459–1465.

  • Dempsey GA, Lyall HJ, Corke CF, Scheinkestel CD. Pyroglutamic acidemia: a cause of high anion gap metabolic acidosis. Crit Care Med 2000;28(6):1803–1807.

  • Walker V, Mills GA, Anderson ME, Ingle BL, Jackson JM, Moss CL, et al. The acetaminophen metabolite N-acetyl-p-benzoquinone imine (NAPQI) inhibits glutathione synthetase in vitro; a clue to the mechanism of 5-oxoprolinuric acidosis? Xenobiotica 2017;47(2):164–175.
  • Published: 2020-04-23

    Issue: Vol 7 No 7 (view)

    Section: Articles

    How to cite:
    van den Bersselaar, L. R., van den Brule, J. M. D., & van der Hoeven, J. G. (2020). Acetaminophen Use Concomitant with Long-Lasting Flucloxacillin Therapy: A Dangerous Combination. European Journal of Case Reports in Internal Medicine, 7(7). https://doi.org/10.12890/2020_001569