Bedside Snapshot

Use It For: Oral ingestion of an adsorbable drug, up to about 6 hr for many poisons (sooner is better); repeat doses for theophylline, phenobarbital, carbamazepine, phenytoin, cardiac glycosides, colchicine
Adult Dose: Single dose: 25–100 g PO, mixed with water (NG only if the airway is already protected)
Repeat doses: toxicology-directed, no fixed max
Pediatric Dose: Under 1 yr: 1 g/kg PO (no max; NG only if airway protected); 1–12 yr: 25–50 g fixed (not per kg), so a child under about 25 kg needs poison-center advice first. Sorbitol product not for under 1 yr or under 32 kg
Onset / Duration: Adsorption in gut: immediate, less effective as time passes. Sorbitol (if directed): catharsis in 1–1.5 hr, lasting 8–12 hr. Not absorbed
Do Not Give / Hold If: Unprotected airway or not fully conscious; known ileus or bowel obstruction; turpentine, corrosives or petroleum distillates ingested (unless directed)
Watch For: Vomiting and aspiration (airway obstruction, pneumonitis); black stools (expected); heavy sorbitol diarrhea with dehydration and hypernatremia; absent bowel sounds with repeated doses
Reversal / Rescue: No antidote: protect the airway, suction, oxygen and ventilation per protocol; replace fluid and check sodium after heavy catharsis
Must Remember: Airway first, then choose the agent: charcoal does not bind iron, lithium, alcohols, metals or caustics, and it is never given into an unprotected airway

Indications

Emergency & Prehospital

Oral ingestion of a charcoal-adsorbable drug: the 2026 consensus supports a single dose after salicylates, paracetamol (acetaminophen), tricyclic antidepressants, beta-blockers, calcium-channel blockers, cardiac glycosides, opioids, SSRIs and sulfonylureas, among others
Early presentation of a potentially toxic oral ingestion: the benefit drops as time passes. Earlier is better. The one-hour mark comes from older position papers (1997, 2005).

ED / ICU / Transport

Single dose beyond 1 hr: for selected poisons, up to about 6 hr after many ingestions, once an individualized risk assessment is done. This is off-label against the older one-hour rule (2026 consensus).
Ongoing absorption: the drug keeps coming. Think pharmacobezoar, certain modified-release products, or a drug burden above its solubility. Charcoal may be given beyond 6 hr for GI decontamination.
Enhanced elimination (multiple-dose charcoal): carbamazepine, cardiac glycosides, colchicine, dapsone, phenobarbital, phenytoin, thallium and theophylline
Completing decontamination (one extra dose): carbamazepine, paracetamol, paraquat, phenobarbital, salicylates, thallium, theophylline, valproic acid and verapamil

Other Uses

Not a treatment for toxic alcohols, lithium, iron or metals: charcoal has no role here (2026 consensus). Details are under Contraindications & Precautions.

Dosing & Administration

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

ACTIDOSE with Sorbitol: ready-to-use suspension, 25 g activated charcoal with 48 g sorbitol in a 120 mL tube. Sorbitol is a cathartic. Skip it unless toxicology specifically directs. Routine cathartic use adds no proven benefit (AACT/EAPCCT).
ACTIDOSE-Aqua: ready-to-use suspension without sorbitol, 25 g in a 120 mL tube. The label also lists 15 g (72 mL) and 50 g sizes. This is the product to pick for single and repeat doses.

Adult Dosing

Indication	Dose & Route	Repeat / Max	Notes
Single dose after oral ingestion of an adsorbable drug	25–100 g PO, mixed with water (NG only if the airway is already protected)	One dose; max 100 g per dose (USP DI range); no repeat unless toxicology directs	Fixed adult amount, not weight-based. The in vitro target of 10:1 charcoal to drug is impractical in overdose (label). Give as early as possible.
Multiple-dose charcoal (enhanced elimination)	Toxicology-directed dose and interval, PO (NG only if the airway is already protected). Regimen not specified here: no verified multiple-dose regimen was found for this page.	No fixed max: toxicology-directed regimen	Use plain charcoal (ACTIDOSE-Aqua, no sorbitol) for repeat doses. The sorbitol product is not recommended during multiple-dose charcoal (label). Monitor bowel sounds.

Pediatric Dosing

Indication	Dose (per kg) & Route	Max Single / Max Total	Notes
Single dose, under 1 year	1 g/kg PO (actual body weight; NG only if the airway is already protected)	No maximum stated in source	USP DI 1997 regimen. The sorbitol product is not recommended under 1 yr.
Single dose, 1–12 years	25–50 g PO (fixed amount, not per kg; protocol-dependent; NG only if the airway is already protected)	50 g per dose	Call poison control (1-800-222-1222) before giving to any child under about 25 kg. At 25 g, a 10 kg child receives 2.5 g/kg, more than twice the 1 g/kg dose used under age 1. Sorbitol product not for children under 32 kg.
Multiple-dose charcoal, children	Toxicology-directed	No fixed max: toxicology-directed	Sorbitol excess risks hypernatremic dehydration. Use with toxicology input only.

Pediatric aspiration data: A Spanish registry substudy covered 517 children under 7 years who got charcoal, 32% by nasogastric tube. Not one had a reported pulmonary aspiration. Still, the table above and the airway rule set the dose.

Preparation & Administration

Shake: shake the container well before use (label: at least 30 seconds).
Dilution: squeeze into a cup with at least 4 oz (120 mL) of liquid, or connect to a charcoal administration set. The OTC label says 20–30 g in at least 8 oz (240 mL). The table above sets the clinical dose.
Additives: syrup, dairy and supplements may reduce adsorption, so do not add them (label).
Flush: rinse the container and give the residue so the full dose is delivered (label).
Line: oral when the patient is alert and protecting the airway. Use an NG or OG tube only where the airway is already protected, such as after intubation for another indication. Do not place one just to give charcoal to a patient who is not intubated (2026 consensus).
Light and storage: keep it at room temperature, 20–25°C (68–77°F). The label says do not refrigerate.

Dosing Notes:

Most cases start with one dose. The 2026 consensus allows timing past 1 hr for selected poisons.
Under 1 year, dose on actual body weight: 1 g/kg.
The OTC consumer label (20–30 g) is for lay use. It cannot stand in for the clinical range.
Do not give the sorbitol product to children under 1 year or under 32 kg. Young children get sorbitol cathartic doses only when they are hospitalized (label).
Timing: a single dose is generally appropriate up to about 6 hr after many ingestions (2026 consensus). Sooner is better.

Contraindications & Precautions

Contraindications

Unprotected airway: no charcoal unless the airway is intact or protected (AACT/EAPCCT position paper).
Not fully conscious: do not use it unless a health professional directs it (label).
Known ileus or bowel obstruction: a relative clinical contraindication. Antiperistalsis can cause obstruction.
Turpentine, corrosives or petroleum distillates ingested: do not use it unless a health professional directs it (label).
Sorbitol product: not for under 1 year, under 32 kg, dehydration or fructose intolerance; not during multiple-dose charcoal (label).

Precautions

Aspiration: vomiting and aspirated charcoal can obstruct the airway, cause pneumonitis and lead to death. Bronchiolitis obliterans has been reported weeks later (label).
Corrosive ingestion: charcoal may blur the endoscopic view of the injury. Use with caution, if at all.
Agents it does not bind: charcoal has no role for arsenic, caesium, copper, ethanol, methanol, ethylene glycol, iron, lead, lithium or metformin (2026 consensus). Low-molecular-weight alcohols, metals and lithium adsorb poorly (label).
Intubation for charcoal: do not intubate solely to give charcoal when significant toxicity is not expected. If it is expected, weigh the risk of intubation against the benefit with toxicology (2026 consensus).
Pregnancy and lactation: safe use is not established. Use only when the benefit justifies the risk (label).

Hold / Reassess If

Decreasing consciousness or a failing airway: stop; secure the airway per protocol before any further dose.
Vomiting or coughing during or after administration: stop, suction and reassess aspiration risk.
Absent bowel sounds or abdominal distension: hold repeated doses and evaluate for ileus.

Aspiration trap: reduced consciousness lets charcoal reach the lungs, and that can be serious. Secure the airway before you give it. Do not force a dose on an unprotected patient.

Adverse Effects & Toxicity

Common

Black stools: expected after charcoal. Black stool alone does not mean bleeding (label).
Vomiting: in a Canadian cohort of poisoned patients over age 5, it was the most common side effect (20.8%).
Diarrhea: comes with the sorbitol product, which is a cathartic.
Gritty texture: sorbitol cuts the grit and improves the taste (label).

Serious / Life-Threatening

Effect	Recognition	Management
Pulmonary aspiration	Cough, desaturation, crackles, new infiltrate after a dose	Stop; suction; oxygen and ventilation per protocol; treat as aspiration pneumonitis. Aspiration in the 2026 review: 1–4% after intubation with charcoal.
Hypernatremic dehydration	Heavy diarrhea, lethargy, thirst, hypernatremia (sorbitol product, especially in children)	Check sodium and volume status; replace fluid per protocol; avoid repeated sorbitol doses.
Ileus or bowel obstruction	Distension, vomiting, absent bowel sounds (more with repeated doses)	Hold further doses; evaluate for obstruction per clinician.
Intubation complications (only if intubated to give charcoal)	Hypotension (1.5–11.8%), desaturation (3.4–7.1%), cardiac arrest (0.4%) across poisoned-patient studies	The 2026 consensus advises against intubation solely for charcoal in patients not expected to develop significant toxicity. Use RSI and monitoring per protocol if airway is indicated for another reason.

Overdose & Toxicity Management

Charcoal itself: there is no specific antidote. Aspiration, catharsis and fluid or electrolyte loss are the main risks.
Repeated sorbitol: check sodium and volume status, and replace fluid per protocol.
Co-ingestant toxicity: treat the drug's own toxicity first. See the matching toxidrome or condition page, such as acetaminophen toxicity.

Monitoring

Parameter	When / How Often	Target / Act If
Clinical
Airway and consciousness	Before each dose, and during and after administration	Not fully conscious or airway unprotected: do not give. Decline in consciousness: stop and secure the airway
Vomiting or cough	During and after administration	Vomiting or coughing: stop, suction and reassess airway
Bowel sounds and abdomen	Before each repeat dose in multiple-dose therapy (label)	Absent sounds or distension: hold further doses, evaluate for ileus
Laboratory
Sodium (Na⁺)	After heavy sorbitol-related diarrhea or repeated cathartic doses	High sodium or signs of dehydration: correct per protocol
Drug Levels
Acetaminophen level, digoxin level	Per the toxin's own timing and monitoring	Use the drug-specific level and its page to guide therapy; charcoal does not change the level target

Interactions & Compatibility

Drug / Class	Effect	What To Do
Oral antidotes (for example oral acetylcysteine)	Charcoal may adsorb oral antidotes and reduce their effect	Check the antidote's page; toxicology decides the order and timing of charcoal and the antidote
Repeated sorbitol (cathartic)	Excess catharsis, dehydration and electrolyte loss	Routine sorbitol adds risk without proven benefit; use plain charcoal (ACTIDOSE-Aqua) for single and repeat doses; sorbitol only if toxicology directs, never during multiple-dose charcoal
Antiperistaltic toxins (anticholinergics, opioids)	Slow transit; higher obstruction risk with repeated doses	Monitor bowel sounds; hold repeated doses if distension
Corrosives (ingested, needing endoscopy)	Charcoal obscures endoscopic view of injury	Use with caution, if at all; coordinate with endoscopy
Co-ingested alcohols, iron, lithium, metals	Not adsorbed; charcoal does not treat these	Do not use charcoal for these; use the specific antidote or treatment

Charcoal is not given IV, so there are no IV compatibility issues to check.

Special Populations

Pediatrics: under 1 year, 1 g/kg, and the sorbitol product is not recommended. Ages 1–12 years get a fixed 25–50 g (see Pediatric Dosing). In small children that fixed amount can exceed 1 g/kg, so call poison control first. Aspiration is the main concern. Intubation adverse events seem more common in children (2026 consensus), so weigh intubation for charcoal carefully.
Neonates: safe use is not established in neonates. Use only with toxicology input.
Pregnancy: charcoal is not absorbed into the body, but safe use in pregnancy is not established. Use it when the benefit justifies the risk (label: no teratogenic effects noted in rabbits or rats).
Lactation: not absorbed into the body. The label says safe use is not established and advises use only when the benefit justifies the risk.
Older Adults: sedation and aspiration risk are higher. This reference does not address AGS Beers Criteria status.
Renal Impairment: no renal adjustment is established. After sorbitol cathartic doses, monitor fluid and electrolytes.
Hepatic Impairment: no specific adjustment is established.
Obesity / Dosing Weight: the adult dose is a fixed amount. Under 1 year, the pediatric dose runs on actual body weight (1 g/kg).

Field & Transport Considerations

Scope: whether charcoal is given depends on state and agency protocol. Give it only on poison control or medical direction advice. Routine prehospital use is discouraged (AACT/EAPCCT position papers). Poison Help: 1-800-222-1222.
Storage & Stability: keep it at 20–25°C (68–77°F). Do not refrigerate. Keep tubes away from heat and direct light (label).
Carried Concentration: Ready-to-use tubes. The sorbitol product and ACTIDOSE-Aqua look alike, so read the label before you grab one. Sorbitol (48 g per 25 g tube) is a cathartic.
Infusions in Transport: not applicable.
Altitude / Environment: not applicable.
Handoff Essentials: the agent and time of ingestion, time and dose of charcoal (grams), sorbitol given, vomiting or aspiration, airway status, and stool output.

Clinical Pearls

The one-hour mark is not a hard cutoff: The 2026 consensus supports a single dose past 1 hr for selected poisons, and up to about 6 hr for many, once the risk is assessed case by case. Earlier still wins. The 1997 and 2005 position papers used 1 hr.

Airway before charcoal: an unprotected airway or reduced consciousness rules charcoal out. Do not intubate just to give it to a patient who is not expected to develop significant toxicity (2026 consensus).

Charcoal does not bind everything: it has no role for iron, lithium, ethanol, methanol, ethylene glycol, lead, arsenic or metformin (2026 consensus). Skip it for caustics or hydrocarbons unless directed.

Sorbitol vs ACTIDOSE-Aqua:

Sorbitol adds risk with no proven benefit. Choose plain charcoal (ACTIDOSE-Aqua) for single and repeat doses
Sorbitol product: not for under 1 yr or under 32 kg, and not during multiple-dose charcoal

Black stool is expected: Charcoal turns the stool black. It turns gastric returns black too, and that hides blood. Judge bleeding by the patient's hemodynamics and hemoglobin, not by color.

Exam discriminator: charcoal adsorbs many organic drugs. It does not adsorb low-molecular-weight alcohols, iron, lithium or metals. Those are the classic no-charcoal answers.

Pharmacology

Mechanism of Action

Adsorbent, not absorbed: it binds drugs and toxins in the gut in a reversible equilibrium. The complex leaves in the stool.
Molecular weight: it works best on substances of about 100–1,000 Daltons (label).
Dose ratio: the in vitro target is 10:1 charcoal to drug. That is impractical in overdose (label).
Desorption: there is limited evidence that a toxin can come back off the charcoal in the gut. That is why repeated cathartic doses are used with care.

Pharmacokinetics

Route	Onset	Peak	Duration
PO / NG (adsorption)	Adsorbs immediately in solution (label)	Not applicable: not absorbed	Until excreted in stool; limited by transit
Sorbitol (cathartic)	About 1–1.5 hr (volunteers); average 7.7 hr in one series of poisoned patients (not verified against full text)	Not applicable	8–12 hr (volunteers)

Half-life: not applicable. Charcoal is not absorbed.
Metabolism: none. Charcoal is not metabolized.
Elimination: in stool, carrying the adsorbed substances with it. Black stools are expected.
Protein binding / Vd: not applicable.

Names & Classification

Generic Name: Activated charcoal
Brand Names: ACTIDOSE with Sorbitol; ACTIDOSE-Aqua (US, OTC poison adsorbents)
Pharmacologic Class: Oral adsorbent (not absorbed)
Therapeutic Class: Antidote adjunct; gastrointestinal decontamination agent
Controlled Substance: Not controlled
ISMP High-Alert: No
Look-Alike / Sound-Alike: None commonly reported (the sorbitol and Aqua tubes look alike)

References

Padagis US LLC. (2026). ACTIDOSE with Sorbitol and ACTIDOSE-Aqua activated charcoal suspension, OTC Drug Facts labels (DailyMed, label date July 2026). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=76e4fe6a-afd4-4f68-b12d-0b094f750615; https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c85dc235-3f42-4361-9bd2-1aaff798ad75. Also the repackaged Actidose label text (HF Acquisition Co, DailyMed, source of the sorbitol age and weight cautions): https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7da3506f-2799-434c-e053-2a91aa0adabb
American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. (2004). Position paper: cathartics. Clin Toxicol (Phila). https://doi.org/10.1081/clt-120039801
Hoegberg LCG, Gosselin S, Buckley NA, Wood DM, et al. (2026). Recommendations from the Clinical Toxicology Recommendations Collaborative on the administration of activated charcoal in acute oral overdose. Clin Toxicol (Phila) 64(6):419–475. https://doi.org/10.1080/15563650.2025.2609807
Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, et al. (2021). Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 59(12):1196–1227. https://doi.org/10.1080/15563650.2021.1961144
Ramirez-Romero J, Cifuentes Zamalloa C, Elorza Elena A, et al. (2025). Pulmonary aspiration after activated charcoal in unintentional acute poisonings in childhood. Arch Dis Child 110(7):510–513. https://doi.org/10.1136/archdischild-2024-327478
Gilbert S, St-Onge M, Neveu X. (2025). Use of activated charcoal in poisoned patients aged over 5 years. Can J Emerg Med 27(5):373–380. https://doi.org/10.1007/s43678-025-00881-x
Chyka PA, Seger D, Krenzelok EP, Vale JA; American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. (2005). Position paper: single-dose activated charcoal. Clin Toxicol (Phila) 43(2):61–87. https://doi.org/10.1081/clt-200051867
American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. (1997). Position statement: single-dose activated charcoal (source of the USP DI 1997 oral regimen cited in the pediatric table). J Toxicol Clin Toxicol 35(7):721–741. https://doi.org/10.3109/15563659709162569

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Activated Charcoal