detectability of drug tablets and capsules by plain radiography
TRANSCRIPT
Detectability of Drug Tablets and Capsules by Plain Radiography
RICHARD P. O’BRIEN, MD, PAUL A. McGEEHAN, MD, ALBERT W. HELMECZI, RPh, DAVID J. DULA, MD
This study was undertaken to determine the detectability of drugs in tablet or capsule form by plain radiography. A total of 459 drugs in tablet or capsule form were radiographed in water with parameters commonly used in routine upper abdominal films. Detectability was judged subjectively by radiologist’s readings and objectively by the use of a densitometer. Of the total, 6.3% were as radiopaque as a ferrous sulfate control tablet, 29.6% were moderately radiopaque, but less than control values, and 64% were essentially nondetectable. Potential benefits of this information in the clinical setting are discussed. (Am J Emerg Med 1988;4:302-312)
Although it is common knowledge that some cap- sules and tablets are reliably detected by plain radiog- raphy, no complete or current attempt has been made to identify and catalog them. The only currently avail- able compilation of radiographically detectable medi- cation was published over 14 years ago by Handy,’ who evaluated only 211 medications.
METHODS
A total of 459 medications including prescription and over-the-counter drugs in tablet and capsule form were obtained using the Geisinger Medical Center Formulary and information supplied by several local pharmacies in Northeastern Pennsylvania as a guide. An attempt was made to include as many commonly prescribed medications in their various formulations as feasible, and to include several recently released drugs.
Our premise was that one intact capsule or tablet would be detectable on the abdominal radiograph. Only intact medications were used for purposes of standardization. As a model, we chose to use the method of Handy. Each medication was radiographed in 20 cm of water to simulate its appearance as might be seen on a routine film of the abdomen. With radio-
From the Departments of Emergency Medicine, Radiology, and Pharmacy, Geisinger Medical Center, Danville, Pennsylvania.
Manuscript received November 12, 1985; revision accepted Jan- uary 2, 1986.
Address reprint requests to Dr. Dula: Department of Emergency Medicine, Geisinger Medical Center, Danville, PA 17822.
Key Words: Drugs, overdose, radio-opacity, toxicology.
0735-6757186 $00.00 + .25
302
lucent glue, 38 drugs at a time were positioned on a clear piece of x-ray film to which lead numbers and letters were affixed creating a 40-point grid (Fig. 1). Each grid had two remaining points containing a nega- tive (empty point with the glue applied to the film) and a positive (ferrous sulfate2v3 300 mg tablet) control. Cold water to a depth of 20 cm was put in a large plastic container, the bottom of which was composed solely of 5-mil-thick clear plastic (Fig. 2). The test grids were suspended in the water at a depth of 10 cm, which was also 10 cm above a standard x-ray table. Exposures were made consistently at appropriate set- tings (0.4 seconds, 250 mA, 60 KV) on the same radio- graphic equipment (Phillips Diagnost 73), with a tube- to-table distance of 40 cm. Irregularly shaped drugs were placed on the grid so that the thinnest dimension of the tablet or capsule was perpendicular to the x-ray beam to insure uniformity.
Tabulation of results was done as follows. Each film was read by four board-certified radiologists. The film reader was informed that point E8 on each film con- tained a ferrous sulfate tablet. The reader was not told the identity of any other drug on the film. He was also informed that point E7 always contained a nondetect- able drug (actually the negative control) for compar- ison purposes. A grading system for x-ray detect- ability was used where grade 0 is less dense than background, grade 1 + is minimally or nondetectable, grade 2 + is detectable but less so than ferrous sulfate controls, grade 3 + is detectable comparable with ferrous sulfate control, and grade 4+ is more radio- paque than the ferrous sulfate control (Table 1).
298 cm
238 cm
FIGURE 1. Diagram of 40-point grid to which the drugs tested were attached (38 at a time).
O’BRIEN ET AL W DETECTABILITY OF TABLETS AND CAPSULES
In addition, densitometry readings using a Digital Densitometer II’s’ (Nuclear Associates, Inc., Carle Place, New York) were performed on each film in an attempt to objectively grade the radiodensity of each drug. These measurements proved to be less useful than expected because the optical density varied in magnitude less than the calibration of the densitom- eter at random points on all films and from film to film. These readings are presented in our tables of re- sults but were not relied upon to grade the drugs under study.
RESULTS
Using the premise that drugs with a radiopacity ap- proximately comparable with or greater than ferrous sulfate are reliably detectable by plain radiography, we list all medications that were consistently graded as 3 + or 4+ as such in Table 2. It should be noted that in this category (as well as in the categories that follow), there was almost unanimous agreement among our film readers in scoring each individual drug. A total of 29 drugs (including our control), or 6.3% of the total studied, met this criteria. For the sake of completeness, Table 2 also contains a list of four medications not considered in our study that re- ceived a similar evaluation by Handy.’
Drugs that were rated in the 2 + category might well be described as moderately detectable. In the clinical setting, we believe any expectation of seeing one of these preparations on a film of the upper abdomen would be at least somewhat suspect. A total of 136 medications, or 29.6% of the total studied, met this criteria (Table 3).
Drugs rated as either 0 or 1 + by our readers are grouped together as essentially nondetectable. A total of 294 preparations (64%) were judged to be in this category (Table 4).
DISCUSSION
Drug overdose is a common problem in emergency medicine, and the emergency physician may need to
SuSPended preproces
FIGURE 2. Diagram of the plastic container in which drugs were tested for radiopacity.
TABLE 1. Grading Scale for Radiopacity of Drugs
Grade Explanation
0 Less dense than background 1+ Not or minimally detectable 2+ Radiopacity less than ferrous sulfate control
but greater than 1 + 3+ Radiopacity approximately comparable
with ferrous sulfate control 4+ Radiopacity greater than ferrous
sulfate control tablet -
determine whether a drug was taken or how much of the drug remains in the stomach after gastric lavage or emesis with ipecac. Patient histories are frequently in- accurate or unobtainable, and it is not unusual for treatment of ingestions to be begun empirically. As an adjunctive diagnostic measure in this problem, the de- tection of drugs by radiology of the abdomen can be considered. This intervention is rapid, safe, and easy to perform, and can yield valuable information to the physician if the drug is radiopaque. Having a refer- ence list of drugs that are known to be radiopaque could guide the emergency physician to obtain radio- graphs of the abdomen of overdose victims who have taken substances that they expect to be visualized. Prior to this study, only a partial and outdated list of such drugs was available for referencing. With the in- formation contained in this study, the emergency phy- sician should be able to judge which patients who have ingested drugs may benefit from a radiograph of the abdomen. While the indiscriminate use of the x-ray film of the abdomen on potential overdose victims may occasionally provide useful information, the spe- cific use of this x-ray film on patients who have in- gested radiopaque drugs will provide a higher yield and be more cost-effective. In addition to aiding the emergency physician in determining whether an over- dose has occurred, a radiograph of the abdomen, if positive, may help to determine the amount of drug that has been taken. A repeat radiograph of an over- dose patient with radiopaque drug fragments will help determine the efficacy of gastric emptying and identify those patients who require further treatment to empty the stomach. However, a negative abdominal radio- graph in the setting of a suspected overdose, even if radiopaque material has been ingested, must not be over-interpreted. Dissolution of the fragments in the gastric fluid may render them radiolucent and result in a false-negative result. Thus, the dissolution time of medication is also an important parameter in their ra- diographic detectability and has not been taken into account in this study. Similarly disintegration of pills or tablets may occur, resulting in a homogeneous mix- ture in the stomach that would be undetectable on a radiograph.
303
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 4, Number 4 D July 1986
TABLE 2. Drugs with a Radiopacity Approximately Comparable with or Greater than Ferrous Sulfate Control
Generic Name Brand Name Strength Form Manufacturer
Optical
Density
(Urll&)
Bethanechol
Busulfan
Calcium carbonate
Calcium carbonate
Calcium carbonate
Chloral hydrate Chlorpheniraminei
phenylephrine
Ephedrine/phenobarbital/
theophylline Ferrous fumaratel
ascorbic acid
Ferrous fumaratel
ascorbic acid
Ferrous fumarate/
ascorbic acid
Ferrous sulfate
Ferrous sulfate
Glyburide
Haloperidol
Liothyronine Meclizine
Phosphorus
Potassium chloride Potassium chloride
Potassium chloride
Simethicone/pancreatic enzymes
Sodium chloride
Sodium fluoride/
calcium carbonate
Spironolactone Trifluoperazine
Vitaminsifolic acid
Vitamins/minerals/iron
Vitamins multiple
Vitamins multiple/minerals Zinc sulfate
Previously reported drugs* Ammonium chloride
lopanoic Acid Potassium iodide
Potassium permanganate
Duvoid
Myleran
Oscal
Oscal -
Noctec Demazin
Quadrinal
Ferancee-HP
Vitron C
Vitron C Plus
Slow Fe
Generic
Micronase
Haldol
Cytomel Antivert
Neutraphos
Slow K Kaon Cl K Tab
Phazyme 95
-
Florical
Aldactone Stelazine
Stuart Natal 1 + 1
Tabron
Stuart Natal One-A-Day Maximum -
-
Telepaque -
-
50 mg
2mg 250 mg
500 mg
650 mg
500 mg
24 mgl 24 mg/130 mg
110 mg/600 mg
200 mg/125 mg
400 mgi250 mg
160 mg
300 mg
5mg 10mg
25 kg 25 mg
1,450 mg
600 mg 750 mg
750 mg
1,000 mg
50 mg
2mg
220 mg
500 mg 500 mg
300 mg
325 mg
Tablet Norwich Eaton 0.80
Tablet Burroughs Wellcome 0.74
Tablet Marion 0.47
Tablet Marion 0.69
Tablet Lilly 0.75
Capsule Squibb 0.80
Tablet Schering 0.70
Knoll 0.24
Tablet Stuart 0.71
Tablet Fisons 0.67
Tablet Fisons 0.56
Tablet Ciba 0.68
Tablet (control) 0.48
Tablet Upjohn 0.65
Tablet McNeil 0.86 Tablet Smith, Kline, and French 0.68
Tablet Pfizer 1.08
Capsule Willen 0.61 Tablet Ciba 0.53
Tablet Adria 0.46
Tablet Abbott 0.42
Tablet Reed and Carnrick 0.73
Tablet Lilly 0.80
Capsule Mericon 0.61
Tablet
Tablet
Searle
Smith, Kline, and French
Tablet
Tablet
Tablet Tablet
Parke Davis
Stuart Miles
Generic
0.69 0.75
0.65 0.58
0.56
0.87 0.71
Tablet
Tablet
Tablet Tablet
Lilly
Winthrop Lilly
Lilly
- -
-
-
l From Handy CA. Radio-opacity of oral nonliquid medications. Radiology 1971;98:525-533.
TABLE 3. Drugs Found to Be Moderately Radiopaque
Generic Name
Acetazolamide Acetohexamide Acetophenazine Albuterol Allopurinol
Aluminaimagnesial simethicone
Aluminum carbonate Aluminum hydroxide/
magnesium hydroxide
Brand Name Strength Form Manufacturer
Diamox 250 mg Tablet Lederle Dymelor 250 mg Tablet Lilly Tindal 20 mg Tablet Schering Ventolin 2mg Tablet Glaxo Zyloprim 100 mg Tablet Burroughs Wellcome Maalox Plus 20012OOf25 mg Tablet Rorer
Basaljel 608 mg Capsule Wyeth Mylanta - Tablet Stuart
Optical Density
(Units)
0.95 1.06 0.87 1.08 1.17 0.77
0.91
0.86
304
O’BRIEN ET AL w DETECTABILITY OF TABLETS AND CAPSULES
TABLE 3-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical
Density
(Units)
Amiloride
Amiloride/
hydrochlorothiazide Aminophylline
Amitriptyline
Amoxapine Amoxicillin
Amoxicillin/potassium
clavulanate
Amphetamine/
dextraoamphetamine
Ascorbic acid
Aspirin (buffered)
Aspirin (buffered)
Aspirin (enteric)
Bacampicillin
Benztropine
Bethanechol
Birth Control
Brompheniramine
phenylephrinel phenylpropanolamine
Butabarbital
Calcium gluconate Calcium lactate
Calcium polycarbophil
Chloramphenicol
Chloroquine phosphate Chlorothiazide
Chlorpheniramine
Chlorpheniramine/
pseudoephedrine
Chlorpropamide
Chlorzoxazone/ acetaminophen
Cimetidine
Clemastine/
phenylpropanolamine
Clindamycin Clofibrate
Clotrimazole
Cyclophosphamide
Cyproheptadine Danthron
Desipramine
Dextromethorphan/
phenylpropanolamine Dextrothyroxine Dicyclomine Dimenhydrinate
Dyphyllinelguaifenesin Ephedrine/theophylline/
hydroxyzine Ergotamine/caffeine Estrogens (conj)
Ethacrynic acid Ethambutol
Ethchlorvynol Ethinyl estradiol Etidronate
Fludrocortisone Fluphenazine
Midamor 5mg Tablet Merck, Sharp, and Dohme 0.68 Moduretic 5150 mg Tablet Merck, Sharp, and Dohme 0.79
-
-
Asendin
Amoxil Augmentin
200 mg Tablet Searle 0.71 10 mg Tablet Roxane 0.99 50 mg Tablet Lederle 0.83
250 mg Tablet Beecham 0.76 250 mg Tablet Beecham 0.92
Biphetamine 7.5 mg Capsule Pennwalt 0.92
-
Ascriptin AD
Ascriptin
Easprin
Spectrobid
Cogentin
Urecholine
Ovcon 35 Dimetapp Extentab
250 mg
325 mg
325 mg
975 mg
400 mg
1 mg
5mg -
Tablet Roxane 1.08 Tablet Rorer 1.21
Tablet Rorer 1.23
Tablet Parke-Davis 0.71
Tablet Roerig 1.26 Tablet Merck, Sharp, and Dohme 0.83
Tablet Merck, Sharp, and Dohme 0.91 Tablet Mead Johnson 0.91 Tablet A. H. Robins 1.14
Butisol -
-
Mitrolan
Chloromycetin -
Diuril
Chlortrimeton
Deconamine
15mg Tablet Wallace 0.84 1000 mg Tablet Westward 0.64 325 mg Tablet Lilly 0.65 500 mg Tablet A. H. Robins 1.17 250 mg Capsule Parke-Davis 1.06 500 mg Tablet Wyeth 0.62 500 mg Tablet Merck, Sharp, and Dohme 0.68
12mg Tablet Schering 0.78 4160 mg Tablet Berlex 0.67
Diabinese 250 mg Tablet Pfizer 0.70 Parafon Forte 250/300 mg Tablet McNeil 1.24
Tagamet Tavist-D
300 mg 1.34175 mg
Tablet
Tablet
Smith, Kline, and French Sandoz
0.74
0.73
Cleocin 150 mg Capsule Upjohn 1.14 Atromid-S 500 mg Capsule Ayerst 0.78 Mycelex 10mg Tablet Miles 1.12 Cytoxan 50 mg Tablet Mead Johnson 1.08 Periactin 4mg Tablet Merck, Sharp, and Dohme 1.04 Modane 75 mg Tablet Adria 0.85 Norpramin 75 mg Tablet Merrell 0.84 Ornacol 30125 mg Capsule Menley and James 0.77
Choloxin 1 mg Tablet Flint 0.72 Bentyl 20 mg Tablet Merrell Dow 0.89 Dramamine 50 mg Tablet Searle 0.88 Lufyllin GG 200/200 mg Tablet Wallace 0.71 Marax 25/l 30/l 0 mg Tablet Roerig 0.61
Cafergot l/100 mg Tablet Sandoz 0.78 Premarin 0.625 mg Tablet Ayerst 0.86 Edecrin 25 mg Tablet Merck, Sharp, and Dohme 1.17 Myambutol 400 mg Tablet Lederle 1 .Ol Placidyl 500 mg Capsule Abbott 0.88 Estinyl 0.02 mg Tablet Schering 0.44 Didronel 200 mg Tablet Norwich Eaton 1.09 Florinef 0.1 mg Tablet Squibb 0.91 Prolixin 2.5 mg Tablet Squibb 0.94
305
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 4, Number 4 n July 1986
TABLE 3-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical
Density
(Units)
Folic acid
Glyburide
Glyburide Griseofulvin
Hydrochlorothiazide
Hydrocodonel phenyltoloxamine
Hydroxychloroquine
Hydroxyzine
lbuprofin
lbuprofin
lmipramine
Isometheptene/
dicloralphenazone/
acetaminophen Isoxsuprine
Ketoconazole
Lactobacillus
Lithium
Lithium
Maprotiline
Megaldrate
Megestrol
Mesoridazine
Metaproterenol
Methanamine/methylene
methazolamide
Methyldopa/
hydrochlorothiazide Methylergonovine blue/
phenylsalicylate/
benzoic acid/atropine/
hyoscyamine Methysergide
Metyrapone Mitotane
Multivitamins/iron
Multivitamins/minerals
Neomycin sulfate
Oxyphenbutazone Pancrelipase Penicillamine
Penicillin VK Pentazocine Pentoxifylline
Perphenazine/amitriptyline Perphenazine/amitriptyline
Phenobarbital/hyoscyamine/ atropine/scopolamine
Phytonadione
Primaquine phosphate Probenecid Probenecid/colchicine
Procainamide amitriptyline Propantheline bromide Propranolol/
hydrochlorothiazide Pyridostigmine Quinidine Ranitidine
306
Folvite
Diabeta Micronase Fulvicin -
Tussionex
1 w Tablet Lederle 0.87
5m9 Tablet Hoerchst-Roussel 0.81
5w Tablet Upjohn 0.95
250 mg Tablet Schering 0.97
50 mg Tablet Parke-Davis 0.71
5110 mg Tablet Pennwalt 0.69
Plaquenil
Atarax
Advil
Motrin -
Midrin
200 mg
25 mg
200 mg
400 mg
25 mg
65/l 001325 mg
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Winthrop Pfizer
Whitehall
Upjohn
Geneva Carnrick
1.07
1.04
0.86
0.71
1.15
0.94
Vasodilan 10mg Tablet
Nizoral 200 mg Tablet Lactinex - Tablet
Mead Johnson Janssen
Hynson, Westcott, and Dunning
Smith, Kline, and French
Ciba
Ciba Ayerst
Mead Johnson
Boehringer lngelheim
Boehringer
Lederle
1.09 0.76 0.71
Eskalith CR
Lithobid
Ludiomil
Riopan
Megace
Serentil
Alupent
Neptazone
450 mg
300 mg 25 mg
480 mg 20 mg
50 mg
20 mg
50 mg
Tablet Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
0.88
0.80 0.76
0.83 0.84
0.88
1.06
0.96
Aldoril 250/25 mg Tablet Merck, Sharp, and Dohme 0.60
Methergine
Urised
Sansert
Metopirone Lysodren
Centrum Jr./Iron
Vicon-C
0.2 mg 40.815.41
4.510.31
0.3 mg
2mg 250 mg
500 mg -
Tablet Sandoz 0.93
-
-
Tanderil
Viokase Depen -
Talwin
Trentai Etrafon
Procan SR Donnatal
Extentabs
500 mg
100 mg -
Mephyton -
Benemid
Colbenemid Triavil
Probanthine lnderide
250 mg 250 mg
50 mg 400 mg
2110 mg 750 mg
48.610.311 0.0581
0.019 mg
5mg 26.3 mg 500 mg
0.510.5 mg
4125 mg 15mg
80125 mg
Tablet Webcon 0.74
Tablet Sandoz 0.66 Tablet Ciba 0.98 Tablet Bristol 0.72
Tablet Lederle 0.82
Capsule Glaxo 0.84
Tablet Roxane 1.03
Tablet Geigy 0.72
Tablet Viobin 0.71
Tablet Wallace 0.98 Tablet Squibb 1.08 Tablet Winthrop 1.10 Tablet Hoechst-Roussel 0.90 Tablet Schering 0.58 Tablet Parke-Davis 0.79
Tablet A. H. Robins 1.14
Tablet Merck, Sharp, and Dohme 1.15 Tablet Generic 0.83 Tablet Merck, Sharp, and Dohme 1.03 Tablet Merck, Sharp, and Dohme 0.74
Tablet Merck 0.84 Tablet Searle 0.77 Tablet Ayerst 0.68
Mestinon Quinidex Zantac
60 mg 300 mg 150 mg
Tablet Tablet Tablet
Roche A. H. Robins Glaxo
0.68 1.20 0.74
O’BRIEN ET AL n DETECTABILITY OF TABLETS AND CAPSULES
TABLE J-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical
Density (Units)
Reserpine/hydralazine/
hydrochlorothiazide Reserpinei
hydrochlorothiazide
Sodium bicarbonate
Spironolactone/
hydrochlorothiazide Sulcrafate
Sulfadiazine
Sulfamethoxazole
Sulfapyridine
Sulfasalazine
Sulfisoxazole
Sulfisoxazolel
phenazopyridine Thiamine
Thioguanine Thioridazine
Tocainide
Tolazamide
Tolbutamide
Trazodone
Triamterenel
hydrochlorothiazide
Trihexyphenidyl
hydrochloride Trioxsalen
Trisalicylate
Triprolidine/
pseudoephedrine Verapamil Zomepirac
Ser-Ap-Es 0.1/25/15 mg Tablet Ciba 0.75
Hydropres 0.125/25 mg Tablet Merck, Sharp, and Dohme 0.67
- 325 mg Tablet Lilly 1.11 Aldactazide 25125 mg Tablet Searle 0.89
Carafate - Gantanol - SAS-500
Gantrisin
AzoGantrisin
- - Mellaril
Tonocard
Tolinase -
Desyrel
Maxzide
Artane 2mg Tablet Lederle 0.56
Trisoralen 5mg Tablet Elder 1.13 Trilisate 750 mg Tablet Purdue Frederick 0.84 Actifed 2.5/60 mg Tablet Burroughs Wellcome 1.17
Calan Zomax
TABLE 4. Drugs Found to Be Not or Minimally Radiopaque
lg Tablet Marion 0.69 500 mg Tablet Lilly 0.69 500 mg Tablet Roche 0.73 500 mg Tablet Lilly 0.70 500 mg Tablet Rowell 0.69 500 mg Tablet Roche 0.98
500/50 mg Tablet Roche 0.75
100 mg Tablet Westward 1 .oo 40 mg Tablet Burroughs Wellcome 0.67 50 mg Tablet Sandoz 0.87
400 mg Tablet Merck, Sharp, and Dohme 0.93 250 mg Tablet Upjohn 0.82 500 mg Tablet Ascot 0.67
50 mg Tablet Mead Johnson 0.78 75150 mg Tablet Lederle 0.64
120 mg
100 mg
Tablet Tablet
Searle
McNeil 1.12
0.95
Generic Name Brand Name Strength Form Manufacturer
Optical Density
(units)
Acetaminophen Acetaminophen
Acetaminophen Acetaminophen
Acetaminophen Acetaminophen/codeine Activated charcoal Acyclovir
Alprazolam
Alprazolam
Amantadine
Aminocaproic acid Aminoglutethimide Amobarbital Amoxicillin
Amphetamine Ampicillin Aspirin Aspirin Aspirin (buffered) Aspirin/codeine
Tylenol Tylenol
Tylenol Phenathen
St. Joseph Tylenol No. 3 - Zovi rax
Xanax
Xanax Symmetrel
Amicar
Cytadren Amytal Polymox Dexadrine
Principen Bayer Encaprin Bufferin Empirin 3
160 mg
325 mg
500 mg 325 mg
80 mg 300130 mg
260 mg
200 mg 0.25 mg
0.5 mg 100 mg
500 mg
250 mg 50 mg
250 mg 15mg
250 mg 325 mg 500 mg
324 mg 300130 mg
Tablet
Tablet
Caplet
Capsule Tablet
Tablet
Capsule Capsule Tablet
Tablet
Tablet
Tablet Tablet
Capsule Capsule Tablet Tablet Capsule Tablet Tablet
McNeil 0.92
McNeil 0.88 McNeil 0.70 AH Robins 0.90 Plough 1.09 McNeil 1.01
Generic 0.85 Burroughs Wellcome 0.84
Upjohn 0.95
Upjohn 0.89 DuPont 0.77
Lederle 1.18
Ciba 1.18 Lilly 0.81 Bristol 0.67 Smith, Kline, and French 1.02
Squibb 1.15 Bayer 0.79 Norwich Eaton 1 .oo Brisol-Myers 1.17 Burroughs Wellcome 0.73
307
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 4, Number 4 n July 1986
TABLE 4-Conrinued
Generic Name Brand Name Strength Form Manufacturer
Optical Density
(Units)
Aspirin (enteric)
Atenolol
Atropine sulfate
Azatadine Azathioprine
Baclofen
Benzonatate
Betacarotene
Bioflavonoids
Birth control Birth control
Birth control Birth control
Birth control/iron
Bisacodyl Bromocriptine
Bumetanide
Bumetanide
Butalbital/aspirin/caffeine
Calcitriol
Captopril
Caramithen/phenylpropanolamine
Carbamazepine Carbenicillin
Carbidopatlevodopa Carbinoxamine/pseudoephedrine Carisoprodol
Carisoprodol/aspirin Carisoprodol/aspirin/Codeine
Cefaclor Cefradroxil
Cephalexin Cephradine
Chlorambucil
Chlordiazepoxide Chlordiazepoxide
Chlordiazepoxide/amitriptyline Chlordiazepoxideiclidinium
Chlorpheniramine
Chlorpheniraminelphenyltoloxaminei phenylephrine
Chlorpheniramine/pseudoephedrine Chlorpromazine Chlorthalidone
Clemastine fumarate
Clomiphene citrate
Clonazepam Clonidine
Clorazepate
Codeine Colchicine
Cortisone acetate Cromolyn sodium Cyclacillin Cyclandelate Cyclizine Cyclobenzaprine Danocrine Dantrolene
Dapsone Dexamethasone Dextroamphetamine
308
Ecotrin
Tenormin -
Optimine
lmuran
Lioresal
Tessalon
Solatene -
Ortho-Novum Tri-Norinyl Norinyl 1 + 50
Ortho Novum 7/7/7
Loestrine Fe Dulcolax
Parlodel
Bumex
Bumex Fiorinal
Rocaltrol
Capoten
Tuss-Ornade
Tegretol
Geocillin
Sinemet Rondec TR
Soma Soma Compound
Soma with Codeine Ceclor
Ultracef
Keflex
Velosef
Lukeran -
-
Limbritol
Librax Teldrin
Comhist LA
Deconamine SR Thorazine Thalitone
Tavist -
Clonopin
Catapres Tranxene - - -
lntal
Cyclapen Cyclospasmol Marezine Flexeril Danazol Dantrium -
Hexadrol Dexedrine
325 mg 50 mg
0.3 mg
1 mg 50 mg
20 mg
100 mg
30 mg -
10111 mg -
- -
1.5130 mg
5mg 2.5 mg
1 mg 0.5 mg
501325/40 mg
0.25 kg
25 mg
40175 mg
200 mg
382 mg 25/l 00 mg
8/l 20 mg
350 mg 200/325 mg
200/325/l 6 mg 250 mg
500 mg
250 mg
500 mg
2mg 10mg
25 mg
5112.5 mg
512.5 mg
8mg 4150120 mg
81120 mg Capsule 75 mg Capsule 25 mg Tablet
2.68 mg Tablet 50 mg Tablet
0.5 mg Tablet 0.1 mg Tablet 7.5 mg Capsule 15mg Tablet
0.6 mg Tablet
5mg Tablet 20 mg Capsule
250 mg Tablet 400 mg Capsule
50 mg Tablet 10 mg Tablet
200 mg Capsule 25 mg Capsule 25 mg Tablet
4mg Tablet 15mg Capsule
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Capsule
Capsule Tablet
Tablet Tablet
Tablet Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Tablet
Capsule
Tablet
Tablet Tablet
Tablet Tablet
Tablet
Tablet
Capsule
Capsule
Capsule
Tablet
Capsule
Capsule
Tablet
Capsule
Capsule Capsule
Menley and James 0.88
Stuart 0.92
Generic 0.80 Schering 0.86 Burroughs Wellcome 1.03
Geigy 1 .oo
DuPont 0.84
Roche 1.22
Beutlich 0.65
Ortho 0.89 Syntex 0.64
Syntex 0.75
Ortho 0.84
Parke-Davis 0.96 Boehringer lngelheim 0.69
Sandoz 0.89
Roche 1.22
Roche 1.21
Dorsey 0.87
Roche 1.05
Squibb 1.19
Smith, Kline, and French 1.18
Geigy 0.85 Roerig 1.12
Merck, Sharp, and Dohme 0.70
Ross 0.87 Wallace 0.93
Wallace 0.86
Wallace 0.89 Lilly 1.08
Bristol 0.96 Dista 1.05
Squibb 1 .Ol
Burroughs Wellcome 0.73
Ascot 1.07
Parke-Davis 1 .Ol
Roche 0.78
Roche 0.93 Smith, Kline, and French 1.14
Norwich Eaton 0.91
Berlex 0.77
Smith, Kline, and French 0.99 Boehringer lngelheim 0.90 Sandoz 0.86 Merrell 0.76
Roche 0.79 Boehringer lngelheim 0.79
Abbott 0.89 Wyeth 0.92 Lilly 0.90
Upjohn 0.93 Fisons 1.37 Wyeth 1.26 Ives 0.78 Burroughs Wellcome 0.61 Merck, Sharp, and Dohme 1.16 Wyeth 0.84 Norwich Eaton 1.07 Jacobus 0.98 Organon 0.89 Smith, Kline, and French 0.75
O’BRIEN ET AL n DETECTABILITY OF TABLETS AND CAPSULES
TABLE 4-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical
Density
(units)
Diazepam
Diazepam
Diazoxide
Dicloxacillin
Dicyclomine
Dicyclomine
Diethylstilbesterol
Diflunisal Digitoxin
Digoxin Dihydrocodeine/aspirin/caffeine
Dihydrotachysterol
Diltiazem
Diphenhydramine
Diphenoxylate/atropine
Disopyramide
Docusate
Doxepin
Doxepin
Doxycycline
Dypridamole
Ephedrine sulfate Ergocalciferol
Ergoloid mesylates Ergoloid mesylates
Erythromycin
Erythromycin Estramustine
Estropipate
Ethosuximide
Fenoprofen Flucytosine
Fluoxymesterone
Flurazepam
Furosemide
Gelatin Gemfibrozil
Glipizide Glutethamide
Guanabenz
Guanadrel Guanethidine
Hydralazine
Hydrocortisone
Hydromorphone
Hydroxyurea
Hyoscyamine Hyroxyzine
lndapamide
lndomethacin lndomethacin lsoniazid
lsosorbide dinitrate
lsotretinoin Labetalol Levodopa Levophanol Levothryoxine
Lincomycin Lomustine
Loperamide Lorazepam
Valium
Valrelease
Proglycem
Dynapen
Bentyl
Bentyl -
Dolobid -
Lanoxin
Synalgos DC DHT
Cardiazem
Benadryl
Lomotil
Norpace CR
Colace
Sinequan
Adapin
Vibratabs Persantine -
Drisdol
Hydergine Hydergine
EES ERYC
Emcyt Ogen
Zarontin Nalfon
Ancobon Malotestin
Dalmane
Lasix -
Lopid Glucotrol Doriden
Wytensin Hylorel
lsmelin -
Hydrocortone Dilaudid
Hydrea Levsin
Vistaril
Lozol lndocin SR
lndocin -
Sorbitrate
Accutane Normodyne Dopar Levo-Dromoran
Synthroid Lincocin
Ceenu lmodium Ativan
5 mg Tablet Roche 0.88 15mg Capsule Roche 0.82
500 mg Capsule Schering 1.21
250 mg Capsule Bristol 1.08
10mg Capsule Merrill Dow 1 .Ol
20 mg Tablet Merrell Dow 0.89
5 mg Tablet Lilly 1.11
500 mg Tablet Merck, Sharp, and Dohme 1 .oo 0.1 mg Tablet Purepac 0.84
0.125 mg Tablet Burroughs Wellcome 1.21 161356.4130 mg Capsule Ives 1.03
0.2 mg Tablet Roxane 1.20 30 mg Tablet Marion 0.77 25 mg Capsule Parke-Davis 1.24
2.5iO.025 mg Tablet Searle 0.83 100 mg Capsule Searle 1.24 100 mg Capsule Meade Johnson 1.21
25 mg Capsule Roerig 1.12 25 mg Capsule Pennwalt 0.70
100 mg Tablet Pfizer 0.95
50 mg Tablet Boehringer lngelheim 0.68
25 mg Capsule Lilly 0.74 1.25 mg Capsule Wyeth 0.73
1 mg Capsule Sandoz 0.77
1 mg Tablet Sandoz 0.86 400 mg Tablet Abbott 0.88
250 mg Capsule Parke-Davis 0.98 140 mg Capsule Roche 0.98
0.625 mg Tablet Abbott 0.91 250 mg Capsule Parke-Davis 0.69
300 mg Capsule Dista 0.90
500 mg Capsule Roche 0.83
10mg Tablet Upjohn 1.11
30 mg Capsule Roche 1.03 40 mg Tablet Hoechst 0.66
empty #4 Capsule Generic 0.74
300 mg Capsule Parke-Davis 1.13
5mg Tablet Pfizer 0.84
500 mg Tablet usv 0.98
4mg Tablet Wyeth 1.17 10mg Tablet Pennwalt 0.92 10 mg Tablet Ciba 0.90 25 mg Tablet Rugby 1.27
10mg Tablet Merck, Sharp, and Dohme 1.04
1 w Tablet Knoll 0.80
500 mg Capsule Squibb 1.02 0.125 mg Tablet Kremers-Urban 0.82
50 mg Capsule Pfizer 0.95
2.5 mg Tablet USV Pharmaceuticals 0.90 75 mg Capsule Merck, Sharp, and Dohme 0.84
25 mg Capsule Merck, Sharp, and Dohme 0.88 100 mg Tablet Lilly 0.77
5mg Tablet Stuart 0.62 40 mg Tablet Roche 1.18
200 mg Tablet Schering 0.81 250 mg Capsule Eaton 1.08
2 mg Tablet Roche 0.82 0.1 mg Tablet Flint 0.80
250 mg Tablet Upjohn 0.68 10 mg Capsule Bristol 0.63
2 mg Capsule Janssen 0.90
t mg Tablet Wyeth 1.12
309
AMERICAN JOURNAL OF EMERGENCY MEDICINE H Volume 4, Number 4 n July 1988
TABLE 4-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical
Density (units)
Loxapine
Mebendazole
Meclofenamate
Medroxyprogesterone Mefanamic acid
Melphalan Meperidine
Meprobamate
Meprobamatelaspirin
Mercaptopurine
Methadone
Methamphentamine
Methaqualone
Metharbital Methenamine mandelate
Methenytoin
Methimazole
Methobarbital Methocarbamol
Methocarbamol/aspirin Methotrexate
Methoxsalen
Methsuximide Methyclothiazide
Methyldopa Methylprednisolone
Methyltesterone
Metoclopramide
Metolazone
Metoprolol
Metronidazole
Metronidazole Metyrosine
Minocycline Minoxidil Multivitamins Multivitamins
Nadolol
Nadololibendroflumethiazide
Naltrexone
Naproxen
Naproxen (sodium) Neostigmine Niacin
Nifedipine
Nitrofurantoin Nitroglycerin
Nitroglycerin Nitroglycerin Norethindrone Nortriptyline Nylidrin Nystatin Orphenadrine
Orphenadrine/aspirin/caffeine Oxacillin
Oxandrolone Oxazepam Oxtriphylline Oxybutnin
Cxycodone/acetaminophen Dxycodone/acetaminophen
310
Loxitane
Vermox
Meclomen
Provera
Ponstel Alkeran -
Equanil Equagesic
Purinethol
Dolophine
Desoxyn -
Geomonil
Mandelamine
Mesantoin
Tapazole Mebaral
Robaxin Robaxisal -
Oxsoralen Celontin
Enduron
Aldomet
Medrol -
Reglan
Zaroxolyn
Lopressor
Protostat
Flagyl Demsar Minocin Loniten -
Albee with C Corgard
Corzide
Trexan Naprosyn
Anaprox Prostigmin -
Procardia
Macrodantin
Nitrostat SR Nitrostat
Nitrobid
Aygestin Pamelor
Arlidin
10mg
100 mg
100 mg
10mg
250 mg
2mg 50 mg
200 mg
2001325 mg 50 mg
5mg
5mg 150 mg
100 mg
500 mg
100 mg
10mg 32 mg
750 mg
4001325 mg 2.5 mg
10mg
150 mg
5mg 250 mg
32 mg
10mg
10mg
2.5 mg
50 mg
250 mg
250 mg 250 mg
50 mg
2.5 mg - -
40 mg
4015 mg
400 mg 250 mg
275 mg
14mg
100 mg
10 mg 50 mg
6.5 mg
0.4 mg 2.5 mg
5mg 75 mg
6mg - 500,000 u Norflex 100 mg
Norgesic Forte 50/770/60 mg Prostaphlin 250 mg Anavar 2.5 mg Serax 30 mg
Choledyl SA 400 mg Ditropan 5mg Tylox 51500 mg Percocet 51300 mg
Capsule
Tablet
Capsule
Tablet
Capsule Tablet Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet Tablet
Tablet
Tablet Tablet
Tablet
Capsule Capsule
Tablet
Tablet
Tablet
Tablet
Tablet Tablet
Tablet
Tablet Tablet
Capsule Capsule Tablet
Tablet
Capsule Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet Capsule
Capsule Capsule Tablet
Capsule
Tablet Capsule Tablet Tablet
Tablet Tablet
Capsule Tablet Capsule Tablet Tablet Capsule Tablet
Lederle 1.01
Janssen 0.80
Parke-Davis 0.89
Upjohn 0.86
Parke-Davis 0.98
Burroughs Wellcome 0.68
Wyeth 0.78
Wyeth 0.88
Wyeth 1.22
Burroughs Wellcome 0.78
Lilly 0.93
Abbott 0.99
Rorer 0.88
Abbott 0.82
Parke-Davis 1.00
Sandoz 1.08
Lilly 0.76
Breon 0.97
AH Robins 0.78
AH Robins 0.88 Generic 1.02
Elder 0.80
Parke-Davis 0.78
Abbott 0.69
Merck 0.88
Upjohn 0.93
Schering 0.70
AH Robins 1.07
Pennwalt 0.90
Geigy 1.12
Ortho 0.91
Searle 0.78
Merck, Sharp, and Dohme 0.93
Lederle 0.86 Upjohn 0.84 Rowell 0.91
AH Robins 0.97
Squibb 0.93
Squibb 0.76
DuPont 0.94
Syntex 0.75
Syntex 1.22 Roche 0.66
Roxane 1.03 Pfizer 0.80 Norwich Eaton 1.05
Parke-Davis 1.07
Parke-Davis 1.27 Marion 1.13
Ayerst cl.97 Sandoz 0.96 usv 0.90 Squibb 0.88 Riker 1.09 Riker 0.74 Bristol 1.07
Searle 0.81 Wyeth 0.69 Parke-Davis 1.16 Marion 0.90 McNeil 0.87 DuPont 1.04
O’BRIEN ET AL D DETECTABILITY OF TABLETS AND CAPSULES
TABLE 4-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical
Density
(Units)
Oxycodonelaspirin
Oxymetholone
Pancrelipase
Papaverine hydrochloride Pemoline
Pentaerythritol tetranitrate
Pentobarbital Phenobarbital
Phenoxybenzamine
Phentermine
Phenylbutazone
Phenylephrine/phenylpropanolamine/
quaifensin
Phenylpropanolaminel
chlorpheniramine
Phenylpropanolamine/phenylephrine/
phenyltoloxamine/ chlorpheniramine
Phenytoin
Phenytoin Pindolol
Piroxicam
Prazepam Prazosin
Prednisolone
Prednisone
Primidone
Probucol
Procarbazine
Prochlorperazine
Prochlorperazine/isopropamide Procyclidine
Promethazine
Propoxyphene
Propoxyphene/acetaminophen
Propranolol Propylthiouracil Pseudoephedrine
Pseudoephedrine/chlorpheniramine
Pyridoxine hydrochloride
Pyrimethamine
Pyrvinium
Quinestrol
Quinidine
Quinidine gluconate
Quinidine sulfate Reserpine Riboflavin Rifampin
Salsalate Secobarbital Senna concentrate
Sodium fluoride
Sumnpyrazone Sulindac Tamoxifen
Temazepam
Terbutaline Tetracycline Theophylline Theophylline Theophylline
Percodan Anadrol
Pancrease -
Cylert Peritrate Nembutal -
Dibenzyline
Fastin Butazolidin
Entex
5f300 mg Tablet
50 mg Tablet - Capsule
100 mg Tablet 37.5 mg Tablet
20 mg Tablet
100 mg Capsule 15mg Tablet
10mg Capsule 30 mg Capsule
100 mg Tablet 5/45/200 mg Capsule
Ornade 75/l 2 mg Capsule
Naldecon 40/l O/l 515 mg Tablet
Dilantin
Dilantin
Visken Feldene
Centrax Minipress -
Deltasone
Mysoline
Lorelco
Matulane
Compazine
Combid Kemadrin
Phenergan
Darvon
Darvocet-N 100 lnderal LA -
Novafed
Novafed A -
Daraprim
Povan Estrovis
Quinaglute
Quinaglute -
-
-
Rifadin Disalcid
Seconal
Senokot Luride
Anturane Clinoril Nolvadex
Restoril
Brethine Sumycin Elixophyllin SR
Slobid Slophyllin
100 mg Capsule
30 mg Capsule
5mg Tablet
20 mg Capsule
5mg Capsule
1 mg Capsule
5mg Tablet
10 mg Tablet
50 mg Tablet
250 mg Tablet
50 mg Capsule 10mg Capsule
1 O/5 mg Capsule
5mg Tablet
25 mg Tablet
65 mg Capsule 100/650 mg Tablet
60 mg Capsule 50 mg Tablet
120 mg Capsule 120/6 mg Tablet
25 mg Tablet
25 mg Tablet
50 mg Tablet
0.1 mg Tablet
324 mg Tablet
325 mg Tablet
200 mg Tablet 0.1 mg Tablet 10mg Tablet
300 mg Capsule 750 mg Table:
50 mg Capsule - Tablet
2.2 mg Tablet
200 mg Capsule 200 mg Tablet
10 mg Tablet
15mg Capsule
5mg Tablet
250 mg Capsule 250 mg Capsule 100 mg Capsule 60 mg Capsule
Dupont 0.66
Syntex 0.75 McNeil 1.11 Lilly 0.94
Abbott 1.03 Parke-Davis 7.10
Abbott 1.04 Parke-Davis 0.96 Smith, Kline, and French 1.02
Beecham 0.97
Geigy 1.15
Norwich Eaton 0.92
Smith, Kline, and French 1.11
Bristol 1.04
Parke-Davis 1 .oo Parke-Davis 1 .oo Sandoz 1.16
Pfizer 0.77 Parke-Davis 0.66 Pfizer 0.75
Roxane 1.01
Upjohn 1.14
Ayerst 0.92 Merrell Dow 1 .os
Roche 1.20
Smith, Kline, and French 0.99
Smith, Kline, and French 1.22 Burroughs Wellcome 0.62
Wyeth 0.66 Lilly 0.92 Lilly 0.96
Ayerst 1.24 Lilly 0.60
Dow 0.67
Dow 0.87 West-Ward 0.80 Burroughs Wellcome 0.88 Parke-Davis 0.86 Parke-Davis 0.92
Berlex 0.76
Berlex 0.74
Whitehall 0.75 West-Ward 0.97 Lilly 1.10
Ciba 1.18
Riker 1.18 Lilly 0.74
Purdue 0.96
Hoyt 1.08
Ciba 0.74 Merck, Sharp, and Dohme 1.25
Stuart 0.81
Sandoz 1.26
Geigy 0.98
Squibb 0.89 Berlex 1.14
Rorer 0.99 Rorer 0.73
311
AMERICAN JOURNAL OF EMERGENCY MEDICINE w Volume 4, Number 4 n July 1986
TABLE 4-Continued
Generic Name Brand Name Strength Form Manufacturer
Optical Density
(Units)
Theophylline
Theophylline Theophylline
Theophylline/ephedrine/
phenobarbital Thiothixene
Thyroglobulin
Thyroglobulin
Thyroid
Timolol
Timololihydrochlorothiazide
Tolmetin Triamcinolone
Triamterene
Triamterene/hydrochlorothiazide Triflupromazine
Trimeprazine
Trimethobenzamide Trimethoprim
Trimethoprim/sulfa
Trimipramine Tripelenamine
Valproic acid
Verapamil
Vitamin A
Vitamin E Vitamin E
Vitamins
Vitamins/fluoride
Warfarin
Yeast
Somophyllin-T Theo-Dur
Theo-Dur Sprinkle
Tedral
Navane
Proloid
Proloid - Blocadren
Timolide
Tolectin Aristocort
Dyrenium
Dyazide Vesprin
Temaril Tigan
Proloprim
Bactrim DS
Sumontil
PBZ Depakene
lsoptin
Aquasol A - - Polyvisol
Polyviflor Coumadin -
200 mg Capsule 200 mg Tablet
125 mg Capsule 13012418 mg Tablet
2m9 32 mg
65 mg
60 mg
10mg
1 O/25 mg
400 mg
2mg 100 mg
50125 mg
10mg
5mg 250 mg 200 mg
160/800 mg
50 mg
25 mg 250 mg
80 mg
25,000 U
100 IU
100 IU -
1 mg 5 mg
450 mg
Capsule
Tablet Tablet
Tablet
Tablet
Tablet
Capsule Tablet
Capsule
Capsule Tablet
Capsule Capsule
Tablet Tablet
Capsule Tablet
Capsule Tablet
Capsule
Capsule Capsule
Tablet
Tablet Tablet
Tablet
Fisons 1.25
Key 1.00
Key 1.23
Parke-Davis 0.77
Roerig 1.25
Parke-Davis 1.07
Parke-Davis 0.81
Armour 1.02
Merck, Sharp, and Dohme 0.86
Merck, Sharp, and Dohme 0.75 McNeil 1.33
Lederle 0.83 Smith, Kline, and French 1 .oo Smith, Kline, and French 1.33
Squibb 0.84
Smith, Kline, and French 0.88 Beecham 0.86 Burroughs Welcome 0.81
Roche 0.88
Ives 0.63
Geigy 0.80
Abbott 1 .Ol
Knoll 1 .oo
Armour 0.76
Generic 0.69 Generic 0.99 Mead Johnson 0.98
Mead Johnson 1.04
DuPont 0.88 Lee 0.84
Despite these limitations, while a negative film of the abdomen is of little help to the emergency physi- cian in the overdose victim, the positive detection of drugs on a radiograph of the abdomen will aid in the determination of the amount of drug taken and the ef- ticacy of gastric emptying by lavage or emesis. The list of radiopaque medications produced by this study will help guide the emergency physician in ordering of such radiographs in an efficient and cost-effective fashion, and perhaps this list will improve the care of the overdose or poisoned patient.
The authors thank Ms. Selma Etter and Mr. Jerry Troutman for their help in the development of this project.
REFERENCES
1. Handy CA. Radio-opacity of oral nonliquid medications. Ra-
diology 1971;98:525-533.
2. Raymond CW. Iron poisoning: Assessment of radiography in diagnosis and management. Clin Pediatr 1979;18:614- 616.
3. Staple TW, McAlister WH. Roentgenographic visualization
of iron preparations in the gastrointestinal tract. Radi- ology 1964;83:1051-1056.
312