N-Acetylcysteine

Aka: N-Acetylcysteine, Acetylcysteine, Acetadote, Mucomyst, Cetylev, NAC

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II. Indications

  1. Established Toxicology
    1. Acetaminophen Overdose
    2. Mushroom Poisoning
    3. Heavy Metal Poisoning
      1. Not first-line, but may reduce oxidative stress
    4. Contrast-Induced Nephropathy prevention
      1. Not typically used in U.S. (hydration is used instead)
  2. Controversial Use as Mucolytic in Chronic Lung Disease (conflicting evidence of benefit)
    1. Prevention of COPD Exacerbation
      1. Dose: 600-1200 mg/day in divided dosing
      2. Decramer (2005) Lancet 365(9470):1552-60 [PubMed]
    2. Idiopathic Pulmonary Fibrosis
      1. Dose: 1800 mg/day in divided dosing
      2. Demedts (2005) N Engl J Med 353(21):2229-42 [PubMed]

III. Mechanism

  1. N-Acetylcysteine increases glutathione levels
    1. Acts as detoxification agent
    2. Acts as antioxidant
  2. N-Acetylcysteine increases nitric oxide concentrations
    1. Stimulates vasodilation
  3. N-Acetylcysteine acts as a mucolytic
    1. Cleaves Protein complexes and decreases mucous viscosity
    2. May be effective in Chronic Bronchitis

IV. Dosing: Acetaminophen Overdose

  1. Protocol
    1. See Acetaminophen Overdose
    2. Directed by Rumack-Matthew Acetaminophen Nomogram
      1. http://www.ars-informatica.ca/toxicity_nomogram.php?calc=acetamin
    3. Continue NAC beyond protocol below if any of the following persist at end of protocol
      1. High Acetaminophen level or
      2. Increasing Bilirubin, INR or transaminases
  2. Formulation
    1. Intravenous indications
      1. Fulminant hepatic failure (best studied)
      2. Pregnancy
      3. Intractable Vomiting
    2. Oral advantages
      1. Preferred route
      2. Cheap and effective
      3. Lower Incidence of anaphylactoid reaction than with IV form
  3. Adults
    1. Oral (72 hour protocol)
      1. Load: 140 mg/kg orally for 1 dose
      2. Next 70 mg/kg every 4 hours for total of 17 doses
      3. Administration pearls
        1. Better tolerate when chilled or mixed with orange juice or soda
        2. NAC smell may decrease tolerability (consider placing in covered cup with straw)
        3. Vomiting
          1. Re-dose if vomits within one hour of dose
            1. No need to re-dose if Vomiting after one hour (Absorbed quickly)
          2. Consider concurrent Ondansetron (Zofran) or other Antiemetic
          3. Consider switching to intravenous NAC
    2. Intravenous (21 hour protocol)
      1. Load: 150 mg/kg in 200 ml D5W IV over 1 hour for 1 dose
      2. Next: 12.5 mg/kg/hour for 4 hours (50 mg/kg in 500 ml D5W given over 4 hours)
      3. Next: 6.25 mg/kg/hour for 16 hours (100 mg/kg in 1000 ml D5W given over 16 hours)
        1. May be extended for ongoing hepatotoxicity until Liver Function Tests start improving
  4. Child
    1. Oral: Same as for adults
    2. IV: Same as for adults
      1. EXCEPTION: For <88 lb (40 kg), dilute to 40 mg/ml in D5W
      2. Smaller volume to prevent Hyponatremia

V. Dosing: Respiratory Mucolytic

  1. Inconsistent evidence of benefit
  2. Prevention of COPD Exacerbation
    1. Dose: 600-1200 mg/day in divided dosing
    2. Decramer (2005) Lancet 365(9470):1552-60 [PubMed]
  3. Idiopathic Pulmonary Fibrosis
    1. Dose: 1800 mg/day in divided dosing
    2. Demedts (2005) N Engl J Med 353(21):2229-42 [PubMed]

VI. Adverse Effects (uncommon at doses 1200 mg/day or less)

  1. Nausea
  2. Vomiting
  3. Diarrhea
  4. Anaphylactoid Reaction (8% with IV)
    1. Typically occurs at 30 to 60 minutes after starting infusion
    2. Stop infusion
    3. Treat reaction
      1. Epinephrine for Anaphylaxis-like symptoms
      2. Diphenhydramine for other allergic symptoms
    4. Restart infusion slowly
      1. Contact poison control for rate adjustment in Acetaminophen Overdose
      2. Stop infusion if anaphylactoid reaction recurs or increases in severity
        1. Discontinue for severe reactions (deaths have occurred)

VII. Safety

  1. Pregnancy Category B
  2. Unknown safety in Lactation

VIII. Resources

  1. N-Acetylcysteine Oral Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=75b48fab-cef6-465c-a1e0-d085b3988bc4
  2. N-Acetylcysteine Injection Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d990ef51-ced2-4359-b99b-092334d2dc9b

IX. References

  1. Nordt and Swadron in Majoewsky (2013) EM:Rap 13(4): 10-11
  2. Rowden (2006) Clin Lab Med 26(1): 49-65 [PubMed]
  3. Sung (1997) Pediatrics 100(3 pt 1): 389-91 [PubMed]

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Related Studies

Cost: Medications

acetylcysteine (on 4/20/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
ACETYLCYSTEINE 10% VIAL (NOT FOR INJECTION) Generic $0.38 per ml
ACETYLCYSTEINE 20% VIAL (NOT FOR INJECTION) Generic $1.80 per ml
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

Ontology: Acetylcysteine (C0001047)

Definition (NCI) A synthetic N-acetyl derivative of the endogenous amino acid L-cysteine, a precursor of the antioxidant enzyme glutathione. Acetylcysteine regenerates liver stores of glutathione. This agent also reduces disulfide bonds in mucoproteins, resulting in liquification of mucus. Some evidence suggests that acetylcysteine may exert an anti-apoptotic effect due to its antioxidant activity, possibly preventing cancer cell development or growth. In addition, acetylcysteine has inhibited viral stimulation by reactive oxygen intermediates, thereby producing antiviral activity in HIV patients. (NCI04)
Definition (NCI_NCI-GLOSS) A drug usually used to reduce the thickness of mucus and ease its removal. It is also used to reverse the toxicity of high doses of acetaminophen.
Definition (MSH) The N-acetyl derivative of CYSTEINE. It is used as a mucolytic agent to reduce the viscosity of mucous secretions. It has also been shown to have antiviral effects in patients with HIV due to inhibition of viral stimulation by reactive oxygen intermediates.
Definition (CSP) N-acetyl derivative of cysteine; used as a mucolytic agent to reduce the viscosity of mucous secretions.
Definition (PDQ) A synthetic N-acetyl derivative of the endogenous amino acid L-cysteine, a precursor of the antioxidant enzyme glutathione. Acetylcysteine regenerates liver stores of glutathione. This agent also reduces disulfide bonds in mucoproteins, resulting in liquification of mucus. Some evidence suggests that acetylcysteine may exert an anti-apoptotic effect due to its antioxidant activity, possibly preventing cancer cell development or growth. In addition, acetylcysteine has inhibited viral stimulation by reactive oxygen intermediates, thereby producing antiviral activity in HIV patients. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=39130&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=39130&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C200" NCI Thesaurus)
Concepts Pharmacologic Substance (T121) , Amino Acid, Peptide, or Protein (T116)
MSH D000111
SnomedCT 323348003, 320924004, 391709004, 330766004, 387440002, 77731008
English Acid, Mercapturic, Mercapturic Acid, N-Acetylcysteine, N Acetylcysteine, L-Cysteine, N-acetyl-, Acetylcysteine [eyes], Acetylcysteine [paracet pois], Acetylcysteine [resp], N Acetyl L cysteine, N-Acetyl-L-cysteine, Acetylcysteine (Obsolete), acetylcysteine, L-Alpha-acetamido-beta-mercaptopropionic Acid, N-acetyl-3-mercaptoalanine, N-Acetyl Cysteine, Acetylcysteine [paracetamol poisoning treatment], Acetylcysteine [respiratory use], ACETYLCYSTEINE, acetylcysteine (medication), acetylcysteine as mucolytic (medication), acetylcysteine as mucolytic, N-ACETYL-L-CYSTEINE 100 %, Acetylcysteine [Chemical/Ingredient], acetylcysteine n, n-acetyl-l-cysteine, mercapturic acid, n-acetylcysteine, l cysteine n acetyl, n acetyl l cysteine, acetyl cysteine, n acetylcysteine, acetyl cysteine l n, Acetylcysteine [paracetamol poisoning treatment] (product), Acetylcysteine [respiratory use] (product), Acetylcysteine - chemical, Acetylcysteine - chemical (substance), Acetylcysteine [eyes] (product), Acetyl cysteine, N-acetyl-L-cysteine, N-acetylcysteine, Acetylcysteine (product), Acetylcysteine (substance), Acetylcysteine, Acetylcysteine [eyes] (substance), Acetylcysteine [paracetamol poisoning treatment] (substance), Acetylcysteine [respiratory use] (substance), NAC
German N-Acetylcystein, N-Acetyl-Cystein, N-Acetyl-L-Cystein, Acetylcystein, Mercaptursäure
Swedish Acetylcystein
Czech acetylcystein
Finnish Asetyylikysteiini
Italian N-acetilcisteina, N-acetil-L-cisteina, Acido mercapturico, Acetilcisteina
Russian ATSETILTSISTEIN, MERKAPTUROVAIA KISLOTA, АЦЕТИЛЦИСТЕИН, МЕРКАПТУРОВАЯ КИСЛОТА
Japanese メルカプツル酸, アセチルシステイン
Polish Acetylocysteina
Croatian Acetilcistein
Spanish acetilcisteína [tratamiento de la intoxicación por paracetamol] (producto), acetilcisteína [tratamiento de la intoxicación por paracetamol], acetilcisteína (ocular), acetilcisteína (ocular) (producto), acetilcisteína [uso respiratorio] (producto), acetilcisteína [uso respiratorio], N-acetil-L-cisteína, N-acetilcisteína, acetilcisteína (producto), acetilcisteína (sustancia), acetilcisteína, Acetilcisteína, Ácido Mercapturico
French N-Acétyl-cystéine, Acétylcystéine, Acide mercapturique, N-Acétyl-L-cystéine, N-Acétylcystéine
Portuguese Acetilcisteína, Ácido Mercaptúrico
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Mucomyst (C0699252)

Concepts Pharmacologic Substance (T121) , Amino Acid, Peptide, or Protein (T116)
MSH D000111
German Acetylin, Mucomyst
English mucolytics acetylcysteine (mucomyst), acetylcysteine (Mucomyst), mucomyst, Bristol Myers Squibb Brand of Acetylcysteine Sodium Salt, Bristol Myers Squibb Brand of Acetylcysteine, Bristol-Myers Squibb Brand of Acetylcysteine Sodium Salt, Bristol-Myers Squibb Brand of Acetylcysteine, Produpharm Lappe Brand of Acetylcysteine, Roberts Brand of Acetylcysteine, UPSA Brand of Acetylcysteine, Acetylcysteine Roberts Brand, Acetylcysteine UPSA Brand, Acetylin, Mucomyst
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acetadote (C1330030)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
English Acetadote
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Pharmacology

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