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N-Acetylcysteine
Aka: N-Acetylcysteine, Acetylcysteine, Acetadote, Mucomyst, NAC
- Indications: Established
- Acetaminophen Overdose
- Contrast-Induced Nephropathy prevention
- Indications: Evolving
- Prevention of COPD Exacerbation
- Dose: 600-1200 mg/day in divided dosing
- Decramer (2005) Lancet 365(9470):1552-60 [PubMed]
- Idiopathic Pulmonary Fibrosis
- Dose: 1800 mg/day in divided dosing
- Demedts (2005) N Engl J Med 353(21):2229-42 [PubMed]
- Mechanism
- N-Acetylcysteine increases glutathione levels
- Acts as detoxification agent
- Acts as antioxidant
- N-Acetylcysteine increases nitric oxide concentrations
- Stimulates vasodilation
- Adverse Effects (uncommon at doses 1200 mg/day or less)
- Nausea
- Vomiting
- Diarrhea
- Anaphylactoid Reaction (8% with IV)
- Contact poison control for rate adjustment in Acetaminophen Overdose
- Stop infusion for severe reactions (deaths have occurred)
- Safety
- Pregnancy: Category B
- Dosing: Acetaminophen Overdose
- Protocol
- See Acetaminophen Overdose
- Directed by Rumack-Matthew Acetaminophen Nomogram
- http://www.ars-informatica.ca/toxicity_nomogram.php?calc=acetamin
- Continue NAC beyond protocol below if any of the following persist at end of protocol
- High Acetaminophen level or
- Increasing Bilirubin, INR or transaminases
- Formulation
- Intravenous indications
- Fulminant hepatic failure (best studied)
- Pregnancy
- Intractable Vomiting
- Oral advantages
- Preferred route
- Cheap and effective
- Lower Incidence of anaphylactoid reaction than with IV form
- Adults
- Oral
- Load: 140 mg/kg orally for 1 dose
- Next 70 mg/kg every 4 hours for total of 17 doses
- Administration pearls
- Better tolerate when chilled or mixed with orange juice or soda
- NAC smell may decrease tolerability (consider placing in covered cup with straw)
- Vomiting
- Re-dose if vomits within one hour of dose
- No need to re-dose if Vomiting after one hour (Absorbed quickly)
- Consider concurrent Ondansetron (Zofran) or other Antiemetic
- Consider switching to intravenous NAC
- Intravenous
- Load: 150 mg/kg in 200 ml D5W IV over 1 hour for 1 dose
- Next: 12.5 mg/kg/hour for 4 hours (50 mg/kg in 500 ml D5W given over 4 hours)
- Next: 6.25 mg/kg/hour for 16 hours (100 mg/kg in 1000 ml D5W given over 16 hours)
- May be extended for ongoing hepatotoxicity until Liver Function Tests start improving
- Child
- Oral: Same as for adults
- IV: Same as for adults
- EXCEPTION: For <88 lb (40 kg), dilute to 40 mg/ml in D5W
- Smaller volume to prevent Hyponatremia
- References
- Nordt and Swadron in Majoewsky (2013) EM:Rap 13(4): 10-11
- Rowden (2006) Clin Lab Med 26(1): 49-65 [PubMed]
- Sung (1997) Pediatrics 100(3 pt 1): 389-91 [PubMed]