Intravenous acetylcysteine for the treatment of acetaminophen overdose.
BACKGROUND
Acetaminophen is a leading cause of overdose-related hepatotoxicity. Although acetylcysteine prevents or minimizes acetaminophen-induced hepatotoxicity and reduces mortality, some patients presenting with complicated overdose scenarios (massive ingestions or combination or modified-release formulations) may develop toxicity despite administration of recommended dosage regimen.


METHODS
The article evaluates evidence regarding intravenous acetylcysteine's effectiveness in patients with acute overdoses who receive treatment within 10 h or > 10 h, patients with chronic supratherapeutic ingestions, and those with acetaminophen-induced fulminant hepatic failure. Intravenous and oral acetylcysteine are compared.


RESULTS
A one-size-fits-all approach towards acetylcysteine therapy provides suboptimal care in some patients. High-risk patients are identified. Specific discontinuation criteria are presented.


CONCLUSIONS
The standard intravenous regimen will effectively treat most early-presenting uncomplicated overdoses. Acetylcysteine dosing should be individualized in patients with complicated presentations and in particular situations in which plasma acetaminophen concentrations may be persistently elevated at the end of the infusion or in late presenters. More studies are needed to evaluate the optimal intravenous dosage regimen and the role of oral acetylcysteine in these high-risk patients. Treatment decisions may be aided by consultation with a poison center and/or clinical toxicologist.
University of Maryland, School of Pharmacy, 220 Arch Street, Room 01-108, Baltimore, MD 21201, USA. wkleinsc@rx.umaryland.edu
Wendy
W
Klein-Schwartz
Suzanne
S
Doyon
D000082:Acetaminophen / Q000506:poisoning*; D000111:Acetylcysteine / Q000008:administration & dosage*; D000208:Acute Disease; D000284:Administration, Oral; D000931:Antidotes / Q000008:administration & dosage*; D056486:Chemical and Drug Induced Liver Injury / Q000188:drug therapy* / Q000378:metabolism; D004334:Drug Administration Schedule; D062787:Drug Overdose / Q000188:drug therapy*; D016166:Free Radical Scavengers / Q000008:administration & dosage*; D006801:Humans; D007275:Injections, Intravenous; D013997:Time Factors; D016896:Treatment Outcome
D000931:Antidotes; D016166:Free Radical Scavengers; D000082:Acetaminophen; D000111:Acetylcysteine