How are administration errors with IV N -acetylcysteine (NAC) for the treatment of acetaminophen toxicity minimized?

Updated: Jan 17, 2020
  • Author: Susan E Farrell, MD; Chief Editor: Michael A Miller, MD  more...
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To reduce the risk of reconstitution and administration errors, simpler IV NAC regimens have been developed. [41] One such off-label regimen consists of a loading dose of 150 mg/kg, given over 60 minutes, followed by a maintenance infusion of 15 mg/kg/hr, which is continued until the serum acetaminophen concentration measures less than 10 mg/L and the liver enzyme concentrations remain normal or are trending downward. [42]

In a retrospective study in 59 pediatric patients, age 2 months to 18 years, the above described regimen appeared effective and well tolerated. Treatment durations ranged from 4.25 to 89 hours.Two patients developed hepatoxicity, but none experienced liver failure. The only documented adverse reactions to NAC were minor anaphylactoid reactions, including flushing, facial redness, and itching. These reactions occurred at the end of the loading dose infusion of IV NAC, and responded to IV diphenhydramine or slowing of the infusion rate. [42]

A randomized, controlled trial by Bateman et al reported less vomiting, retching, or need for rescue antiemetic treatment at 2 hours with a modified regimen in which IV NAC was given in a dose of 100 mg/kg over 2 hours followed by 200 mg/kg over 10 hours. The study was not powered to detect non-inferiority of the shorter protocol versus the standard approach, but the proportion of patients with a 50% increase in alanine aminotransferase concentrations did not differ between the standard and shorter modified regimen. [43]

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