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Acetylcysteine: Drug information

Acetylcysteine: Drug information
(For additional information see "Acetylcysteine: Patient drug information" and see "Acetylcysteine: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Acetadote
Brand Names: Canada
  • Parvolex [DSC]
Pharmacologic Category
  • Antidote;
  • Mucolytic Agent
Dosing: Adult
Acetaminophen overdose

Acetaminophen overdose: Note: Consultation with a poison control center or clinical toxicologist is highly recommended to determine optimal patient care.

Initiation of therapy:

Acute acetaminophen ingestion when the time of ingestion and history is known: Treatment should begin as soon as the need becomes evident, preferably starting no later than 8 to 10 hours postingestion (Ref). The decision to initiate treatment following acute ingestion is based on patient history (eg, time of ingestion, the timing of presentation, dose, formulation, duration of ingestion, concomitant medications, comorbid conditions), physical exam (including signs or symptoms of liver injury), and the initial serum acetaminophen concentration. Ideally, the initial serum acetaminophen concentration should be drawn between 4 and 24 hours postingestion to determine if the patient is a candidate for acetylcysteine therapy. If the serum acetaminophen concentration will return >8 hours postingestion or if the ingestion was ≥30 grams, initiate acetylcysteine treatment immediately and continue until stopping criteria are met (Ref).

• Patients who present 0 to 4 hours postingestion: Obtain a serum acetaminophen concentration at 4 hours postingestion and plot on the revised Rumack-Matthew nomograph; initiate acetylcysteine treatment if the serum acetaminophen concentration falls on or above the treatment line and continue until stopping criteria are met. Patients with an undetectable serum acetaminophen concentration at 2 to 4 hours postingestion are unlikely to have ingested a significant amount of acetaminophen; however, consultation with a poison control center or clinical toxicologist is recommended to determine the appropriate course of action (Ref).

• Patients who present 4 to 8 hours postingestion: Obtain a serum acetaminophen concentration immediately and plot on the revised Rumack-Matthew nomograph; initiate acetylcysteine treatment if the serum acetaminophen concentration falls on or above the treatment line and continue until stopping criteria are met (Ref).

• Patients who present 8 to 24 hours postingestion: Immediately initiate acetylcysteine therapy and obtain a serum acetaminophen concentration and complete metabolic panel; when the serum acetaminophen concentration results are available, plot on the revised Rumack-Matthew nomograph. If the serum acetaminophen concentration is on or above the treatment line, continue acetylcysteine therapy until stopping criteria are met; if the initial serum acetaminophen concentration is below the treatment line, discontinuation of acetylcysteine therapy may considered (Ref).

• Patients who present >24 hours postingestion: Immediately initiate acetylcysteine therapy and obtain a serum acetaminophen concentration and complete metabolic panel. If the serum acetaminophen concentration is >10 mcg/mL or if serum transaminases are abnormal (unless the abnormality reflects baseline for that patient), continue acetylcysteine therapy until stopping criteria are met. If the serum acetaminophen concentration is ≤10 mcg/mL and serum transaminases are normal (unless abnormal is baseline for that patient), discontinuation of acetylcysteine therapy may considered (Ref).

• Acute coingestion of acetaminophen and anticholinergic or opioid agonist medications: Obtain a serum acetaminophen concentration between 4 and 24 hours postingestion. Initiate treatment if the serum acetaminophen concentration, when plotted on the revised Rumack-Matthew nomograph, is on or above the treatment line; treatment should continue until stopping criteria are met. If a serum acetaminophen concentration drawn between 4 and 24 hours is below the treatment line but >10 mcg/mL and the patient has concurrently taken agents that may delay acetaminophen absorption (eg anticholinergic or opioid agents), repeat the serum acetaminophen concentrations 4 to 6 hours after the first measurement to determine the need for acetylcysteine therapy (Ref).

• Acute ingestion of an extended-release acetaminophen product: Obtain a serum acetaminophen concentration between 4 and 24 hours postingestion. Initiate treatment if the serum acetaminophen concentration, when plotted on the revised Rumack-Matthew nomograph, is on or above the treatment line; treatment should continue until stopping criteria are met. If a serum acetaminophen concentration drawn between 4 and 12 hours is below the treatment line but >10 mcg/mL, repeat the serum acetaminophen concentrations 4 to 6 hours after the first measurement to determine the need for acetylcysteine therapy (Ref).

Ingestion with an unknown or unreliable history: Obtain a serum acetaminophen concentration and complete metabolic panel. Initiate acetylcysteine therapy if the serum acetaminophen concentration is >10 mcg/mL or if serum transaminases are abnormal (unless the abnormality reflects baseline for that patient); treatment should continue until stopping criteria are met. Do not administer acetylcysteine if serum acetaminophen concentration is ≤10 mcg/mL and serum transaminases are normal (unless abnormal is baseline for that patient) (Ref).

Repeated supratherapeutic acetaminophen ingestion (RSTI): Obtain serum acetaminophen concentration, serum transaminases, and serum creatinine. Initiate acetylcysteine therapy if the serum acetaminophen concentration is ≥20 mcg/mL or if serum transaminases are abnormal (unless the abnormality reflects baseline for that patient); treatment should continue until stopping criteria are met. Do not administer acetylcysteine if serum acetaminophen concentration is <20 mcg/mL and serum transaminases are normal (unless abnormal is baseline for that patient) (Ref).

Duration of therapy and stopping criteria: In patients who were deemed candidates for acetylcysteine therapy, treatment should continue for at least 20 to 24 hours (depending on the regimen chosen). Prior to the end of the infusion, measure the serum acetaminophen concentration, serum transaminases, and PT/INR; discontinue acetylcysteine therapy if the stopping criteria are met. If the stopping criteria are not met, continue acetylcysteine therapy and measure the serum acetaminophen concentration, serum transaminases, and PT/INR every 12 to 24 hours in addition to other clinical variables per institutional protocol (eg, factor V, presence of encephalopathy); once stopping criteria are met, treatment may be discontinued (Ref):

Stopping criteria:

• Serum acetaminophen concentration <10 mcg/mL

• INR <2

• Serum transaminases are normal for the patient or, if elevated, have decreased from the peak by 25% to 50%

• Patient is clinically well

Dosing regimen(s): Multiple regimens are available which may be country- and/or institution-specific; comparative efficacy has not been established. The chosen regimen should deliver at least 300 mg/kg orally or intravenously during the first 20 to 24 hours of treatment (Ref). Higher doses may be required following a high-risk ingestion (≥30 grams or a serum acetaminophen concentration that is on or above the high-risk line when plotted on the revised Rumack-Matthew nomograph) (Ref); consultation with a poison control center or clinical toxicologist is highly recommended.

Labeled regimens and a select number of alternative regimens are provided below; refer institution-specific regimen where applicable.

Oral (solution for oral administration):

72-hour regimen: Consists of 18 doses; total dose delivered: 1,330 mg/kg.

Loading dose: 140 mg/kg.

Maintenance dose: 70 mg/kg every 4 hours; repeat dose if emesis occurs within 1 hour of administration.

IV:

21-hour regimen: Consists of 3 doses; total dose delivered: 300 mg/kg.

Loading dose: 150 mg/kg (maximum: 15 g) infused over 1 hour.

Second dose: 50 mg/kg (maximum: 5 g) infused over 4 hours.

Third dose: 100 mg/kg (maximum: 10 g) infused over 16 hours.

Note: The fluid volume should be reduced in patients weighing ≤40 kg. The IV route may be preferred in pregnant patients; however, there are no data to suggest the oral route would be less effective (Ref).

Alternative recommendations: Refer to institution-specific regimen where applicable. The chosen regimen should deliver at least 300 mg/kg orally or intravenously during the first 20 to 24 hours of treatment (Ref).

"Two bag method" (off-label dosing): Consists of 2 doses; total dose delivered: 300 mg/kg (Ref):

First dose: 200 mg/kg infused over 4 hours.

Second dose: 100 mg/kg infused over 16 hours.

Note: The "two bag method" has been associated with fewer and milder nonallergic anaphylactic reactions as compared to the manufacturer's labeled dosing (Ref).

"Single bag method" (off-label dosing): Total dose delivered 430 mg/kg: Initiate therapy with 150 mg/kg infused over 1 hour; then decrease the rate to 14 mg/kg/hour and infuse for an additional 20 hours (Ref).

Note: Patients weighing >69 kg will require a second bag to complete the dosing regimen.

Obesity: In patients who weigh >100 kg, the calculation of the IV acetylcysteine dose should be capped at 100 kg of body weight (Ref).

Adjuvant therapy in respiratory conditions

Adjuvant therapy in respiratory conditions:

Note: For inhaled/nebulized/direct instillation therapy, may consider premedication with an aerosolized bronchodilator 10 to 15 minutes prior to dose in patients with reactive airway disease or in patients who develop bronchospasm.

Inhalation, nebulization (face mask, mouth piece, tracheostomy): Acetylcysteine 10% and 20% solution (dilute 20% solution with sodium chloride or sterile water for inhalation); 10% solution may be used undiluted: 3 to 5 mL of 20% solution or 6 to 10 mL of 10% solution until nebulized given 3 to 4 times/day; dosing range: 1 to 10 mL of 20% solution or 2 to 20 mL of 10% solution every 2 to 6 hours.

Inhalation, nebulization (tent, croupette): Dose must be individualized; may require up to 300 mL solution/treatment.

Direct instillation:

Into tracheostomy: 1 to 2 mL of 10% to 20% solution every 1 to 4 hours.

Through percutaneous intratracheal catheter: 1 to 2 mL of 20% or 2 to 4 mL of 10% solution every 1 to 4 hours via syringe attached to catheter.

Diagnostic bronchogram

Diagnostic bronchogram: Note : For inhaled/nebulized/direct instillation therapy, may consider premedication with an aerosolized bronchodilator 10 to 15 minutes prior to dose in patients with reactive airway disease or in patients who develop bronchospasm.

Nebulization or intratracheal: 1 to 2 mL of 20% solution or 2 to 4 mL of 10% solution administered 2 to 3 times prior to procedure.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Note: Seventy percent of total clearance is due to non–kidney-related mechanisms (Ref). However, a multiple-dose study of a sustained-release formulation of acetylcysteine in patients with end stage kidney disease demonstrated substantially reduced clearance (decreased by 90%), 7-fold larger AUC and 13-fold longer half-life compared with subjects with normal kidney function (Ref). However, acetylcysteine is generally well-tolerated and short courses of therapy can be considered without dose adjustment for kidney impairment (Ref).

Altered kidney function:

Oral, IV, inhalation: No dosage adjustment necessary for any degree of kidney dysfunction (Ref).

Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m2): Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Younger patients (<55 years of age) admitted post-trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Ref).

Oral, IV, inhalation: No dosage adjustment necessary (Ref).

Hemodialysis, intermittent (thrice weekly):

Oral, IV, inhalation: Dialyzable ~40% to 80% (Ref): No dosage adjustment necessary (Ref). Note: When administered as a continuous IV infusion for the treatment of acetaminophen overdose, double the acetylcysteine dose during the hemodialysis procedure to account for extracorporeal removal of the drug (Ref); consultation with a poison control center or clinical toxicologist is highly recommended to determine optimal patient care.

Peritoneal dialysis: Oral, IV, inhalation: Likely to be dialyzable based on physicochemical characteristics: No dosage adjustment necessary (Ref).

CRRT: Oral, IV, inhalation: No dosage adjustment necessary (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): Oral, IV, inhalation: No dosage adjustment necessary (Ref).

Dosing: Hepatic Impairment: Adult

Oral, IV: There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Obesity: Adult

Refer to indication-specific dosing for obesity-related information (may not be available for all indications).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Acetylcysteine: Pediatric drug information")

Acetaminophen poisoning

Acetaminophen poisoning:

Note: Only the 72-hour oral and 21-hour IV regimens are FDA approved.

Initiation of therapy:

Ideally, in patients with an acute acetaminophen ingestion, treatment should begin within 8 hours of ingestion or as soon as possible after ingestion. If there will be a delay in obtaining a serum acetaminophen concentration, initiate treatment as soon as possible and reevaluate the need for continued acetylcysteine upon receipt of the results. In patients who meet the criteria for acetylcysteine therapy based on the initial serum acetaminophen concentration, there is no reason to obtain additional acetaminophen concentrations, even in a patient who ingested an extended-release product. In patients with a suspected acute ingestion where the time of ingestion is unknown, the serum acetaminophen concentration is unobtainable or uninterpretable within 8 hours of ingestion, the patient presents >8 hours after ingestion, or there is clinical evidence of toxicity, initiate treatment immediately and re-evaluate the need for acetylcysteine upon receipt of the results (if applicable). In patients who present following repeated supratherapeutic ingestions (RSTI) and treatment is deemed appropriate, acetylcysteine should be initiated immediately. It is critical that there is no delay in the administration of the loading dose of acetylcysteine and no delays in the administration of bags 2 and 3 (Ref).

Note: There is no reason to withhold activated charcoal in a patient with an acetaminophen overdose. If activated charcoal is administered within 1 to 2 hours postingestion of acetaminophen, it may provide additional hepatoprotection in patients requiring N-acetylcysteine treatment for acetaminophen overdose (Ref).

Duration of therapy:

Discontinue treatment if the initial serum acetaminophen concentration indicates the patient is at "low" risk for hepatotoxicity when plotted on the Rumack-Matthew nomogram. In those patients who require a follow-up acetaminophen concentration, do not discontinue treatment if the follow-up serum acetaminophen concentration indicates the patient is at "low" risk for hepatotoxicity. In patients who continue to experience symptoms of hepatotoxicity or elevated liver function tests at the conclusion of a 72-hour oral or 21-hour IV regimen, extending the treatment course may be appropriate; however, when and to which patients additional doses should be administered is unclear. Possible candidates for extended therapy include patients with a suspected massive overdose, concomitant ingestion of other substances, or patients with preexisting liver disease. In patients with persistently elevated acetaminophen concentrations, persistently elevated liver function tests, or an elevated INR, additional acetylcysteine should be administered. Typically, an additional "third dose" or "third bag" (IV: 100 mg/kg [maximum dose: 10 g/dose] infused over 16 hours) is administered; however, this dose may be inadequate in some patients (Ref). Regardless of the treatment regimen selected, serum acetaminophen concentrations, liver function, and clinical status should be evaluated during and prior to the end of the treatment regimen to determine if treatment discontinuation is appropriate. Some experts suggest continuing therapy until there are undetectable acetaminophen concentrations, improving hepatic aminotransferases, and improving prognostic markers (eg, creatinine, lactate pH, prothrombin time/INR, phosphate) (Ref). In patients with a low risk for acetaminophen-induced hepatotoxicity, an abbreviated 12-hour N-acetylcysteine dosing regime has been compared to a 20-hour protocol; no difference was shown in measured acetaminophen metabolites or clinical outcomes (Ref). A two-bag regimen with the same total dose of 300 mg/kg has been used, but is not FDA-approved (Ref). Consultation with a poison control center or clinical toxicologist is highly recommended to determine optimal patient care.

Oral: Effervescent tablet (Cetylev) or solution for oral administration (using injectable/nebulizer formulation):

Note: There is no data for use of the OTC supplement tablets for acetaminophen poisoning. Dosing below is based on effervescent tablet (Cetylev) or a solution for oral administration that is prepared from the solution for oral inhalation:

Infants, Children, and Adolescents: 72-hour regimen: Consists of 18 doses; total dose delivered: 1,330 mg/kg.

Loading dose: Oral: 140 mg/kg; maximum dose: 15 g/dose.

Maintenance dose: Oral: 70 mg/kg every 4 hours for 17 doses; maximum dose: 7.5 g/dose; repeat dose if emesis occurs within 1 hour of administration; Note: Although not FDA approved, some experts may recommend a shortened course of oral acetylcysteine therapy (<72 hours of treatment) under certain circumstances (Ref). Consultation with a poison control center or clinical toxicologist is highly recommended when considering the discontinuation of oral acetylcysteine prior to the conclusion of a full 18-dose course of therapy.

IV: Acetadote:

Three-bag method: Infants, Children, and Adolescents: 21-hour regimen: Consists of 3 doses; total dose delivered: 300 mg/kg.

Loading dose: IV: 150 mg/kg infused over 60 minutes; maximum dose: 15 g/dose.

Second dose: IV: 50 mg/kg infused over 4 hours; maximum dose: 5 g/dose.

Third dose: IV: 100 mg/kg infused over 16 hours; maximum dose: 10 g/dose.

Two-bag method: Limited data available: Note: The "two-bag method" has been associated with fewer and milder nonallergic anaphylactic reactions as compared to the manufacturer's labeled dosing (Ref).

Children ≥12 years and Adolescents: 20-hour regimen: Consists of 2 doses; total dose delivered: 300 mg/kg; maximum total dose: 30 g (Ref):

First dose: IV: 200 mg/kg infused over 4 hours.

Second dose: IV: 100 mg/kg infused over 16 hours.

Respiratory conditions, adjuvant therapy

Respiratory conditions, adjuvant therapy: Note: Patients should receive an aerosolized bronchodilator 10 to 15 minutes prior to acetylcysteine:

Nebulized inhalation:

Face mask, mouthpiece, tracheostomy:

Infants: 1 to 2 mL of 20% solution (may be further diluted with sodium chloride or sterile water for inhalation) or 2 to 4 mL of 10% solution (undiluted); administer 3 to 4 times daily.

Children: 3 to 5 mL of 20% solution (may be further diluted with sodium chloride or sterile water for inhalation) or 6 to 10 mL of 10% solution (undiluted); administer 3 to 4 times daily.

Adolescents: 3 to 5 mL of 20% solution (may be further diluted with sodium chloride or sterile water for inhalation) or 6 to 10 mL of 10% solution (undiluted); administer 3 to 4 times daily; usual dosing range: 20% solution: 1 to 10 mL or 10% solution: 2 to 20 mL every 2 to 6 hours.

Tent, croupette: 10% or 20% solution: Dose must be individualized; dose is volume of solution necessary to maintain a very heavy mist in tent or croupette; in some cases, may require up to 300 mL solution/treatment.

Direct instillation: Children and Adolescents:

Endotracheal: 1 to 2 mL of 10% to 20% solution every 1 to 4 hours as needed.

Percutaneous endotracheal catheter: 1 to 2 mL of 20% or 2 to 4 mL of 10% solution every 1 to 4 hours via syringe attached to catheter.

Diagnostic bronchogram

Diagnostic bronchogram: Children and Adolescents: Nebulization or endotracheal: 1 to 2 mL of 20% solution or 2 to 4 mL of 10% solution administered 2 to 3 times prior to procedure.

Distal intestinal obstruction syndrome

Distal intestinal obstruction syndrome (previously known as meconium ileus equivalent): Limited data available; dosing regimens variable (polyethylene glycol has become more widely used for this indication):

Oral:

Children <10 years: 30 mL of 10% solution diluted in 30 mL juice or soda 3 times/day for 24 hours.

Children 10 years and Adolescents: 60 mL of 10% solution diluted in 60 mL juice or soda 3 times/day for 24 hours.

Note: Prior to treatment, administer a phosphosoda enema. A clear liquid diet should be used during the 24-hour acetylcysteine treatment.

Rectal enema: Children: Varying dosages; 100 to 300 mL of 4% to 6% solution 2 to 4 times daily; 50 mL of 20% solution 1 to 4 times daily and 5 to 30 mL of 10% to 20% solution 3 to 4 times daily have been used; rectal enemas appear to have less favorable results than oral administration (Ref). Note: Higher concentrations (10% to 20%) appear to increase fluid in the bowel and lead to increased incidence of adverse effects (Ref).

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions (Significant): Considerations
Nonimmune anaphylaxis

Nonimmune anaphylaxis (previously known as anaphylactoid reactions) may occur, and symptoms include skin rash, flushing, urticaria, respiratory distress, bronchospasm, angioedema, and/or hypotension (Ref). Fatal reactions have been reported (Ref).

Mechanism: Dose-related; nonimmunogenic histamine release from mast cells and basophils (Ref). In contrast to IgE-mediated anaphylaxis, prior exposure to acetylcysteine is not required for development of symptoms; continued or future treatment is not contraindicated (Ref).

Onset: Immediate hypersensitivity reactions: Rapid; occur within 1 hour of administration but may occur up to 6 hours after initial exposure (Ref), and up to 24 hours in rare cases (Ref).

Risk factors:

Modifiable:

• Method of administration: Three-bag IV regimens result in more reactions than two-bag IV regimens (Ref)

• Rapid initial acetylcysteine infusion rate (Ref): Reducing the infusion rate has been shown to reduce the risk of nonimmune anaphylaxis (Ref)

Nonmodifiable:

• History of asthma (Ref)

• Lower acetaminophen concentrations (Ref): Patients with lower acetaminophen concentrations (<150 mg/L) may be at an increased risk for nonimmune anaphylaxis (Ref)

• Females (Ref)

• Age: Unknown. Younger age may result in increased (Ref) or decreased risk (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Intravenous: Reported adverse reactions are for infants, children, adolescents, and adults.

1% to 10%:

Cardiovascular: Edema (1% to 2%), facial flushing (≤8%), flushing (1% to 3%), tachycardia (3%)

Dermatologic: Pruritus (3% to 4%), skin rash (4%), urticaria (≤8%)

Gastrointestinal: Nausea (1%), vomiting (3% to 6%)

Hypersensitivity: Hypersensitivity reaction (including severe hypersensitivity reaction: 1% to 7%)

Nervous system: Tightness in chest or throat (1%)

Respiratory: Respiratory system disorder (2%; including bronchospasm, cough, dyspnea, respiratory distress, stridor, wheezing), rhonchi (1%)

<1%:

Cardiovascular: Hypotension

Hypersensitivity: Anaphylaxis

Inhalation:

Frequency not defined:

Cardiovascular: Chest tightness

Dermatologic: Cold and clammy skin

Gastrointestinal: Nausea, stomatitis, vomiting

Nervous system: Drowsiness

Respiratory: Bronchoconstriction, bronchospasm, rhinorrhea

Miscellaneous: Fever

Postmarketing (any formulation):

Cardiovascular: Presyncope (Bebarta 2010), syncope (Bebarta 2010)

Hematologic & oncologic: Clotting factor suppression (Sandilands 2009), increased INR (Sandilands 2009)

Hypersensitivity: Angioedema (Sandilands 2009), nonimmune anaphylaxis (Bebarta 2010)

Nervous system: Anxiety (Bebarta 2010)

Contraindications

Hypersensitivity to acetylcysteine or any component of the formulation.

Note: A prior anaphylactoid reaction is not a contraindication for administration of acetylcysteine during a subsequent acetaminophen overdose (Dart 2023).

Warnings/Precautions

Other warnings/precautions:

• Acute acetaminophen overdose: Appropriate use: Acetylcysteine is indicated in patients with a serum acetaminophen concentration that is on or above the treatment line when plotted on the revised Rumack-Matthew nomogram (Dart 2023). There are several situations where the nomogram is of limited use. Serum acetaminophen concentrations obtained <4 hours postingestion are not reliable, except to document the presence of acetaminophen (Seifert 2015). An undetectable acetaminophen concentration at 2 to 4 hours postingestion typically rules out signification ingestion; however, consultation with a poison control center or clinical toxicologist is recommended to determine risk of acetaminophen toxicity (Dart 2023). Patients presenting late may have undetectable serum concentrations, despite having received a toxic dose. The nomogram is less predictive of hepatic injury following an acute overdose with an extended release acetaminophen product. The nomogram also does not take into account patients who may be at higher risk of acetaminophen toxicity (eg, patients with alcohol use disorder, malnourished patients, concurrent use of CYP2E1 enzyme-inducing agents [eg, isoniazid]). Nevertheless, acetylcysteine should be administered to any patient with signs of hepatotoxicity, even if the serum acetaminophen concentration is low or undetectable. Patients who present >24 hours after an acute ingestion or patients who present following an acute ingestion with an unknown or unreliable history may be candidates for acetylcysteine therapy; consultation with a poison control center or clinical toxicologist is highly recommended.

• Repeated supratherapeutic ingestion (RSTI) of acetaminophen: Appropriate use: The Rumack-Matthew nomogram is not designed to be used following RSTIs. In general, an accurate past medical history, including a comprehensive acetaminophen ingestion history, in conjunction with serum transaminase concentrations and serum acetaminophen concentrations, may give the clinician insight as to the patient's risk of acetaminophen toxicity. Acetylcysteine is indicated when serum acetaminophen concentrations or serum acetaminophen concentrations are ≥20 mcg/mL, even in the absence of hepatic injury, or in patients with laboratory evidence and/or signs and symptoms of hepatotoxicity (Dart 2023; Hendrickson 2006; Jones 2000). Consultation with a poison control center or a clinical toxicologist is highly recommended.

• Route of administration: Both oral and IV acetylcysteine are effective in reducing the risk of acetaminophen-related hepatotoxicity (Yarema 2009). A comprehensive review concurred that acetylcysteine therapy appears to reduce acetaminophen-related hepatotoxicity; however, it is also concluded that there is paucity of quality data to determine which route of administration or dosing regimen is superior (Chiew 2018). Consultation with a poison control center or a clinical toxicologist is highly recommended to determine the preferred route and duration of administration.

Dosage form specific issues:

• Oral administration: Gastrointestinal hemorrhage: Oral administration of acetylcysteine may result in nausea and vomiting, which may exacerbate vomiting associated with acetaminophen overdose. Therefore, patients at risk of gastrointestinal hemorrhage (eg, esophageal varices, peptic ulcer) may experience an even higher risk of gastrointestinal hemorrhage during therapy.

• Inhalation: Since increased bronchial secretions may develop after inhalation, percussion, postural drainage, and suctioning should follow. If bronchospasm occurs, administer a bronchodilator; discontinue acetylcysteine if bronchospasm progresses.

• IV administration: IV administration can cause fluid overload, potentially resulting in hyponatremia, seizure, and death.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Inhalation:

Generic: 10% [100 mg/mL] (4 mL, 10 mL, 30 mL); 20% [200 mg/mL] (10 mL, 30 mL)

Solution, Inhalation [preservative free]:

Generic: 10% [100 mg/mL] (4 mL, 10 mL, 30 mL); 20% [200 mg/mL] (4 mL, 10 mL, 30 mL)

Solution, Intravenous [preservative free]:

Acetadote: 200 mg/mL (30 mL)

Generic: 200 mg/mL (30 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Acetadote Intravenous)

200 mg/mL (per mL): $9.14

Solution (Acetylcysteine Inhalation)

10% (per mL): $2.84 - $3.36

20% (per mL): $1.80 - $4.20

Solution (Acetylcysteine Intravenous)

200 mg/mL (per mL): $1.48 - $7.52

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Inhalation:

Parvolex: 20% [200 mg/mL] ([DSC])

Generic: 20% [200 mg/mL] (10 mL, 30 mL)

Administration: Adult

Inhalation: Acetylcysteine is incompatible with tetracyclines, erythromycin, amphotericin B, iodized oil, chymotrypsin, trypsin, and hydrogen peroxide. Administer separately. Intermittent aerosol treatments are commonly given when patient arises, before meals, and just before retiring at bedtime.

Oral: Solution for oral administration: For the treatment of acetaminophen overdose, administer orally as a 5% solution. Use within 1 hour of preparation. The unpleasant odor (sulfur-like) becomes less noticeable as treatment progresses. If patient vomits within 1 hour of dose, readminister. (Note: It is helpful to put the acetylcysteine on ice, in a cup with a cover, and drink through a straw; alternatively, administer via an NG tube).

IV (Acetadote): Acetaminophen overdose: Note: It is critical that there is no delay in the administration of the loading dose or subsequent doses of acetylcysteine (Ref). Labeled regimens and a select number of alternative regimens are provided below; refer institution-specific regimen where applicable.

Loading dose: Administer over 1 hour.

Second dose: Administer over 4 hours.

Third dose: Administer over 16 hours.

If the commercial IV form is unavailable, the solution for inhalation has been used; each dose should be infused through a 0.2 micron Millipore filter (in-line) over 60 minutes (Ref); intravenous administration of the solution for inhalation is not USP 797-compliant.

Alternative recommendations (off-label):

"Two bag method" (off-label dosing): Administer first dose (200 mg/kg) over 4 hours, then administer the second dose (100 mg/kg) over 16 hours (Ref).

"Single bag method" (off-label dosing): Administer initial dose (150 mg/kg) over 60 minutes, then decrease the rate and administer the remaining dose (14 mg/kg/hour) over 20 hours (Ref). Note: Patients weighing >69 kg will require a second bag to complete the dosing regimen.

Administration: Pediatric

Oral: Differs based on use.

Acetaminophen poisoning:

Effervescent tablets: Cetylev: Use within 2 hours of preparation. If the patient vomits within 1 hour of administration, repeat that dose. If the patient is persistently unable to retain the orally administered acetylcysteine, acetylcysteine may be administered by nasoduodenal tube.

Solution for oral administration: Administer as a 5% solution (see Preparation for Administration); use within 1 hour of preparation. If patient vomits within 1 hour of dose, readminister. Note: The unpleasant odor (sulfur-like) becomes less noticeable as treatment progresses. It is helpful to put the acetylcysteine on ice, in a cup with a cover, and drink through a straw; alternatively, administer via an NG tube.

Parenteral: Acetaminophen poisoning:

IV: Acetadote:

Three-bag method: Neonates, Infants, Children, and Adolescents:

Loading dose: Administer IV over 60 minutes.

Second dose: Administer IV over 4 hours.

Third dose: Administer IV over 16 hours.

Note: If the commercial IV form is unavailable, the solution for inhalation has been used; each dose should be infused through a 0.2 micron Millipore filter (in-line) over 60 minutes (Ref); intravenous administration of the solution for inhalation is not USP 797-compliant.

Two-bag method: Children ≥12 years and Adolescents:

First dose: Administer IV over 4 hours.

Second dose: Administer IV over 16 hours.

Inhalation solution: May be administered by nebulization either undiluted (both 10% and 20%) or diluted in NS. Acetylcysteine solution for inhalation is incompatible with tetracyclines, erythromycin, amphotericin B, iodized oil, chymotrypsin, trypsin, and hydrogen peroxide. Administer separately. Intermittent aerosol treatments are commonly given when patient arises, before meals, and just before retiring at bedtime.

Rectal: Inhalation solution may be given undiluted (10% to 20%) or diluted to 4% to 6% solution and administer rectally (Ref).

Use: Labeled Indications

Acetaminophen overdose: To prevent or lessen hepatic injury after ingestion of a potentially hepatotoxic quantity of acetaminophen in patients with acute ingestion or from repeated supratherapeutic ingestion (RSTI).

Mucolytic: Adjunct therapy in patients with abnormal, viscid, or inspissated mucous secretions in conditions such as: chronic bronchopulmonary disease (chronic emphysema, emphysema with bronchitis, chronic asthmatic bronchitis, tuberculosis, bronchiectasis, primary amyloidosis of the lung); acute bronchopulmonary disease (pneumonia, bronchitis, tracheobronchitis); pulmonary complications of cystic fibrosis; tracheostomy care; pulmonary complications associated with surgery; use during anesthesia; posttraumatic chest conditions; atelectasis due to mucous obstruction; diagnostic bronchial studies (bronchograms, bronchospirometry, bronchial wedge catheterization).

Medication Safety Issues
Sound-alike/look-alike issues:

Acetylcysteine may be confused with acetylcholine

Mucomyst may be confused with Mucinex

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Charcoal, Activated: May decrease the serum concentration of Acetylcysteine. Risk C: Monitor therapy

Pregnancy Considerations

Acetylcysteine crosses the placenta.

Acetylcysteine may be used to treat acetaminophen overdose during pregnancy (Wilkes 2005). Delaying treatment to pregnant women with acetaminophen toxicity may increase the risk of adverse maternal and fetal outcomes. The IV route may be preferred in pregnant patients; however, there are no data to suggest the oral route would be less effective (Dart 2023). In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003).

Breastfeeding Considerations

It is not known if acetylcysteine is excreted in breast milk. According to the manufacturer, the decision to continue or discontinue breast-feeding during therapy should take into account the risk of infant exposure, the benefits of breast-feeding to the infant, and benefits of treatment to the mother. Based on pharmacokinetics, acetylcysteine should be nearly completely cleared 30 hours after administration; breast-feeding women may consider pumping and discarding breast milk for 30 hours after administration.

Monitoring Parameters

Acetaminophen overdose: Monitor patient for the development of anaphylaxis or anaphylactoid reactions; monitor serum acetaminophen concentrations, AST, ALT, bilirubin, PT, INR, serum creatinine, BUN, serum glucose, hemoglobin, hematocrit, and electrolytes. Assess patient for nausea, vomiting, and skin rash following oral administration. Reassess LFTs for possible hepatotoxicity every 4 to 6 hours. An early elevation in the INR may be related to acetylcysteine therapy (Schmidt 2002). For the purpose of determining if discontinuation of acetylcysteine is appropriate, the serum acetaminophen concentration, serum transaminases, and PT/INR should be evaluated every 12 to 24 hours (Dart 2023).

Mechanism of Action

Acetaminophen overdose: Acetylcysteine acts as a hepatoprotective agent by restoring hepatic glutathione, serving as a glutathione substitute, and enhancing the nontoxic sulfate conjugation of acetaminophen.

Mucolytic: Exerts mucolytic action through its free sulfhydryl group which opens up the disulfide bonds in the mucoproteins thus lowering mucous viscosity.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Inhalation: 5 to 10 minutes.

Duration: Inhalation: >1 hour.

Distribution: Vdss: 0.47 L/kg.

Protein binding: 66% to 87%.

Metabolism: Undergoes extensive first pass metabolism to form cysteine and disulfides (N,N-diacetylcysteine and N-acetylcysteine); cysteine is further metabolized to form glutathione and other metabolites.

Half-life elimination:

Reduced acetylcysteine: 2 hours.

Total acetylcysteine: Adults: 5.6 hours; Newborns: 11 hours.

Time to peak, plasma: Oral solution: 1 to 2 hours.

Excretion: Urine (13% to 38%).

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Fluimucil;
  • (AR) Argentina: AC Lan | Acc | Acemuk | Acetilcisteina Teva | Broncolium | Maxvan;
  • (AT) Austria: Acetylcystein Aponova | Fluimucil Antidot | Nac akut;
  • (AU) Australia: Acetadote;
  • (BD) Bangladesh: Tylace;
  • (BE) Belgium: Acetylcysteine bexal | Acetylcysteine eg | Acetylcysteine eurogenerics | Acetylcysteine merck-generics | Acetylcysteine sandoz | Acetylcysteine teva generics belgium | Bisolaclar | Docacetyl | Lysomucil | Mucovics | Nactop | Touxium Mucolyticum;
  • (BF) Burkina Faso: Fluimucil | Mucomyst;
  • (BG) Bulgaria: Acc | Acc 200 | Fluimucil;
  • (BR) Brazil: Acetilcisteina | Fluicis | Fluimucil | Nac | Pulmonare;
  • (CH) Switzerland: Acc | Acc sandoz | Acemucol | Acetylcystein actavis | Acetylcystein Cimex | Acetylcystein Helvepharm | Acetylcystein klinge | Acetylcystein Teva | Acetylcystein zentiva | Acetylfelan | Amavita acetylcystein | Bexin hustenloeser | Coop vitality Acetylcystein | Dynamucil | Dynamucil 100 | Ecomucyl | Fluimucil | Fluimucil erkaeltungshusten | Fluimucil sugar | Helvetussin | Muco | Muco mepha | Muco X | Mucofluid | Mucomed | Mucosil acc | Mucostop | Neocitran hustenloeser | Secresol | Secresol ohne zucker | Solmucol | Solmucol Erkaeltungshusten | Sun store acetylcystein;
  • (CI) Côte d'Ivoire: Mucospire;
  • (CN) China: A si xin tai | Ao nuo feng | Fluimucil | Fu lou shi | Fu lu shi | Jin kang su li | Mucosof;
  • (CO) Colombia: Acemuk | Aflux | Evaflen | Fluimucil | Zifluvis;
  • (CZ) Czech Republic: Acc | Acc long | Acetylcystein max | Fluimucil | Nac al | Sanomux;
  • (DE) Germany: Acc | ACC akut | Acebraus | Acemuc | Acetylcystein | Acetylcystein Siga | Acetylcystein Trom | Acetyst | Atse | Azubronchin | Bromuc | Bronchowieb | Durabronchal | Fluimucil | Lindocetyl | Muciteran | Myxofat | Nac | Nac aiwa | Nac akut | Nac akut hustenloeser | Nac al | Nac Axcount | Nac stada | Phamuc | Pulmicret | Sigamucil | Siran akut | Stas akut hustenloesung | Tamuc | Temmlermucil | Tussamag Nac akut;
  • (DK) Denmark: Kuril | Mucolysin;
  • (DO) Dominican Republic: Acedip | Acypront | Flemaxin | Fluimucil;
  • (EC) Ecuador: Acemuk | Acetiflux | Acypront | Antusin | Etimucil | Flemil | Flemisol | Flucil | Fluicetil s | Fluidine | Fluimexina | Fluimucil | Virobron;
  • (EE) Estonia: Acc | Acetylcystein | Acetylcystein-stadapharm | Aceylcystein | Bronchostad | Granon | Mucovit | Nac | Sigamucil | Wintrozen;
  • (EG) Egypt: Acc | Fluimucil | Hidonac | Rotacysteine | Windy;
  • (ES) Spain: Acetilcisteina | Acetilcisteina acost | Acetilcisteina Alter | Acetilcisteina aristo | Acetilcisteina Bexalabs | Acetilcisteina davur | Acetilcisteina Kern pharma | Acetilcisteina MABO | Acetilcisteina sandoz | Acetilcisteina stada | Acetilcisteina Teva | Acetilcisteina ur | Bisolvon muco | Cinfamucol acetilcisteina | Fluimucil | Fluimucil forte | Flumil | Flumil Antidoto | Flumilexa | Frionex | Iniston mucus | Mucolibex | Ratiomucol | Sandozcare mucolitico;
  • (ET) Ethiopia: Acetylcisteine | Acetylcysteine sandoz;
  • (FI) Finland: Bisolaclar | Meditus | Mucomyst | Mucoporetta | Mucoratio;
  • (FR) France: Acetylcysteine alpex | Acetylcysteine Arrow | Acetylcysteine biogaran | Acetylcysteine merck | Acetylcysteine sandoz | Exomuc | Fluimucil | Hidonac | Mucodrill | Mucomyst;
  • (GB) United Kingdom: Acecil | Acepiro | Aceteff | Nacsys | Oronac;
  • (GR) Greece: Flumil Antidoto | Hidonac antidoto | Lilovon | Mucomyst | Trebon n | Vlenolys;
  • (HK) Hong Kong: Acypront | Advance mucolytic | Fluimucil | Fluimucil a | Hidonac | Nac;
  • (HR) Croatia: Fluimukan | Fluimukan akut | Fluimukan akut Junior | Fluimukan Long | Naxil forte;
  • (HU) Hungary: Acc | Acc/rg | Fluimucil | Fluimucil antidote | Mentopin;
  • (ID) Indonesia: Acetin | Fluimucil | Hidonac | L acys | Mukosil | Promucil | Resfar | Siran;
  • (IE) Ireland: Acetylcysteine Essential-Healthcare | Fluimucil | Nacsys;
  • (IL) Israel: Reolin | RHEUNAC | Siran;
  • (IN) India: Efetil | Effelyte | Effenac | Fiz nac | Flemonac | Fluimucil | Mucaryl | Mucimega | Mucinac | Mucitec | Mucomelt | Mucomix | Mucosys | Mucotab et | Mucovisc | Mufost | Nacfil | Nacyres | Quicnac | Ventirex evt | Viscojoy;
  • (IT) Italy: Acetilcisteina Angenerico | Acetilcisteina doc | Acetilcisteina eg | Acetilcisteina hexal | Acetilcisteina Mylan | Acetilcisteina pensa | Acetilcisteina ratiopharm | Acetilcisteina zentiva | Bisolmonus | Brocetil | Fluimucil | Fluimucil mucolitico | Fluimucil program san int | Hidonac | N-acetilcisteina | Solmucol | Ultraflu;
  • (KE) Kenya: Trebon n;
  • (KR) Korea, Republic of: Br muco | Copuren | Ilyangbio acetylcysteine | Mirinol | Mucetine | Muteran | Pharmgen acetylcysteine | Sebron | Turant | Uvron | Yteran;
  • (KW) Kuwait: Acc;
  • (LB) Lebanon: Acc long | Fluimucil | Mukozero;
  • (LT) Lithuania: Acc | Acetylcystein stada | Fluimucil | Fluimucil Antidot | Mucanix | Muco | Nac | Respifortin | Wintrozen;
  • (LU) Luxembourg: Acc | Acetylcystein | Acetylcysteine sandoz | Bisolaclar | Lysomucil | Nac;
  • (LV) Latvia: Acc | Granon | Muco | Nac;
  • (MX) Mexico: Acc | Lysomucil | Mucomyst | Sensemoc;
  • (MY) Malaysia: Acetylcysteine sandoz | Fluimucil a | Hidonac | Infusol nac | Mentopin | Sanbeacetin | Stacytine | Stenac;
  • (NG) Nigeria: Acetylcysteine sandoz;
  • (NL) Netherlands: Acetylcysteine actavis | Acetylcysteine Birchwood | Acetylcysteine HTP | Acetylcysteine Imphos | Acetylcysteine m/g | Acetylcysteine Mdq | Acetylcysteine ratiopharm | Acetylcysteine RXT | Acetylcysteine Sanias | Bisolbruis | Etos hoest bruistabletten acetylcysteine | Fluimucil | Idyl Hoest Bruistabletten Acetylcysteine | Livsane hoest bruistabletten acetylcysteine | MAE acetylcysteine | Pharcetil | San acetylcysteine | Vicks Hoest;
  • (NO) Norway: Acetylcystein | Acetylcystein sandoz | Bronkyl | Bronkyl forte | Granon | Mucomyst | Pharmanac;
  • (NZ) New Zealand: Acetadote | Nac ratiopharm;
  • (PE) Peru: Acemuk | Brimodin | Fluidasa | Fluimax | Fluimicar | Fluimucil | Flumikan | Mucocar;
  • (PH) Philippines: Acc | Acetimax | Dextein | Exflem | Fluimucil | Hidonac | Mucocystein | Pneumotyl;
  • (PL) Poland: Acc | Acc Max | Acc mini | Acc optima | Acetylcysteinum Flegamina | Acypront | Fluimucil | Fluimucil Antidot | Fluimucil forte | Muccosinal | Nacecis;
  • (PR) Puerto Rico: Acetadote | Cetylev;
  • (PT) Portugal: Acetilcisteina Alter | Acetilcisteina azevedos | Acetilcisteina Bluepharma | Acetilcisteina Generis | Acetilcisteina Pharmakern | Acetilcisteina sandoz | Acetilcisteina Tolife | Acetilcisteina tussilene | Bisolvon efervescente | Cetussin | Exxelir | Fluimucil | Zentorant;
  • (PY) Paraguay: Broncolium;
  • (QA) Qatar: ACC | ACC Long | Asist Plus | Extal | Mucomyst | Mukozero;
  • (RO) Romania: Acc | Acetilcisteina zentiva | Fluimucil | Hidonac | Mucofortin;
  • (RU) Russian Federation: Acc | Acc 100 | Acc long | Acestin | Acetylcystein | Acetylcystein hemofarm | Acetylcysteine teva | Fluimucil | N ac ratiopharm | Vicks active expectomed;
  • (SA) Saudi Arabia: Acc long | Acetylcistein;
  • (SE) Sweden: Acetylcystein Alternova | Acetylcystein astrazeneca | Acetylcystein meda | Acetylcystein Merck NM | Acetylcystein mint | Acetylcystein mylan | Acetylcystein NM Pharma | Acetylcystein sandoz | Mucomyst | Viskoferm;
  • (SG) Singapore: Fluimucil | Hidonac | Mentopin | Stenac;
  • (SI) Slovenia: Acibel | Fluimucil | Fluimukan | Hidonac antidoto;
  • (SK) Slovakia: Acc | Acc injekt | Acc long | Acetylcystein dr.max | Fluimucil | Mucofortin | Sanomux;
  • (TH) Thailand: Acetin | Cystaline | Enumine nac | Flemex ac | Fluimucil | Fluimucil a | Hidonac | Iraxil | Mysoven | Nac | Nac long | Stenac;
  • (TN) Tunisia: Fluimucil;
  • (TR) Turkey: Acetylcystein | Alles | Astein | Bronpax | Cinetix | Extal | Mentopin | Mucomax | Muconex | Muconex fort | Mucoplus | Mukozero | Nac;
  • (TW) Taiwan: Acc | Acetin | Acetyl | Acetyleine | Chitan | Cystenon | Detoxnac | Encore | Flucil | Fluimucil a | Flutafin | Fumucil | Mucocil | Mucopd | Sistin | Stacytine | Stenac | Tanson;
  • (UA) Ukraine: Ac help | Acc | Acc long | Acetal soluble | Acetin | Acetylcystein | Asibrox | Dvace long | Dvatse | Fluimucil | Multigrip broncho | Sanorin-broncho;
  • (VE) Venezuela, Bolivarian Republic of: Pulmolix | Zifluvis;
  • (ZA) South Africa: Acc | Amuco | Mucatak | Muco acyst | Mucofizz | Mucotrin | Pholtex mucus | Trinflem | Tussmuco;
  • (ZM) Zambia: Acc
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