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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that reduces the viscosity of respiratory secretions. It is also the antidote for acetaminophen overdose.
## Primary Indications
* Adjunct treatment in patients with **acetaminophen overdose**.
* **Pulmonary conditions** associated with abnormal mucus secretion (e.g., chronic bronchitis, emphysema, cystic fibrosis, bronchiectasis).
## Adult Dosing
### Acetaminophen Overdose
* **Oral:** 140 mg/kg loading dose, followed by 70 mg/kg every 4 hours for 17 doses.
* **Intravenous:** 150 mg/kg IV over 1 hour, followed by 12.5 mg/kg/hour IV for 4 hours, then 6.25 mg/kg/hour IV for 16 hours. Dosing can be adjusted based on acetaminophen levels and liver function. Protocols may vary.
### Pulmonary Conditions
* **Nebulized:** 1-10 mL of a 10% or 20% solution, or 2-4 mL of a 20% solution, every 2-6 hours as needed. Frequency and concentration may vary based on patient tolerance and response.
## Pediatric Dosing
### Acetaminophen Overdose
* **Oral:** Same as adult: 140 mg/kg loading dose, followed by 70 mg/kg every 4 hours for 17 doses.
* **Intravenous:** Same as adult: 150 mg/kg IV over 1 hour, followed by 12.5 mg/kg/hour IV for 4 hours, then 6.25 mg/kg/hour IV for 16 hours. Protocols may vary.
### Pulmonary Conditions
* **Nebulized:**
* Infants and children up to 3 years: 1-2 mL of a 20% solution every 2-6 hours.
* Children 3 years and older: 2-4 mL of a 20% solution or 1-5 mL of a 10% solution every 2-6 hours.
## Dose Adjustments
No specific dose adjustments are typically required for renal or hepatic impairment, but caution is advised, especially in overdose situations where liver function is compromised.
## Contraindications
* Hypersensitivity to acetylcysteine.
## Adverse Effects
* **Nebulized:** Bronchospasm (especially in asthmatics), nausea, vomiting, stomatitis, rhinorrhea, urticaria.
* **Intravenous (overdose treatment):** Anaphylactoid reactions (rash, urticaria, pruritus, angioedema, bronchospasm, dyspnea, hypotension), fever, nausea, vomiting.
## Key Drug Interactions
* **Activated charcoal:** May bind to oral acetylcysteine, reducing absorption. Administer acetylcysteine at least 1 hour after activated charcoal.
* **Nitroglycerin:** Increased hypotensive effect.
## Monitoring
* **Acetaminophen overdose:** Serum acetaminophen levels, liver function tests (ALT, AST, bilirubin, INR), glucose, electrolytes, and renal function. Monitor for signs of anaphylactoid reaction.
* **Pulmonary conditions:** Respiratory status, sputum characteristics, and presence of bronchospasm.
## Clinical Pearls
* Dilute nebulized acetylcysteine with sterile water or saline to improve tolerance if needed.
* Pre-treatment with a bronchodilator may be necessary for patients prone to bronchospasm.
* The smell of acetylcysteine is sulfurous and unpleasant; this does not indicate product degradation.
* For IV administration in acetaminophen overdose, close monitoring for anaphylactoid reactions is crucial.
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**Disclaimer:** This information is intended for clinical use and does not replace the need to consult the most current prescribing information, institutional protocols, and patient-specific factors before making any treatment decisions.
