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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that acts by breaking disulfide bonds in mucoproteins, decreasing mucus viscosity. It is also an antidote for acetaminophen overdose by replenishing hepatic glutathione stores.
## Primary Indications
* Acetaminophen overdose
* Mucolytic agent for respiratory conditions (e.g., cystic fibrosis, chronic bronchitis, pneumonia)
## Adult Dosing
* **Acetaminophen Overdose:**
* **Oral:** Loading dose of 140 mg/kg, followed by 70 mg/kg every 4 hours for 17 doses (total 72 hours). Maximum dose: 140 mg/kg per dose.
* **Intravenous (IV):** Typically a 3-bag protocol.
* Bag 1: 150 mg/kg over 60 minutes.
* Bag 2: 50 mg/kg over the next 4 hours.
* Bag 3: 100 mg/kg over the next 16 hours.
* *Specific IV protocols can vary; consult local guidelines.*
* **Mucolytic:** 200-600 mg (typically as a nebulized solution) once to several times daily.
## Pediatric Dosing
* **Acetaminophen Overdose:**
* **Oral:** Same as adult dosing: Loading dose of 140 mg/kg, followed by 70 mg/kg every 4 hours for 17 doses (total 72 hours). Maximum dose: 140 mg/kg per dose.
* **Intravenous (IV):** Same as adult dosing (3-bag protocol). Dosing is weight-based.
* **Mucolytic:** 50-200 mg (typically as a nebulized solution) once to several times daily, depending on age and weight.
## Dose Adjustments
No specific dose adjustments are generally recommended for hepatic or renal impairment, though caution may be warranted in severe cases.
## Contraindications
Hypersensitivity to acetylcysteine or other components of the formulation. Caution is advised in patients with asthma or reactive airway disease due to potential for bronchospasm.
## Adverse Effects
* **Common:** Nausea, vomiting, stomatitis, rash, pruritus, fever.
* **Less Common:** Bronchospasm (especially with nebulized form), anaphylactoid reactions (more common with IV).
## Key Drug Interactions
* **Activated Charcoal:** Can adsorb oral acetylcysteine, reducing its efficacy in acetaminophen overdose. Administer charcoal at least 1 hour after acetylcysteine.
* **Nitroglycerin:** Potential for additive hypotension and headache.
## Monitoring
* **Acetaminophen Overdose:**
* Serum acetaminophen levels (especially at 4 hours post-ingestion).
* Liver function tests (LFTs).
* Prothrombin time (PT).
* Clinical signs of liver injury.
* **Mucolytic:**
* Respiratory status, sputum production.
* Pulmonary function.
## Clinical Pearls
* The smell of acetylcysteine is characteristically unpleasant (sulfurous).
* For IV administration, a continuous infusion is preferred in acetaminophen overdose to maintain adequate therapeutic levels and minimize anaphylactoid reactions.
* Dilute IV acetylcysteine to reduce the risk of anaphylactoid reactions.
* Bronchospasm with nebulized acetylcysteine can sometimes be managed with concurrent bronchodilator therapy.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and local institutional protocols before administering any medication.*
