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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that breaks down thick mucus, facilitating its clearance. It is also the antidote for acetaminophen overdose by replenishing hepatic glutathione stores.
## Primary Indications
* Acetaminophen overdose
* Thick bronchial secretions in patients with cystic fibrosis, chronic bronchitis, or other respiratory conditions
## Adult Dosing
**Acetaminophen Overdose:**
* **IV Loading Dose:** 150 mg/kg over 1 hour.
* **IV Maintenance Doses:**
* 12.5 mg/kg/hour for 4 hours.
* 6.25 mg/kg/hour for 16 hours.
* **Oral:** 140 mg/kg loading dose, followed by 70 mg/kg every 4 hours for 17 doses.
**Mucolytic:**
* **Nebulized:** 3 mL of 20% solution or 6 mL of 10% solution every 2-6 hours.
* **Oral (Effervescent Tablets):** 200 mg (one tablet) 2-4 times daily.
* **Oral (Solution):** 600 mg once daily or 200 mg twice daily.
## Pediatric Dosing
**Acetaminophen Overdose (IV):**
* Dosing is the same as adults (150 mg/kg loading dose, then 12.5 mg/kg/hour for 4 hours, then 6.25 mg/kg/hour for 16 hours).
* **Oral:** 140 mg/kg loading dose, followed by 70 mg/kg every 4 hours for 17 doses.
**Mucolytic:**
* **Nebulized:** 1-3 mL of 20% solution or 3-6 mL of 10% solution every 2-6 hours.
* **Oral (Solution):** 50-100 mg/kg/day in 2-4 divided doses.
## Dose Adjustments
No dose adjustments are typically required for renal or hepatic impairment, although caution is advised in severe cases of hepatic impairment due to potential for increased adverse effects.
## Contraindications
Hypersensitivity to acetylcysteine.
## Adverse Effects
* **Nebulized:** Bronchospasm (especially in asthmatics), nausea, vomiting, stomatitis, rhinorrhea.
* **IV:** Anaphylactoid reactions (rash, urticaria, angioedema, bronchospasm, dyspnea, tachycardia, hypotension), flushing, fever.
* **Oral:** Nausea, vomiting, diarrhea, rash.
## Key Drug Interactions
* **Activated Charcoal:** May adsorb oral acetylcysteine, reducing its efficacy. Administer oral acetylcysteine at least 1 hour after activated charcoal.
* **Nitroglycerin:** Concurrent use may potentiate hypotensive effects.
## Monitoring
* **Acetaminophen Overdose:** Monitor acetaminophen levels, liver function tests (LFTs), prothrombin time (PT), international normalized ratio (INR), and clinical signs of hepatic toxicity.
* **Mucolytic:** Monitor for effectiveness in airway clearance and for adverse effects, particularly bronchospasm.
## Clinical Pearls
* For IV administration in acetaminophen overdose, the protocol may vary based on local guidelines and the patient's acetaminophen level and time of ingestion.
* Administer nebulized acetylcysteine with a bronchodilator if the patient has reactive airway disease to minimize bronchospasm.
* The strong sulfurous odor of acetylcysteine may be unpleasant and can cause nausea and vomiting.
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*This information is intended for healthcare professionals and does not replace the need to consult the most current prescribing information and clinical guidelines.*
