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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that works by breaking disulfide bonds in mucoproteins, reducing the viscosity of mucus. It is also an antidote for acetaminophen overdose.
## Primary Indications
* **Acetaminophen Overdose:** To prevent or reduce liver damage.
* **Mucolytic:** To thin mucus in conditions like cystic fibrosis, chronic bronchitis, and pneumonia.
## Adult Dosing
**Acetaminophen Overdose:**
* **Loading Dose:** 150 mg/kg IV over 1 hour.
* **Second Dose:** 50 mg/kg IV over the next 1 hour.
* **Third Dose:** 100 mg/kg IV over the next 16 hours.
* **Total Duration:** 21 hours.
**Mucolytic (Oral):**
* 200 mg to 400 mg two to three times daily.
**Mucolytic (Inhaled):**
* 3 mL to 5 mL of a 10% solution or 5 mL of a 20% solution via nebulizer every 4 to 12 hours.
## Pediatric Dosing
**Acetaminophen Overdose:**
* Dosing is the same as adult: 150 mg/kg IV over 1 hour, followed by 50 mg/kg IV over 1 hour, then 100 mg/kg IV over 16 hours. Maximum doses are based on ideal body weight.
**Mucolytic (Oral):**
* 100 mg to 200 mg two to three times daily.
**Mucolytic (Inhaled):**
* Dosing depends on the concentration of the solution and patient's ability to tolerate. Generally, 1 mL to 2 mL of a 10% solution or 1 mL to 5 mL of a 20% solution via nebulizer every 4 to 12 hours.
## Dose Adjustments
* **Renal Impairment:** No specific dose adjustment recommendations, but use with caution.
* **Hepatic Impairment:** No specific dose adjustment recommendations, but use with caution.
## Contraindications
* Hypersensitivity to acetylcysteine or any component of the formulation.
## Adverse Effects
* **Common (Oral/Inhaled):** Nausea, vomiting, stomatitis, rhinorrhea.
* **Less Common (IV):** Anaphylactoid reactions (rash, pruritus, urticaria, bronchospasm, angioedema, hypotension), fever, headache.
## Key Drug Interactions
* **Activated Charcoal:** May bind to oral acetylcysteine, reducing its absorption. If co-administered, separate doses by at least 1 hour.
## Monitoring
* **Acetaminophen Overdose:** Liver function tests (AST, ALT, bilirubin, INR), creatinine, glucose, electrolytes. Monitor acetaminophen levels to confirm clearance.
* **Mucolytic:** Respiratory status, sputum production and viscosity.
## Clinical Pearls
* For IV administration, anaphylactoid reactions are common. Premedication with an antihistamine may be considered.
* Dilute IV acetylcysteine to a concentration of 5 mg/mL or less to minimize risk of fluid overload.
* The unpleasant sulfurous odor of acetylcysteine may cause nausea and vomiting; administer with food or juice if tolerated for oral formulations.
* For inhaled acetylcysteine, patients may experience coughing or bronchospasm; consider co-administration of a bronchodilator.
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*Please verify current prescribing information for the most up-to-date dosing and safety recommendations.*
