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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that breaks down thick mucus in the respiratory tract. It also serves as an antidote for acetaminophen overdose by replenishing hepatic glutathione stores.
## Primary Indications
* **Acetaminophen Overdose:** Treatment to prevent or reduce liver damage.
* **Mucolytic:** To thin mucus in respiratory conditions such as bronchitis, cystic fibrosis, and emphysema.
## Adult Dosing
### Acetaminophen Overdose:
* **Loading Dose:** 150 mg/kg IV infused over 1 hour.
* **Second Dose:** 50 mg/kg IV infused over 16 hours.
* **Subsequent Doses:** 12.5 mg/kg/hour IV infused over 16 hours (may be continued for up to 72 hours total if acetaminophen levels remain detectable or liver enzymes are elevated).
* **Oral Protocol (less common, often used when IV access is difficult or unavailable):** 140 mg/kg PO loading dose, followed by 70 mg/kg PO every 4 hours for 17 doses.
### Mucolytic:
* **Inhalation:** 3-5 mL of a 10-20% solution or 6-10 mL of a 5% solution via nebulizer every 3-4 hours as needed. Maximum 600 mg/dose.
## Pediatric Dosing
### Acetaminophen Overdose:
* Dosing is the same as adult dosing (150 mg/kg IV loading dose, then 50 mg/kg IV over 16 hours, then 12.5 mg/kg/hour IV over 16 hours).
* Oral protocol: 140 mg/kg PO loading dose, followed by 70 mg/kg PO every 4 hours for 17 doses.
### Mucolytic:
* **Inhalation:** Generally 1-2 mL of a 10-20% solution or 3-5 mL of a 5% solution via nebulizer every 3-4 hours. Dosing may vary based on weight and severity; consult specific pediatric guidelines.
## Dose Adjustments
No specific dose adjustments are typically required for renal or hepatic impairment in the context of acetaminophen overdose; however, prolonged use in hepatic impairment should be monitored carefully.
## Contraindications
* Hypersensitivity to acetylcysteine or any component of the formulation.
* Active bronchospasm for nebulized formulations.
## Adverse Effects
* **IV:** Anaphylactoid reactions (rash, urticaria, pruritus, angioedema, bronchospasm, dyspnea, facial edema), flushing, tachycardia, hypotension.
* **Nebulized:** Bronchospasm, stomatitis, nausea, vomiting, rhinorrhea.
## Key Drug Interactions
* **Activated Charcoal:** May adsorb oral acetylcysteine, reducing its efficacy in acetaminophen overdose. Administer charcoal at least 1 hour *after* oral acetylcysteine.
## Monitoring
* **Acetaminophen Overdose:**
* Acetaminophen levels (at appropriate intervals post-ingestion).
* Liver function tests (AST, ALT, bilirubin, INR).
* Renal function.
* Signs of anaphylaxis.
* **Mucolytic:**
* Airway patency and secretion clearance.
* Pulmonary function.
* Bronchospasm.
## Clinical Pearls
* For IV administration in acetaminophen overdose, monitor closely for anaphylactoid reactions, especially during the initial loading dose. Slowing the infusion rate may help manage these reactions.
* If a patient vomits during oral administration for acetaminophen overdose, the dose should be re-administered if within 1 hour of the original dose.
* Ensure adequate hydration when using acetylcysteine as a mucolytic to help mobilize secretions.
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*This information is intended for healthcare professionals. Always verify the most current prescribing information with the official product labeling or a reliable drug information resource before making clinical decisions.*
