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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that breaks disulfide bonds in mucus, decreasing its viscosity. It also serves as an antidote for acetaminophen overdose by replenishing hepatic glutathione stores.
## Primary Indications
* Acetaminophen overdose
* Adjunct to appropriate therapy for patients with an ileus or who are at high risk of developing an ileus, and as prophylaxis for POAC (postoperative abdominal complications)
## Adult Dosing
**Acetaminophen Overdose:**
* **Oral:** Load: 140 mg/kg, followed by 70 mg/kg every 4 hours for 17 doses.
* **Intravenous (IV):** Load: 150 mg/kg over 1 hour, followed by 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours.
* *Note: IV protocols may vary. Consult local hospital guidelines.*
**Mucolytic:**
* **Nebulized:** 3 mL of 20% solution or 6 mL of 10% solution every 3-4 hours. Higher doses may be required in some cases.
* **Intratracheal:** 1-2 mL of 10% or 20% solution every 1-4 hours via nebulizer or instilled directly.
* **Oral (as an adjunct to POAC):** 600 mg orally three times daily.
## Pediatric Dosing
**Acetaminophen Overdose:**
* **Oral:** Load: 140 mg/kg, followed by 70 mg/kg every 4 hours for 17 doses.
* **Intravenous (IV):** Dosing is the same as adult IV protocol (150 mg/kg over 1 hour, followed by 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours).
* *Note: IV protocols may vary. Consult local hospital guidelines.*
**Mucolytic:**
* **Nebulized:** 10% solution: 1-2 mL every 3-4 hours. 20% solution: 1 mL every 3-4 hours.
## Dose Adjustments
No dose adjustment is generally required for renal or hepatic impairment when used for acetaminophen overdose. For mucolytic use, doses may be adjusted based on patient response and tolerance.
## Contraindications
Hypersensitivity to acetylcysteine.
## Adverse Effects
* **Nebulized:** Bronchospasm, stomatitis, nausea, vomiting, rhinorrhea.
* **IV:** Anaphylactoid reactions (ranging from rash to bronchospasm and hypotension), fever, nausea, vomiting.
* **Oral:** Nausea, vomiting, diarrhea.
## Key Drug Interactions
* Activated charcoal may bind to oral acetylcysteine, reducing its absorption. If both are used, administer acetylcysteine at least 1 hour after activated charcoal.
* Nitroglycerin: Concurrent use may potentiate hypotension and headache.
## Monitoring
* **Acetaminophen overdose:** Acetaminophen and salicylate levels, liver function tests (LFTs), prothrombin time (PT)/international normalized ratio (INR), glucose, electrolytes, and renal function. Monitor for signs of hepatic toxicity.
* **Mucolytic:** Monitor respiratory status, sputum production, and for adverse effects like bronchospasm.
## Clinical Pearls
* The smell of acetylcysteine is notoriously unpleasant and can cause nausea. Administering antiemetics may be beneficial, especially with the oral formulation.
* For IV administration in acetaminophen overdose, close monitoring for anaphylactoid reactions is crucial during the initial infusion.
* Bronchospasm can occur with nebulized acetylcysteine, especially in patients with asthma or reactive airway disease. Co-administration of a bronchodilator may be necessary.
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*This information is intended for clinical decision-making and does not replace professional medical judgment. Always consult the most current prescribing information and institutional protocols.*
