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# Acetylcysteine
## Overview
Acetylcysteine is a mucolytic agent that decreases the viscosity of respiratory tract secretions by disrupting disulfide bonds in mucoproteins. It is also an antidote for acetaminophen overdose.
## Primary Indications
* **Acetaminophen overdose:** To prevent or reduce liver toxicity.
* **Adjunct to bronchodilator therapy** in patients with chronic obstructive pulmonary disease (COPD) to help mobilize and expectorate mucus.
* **Adjunct in cystic fibrosis** to help mobilize and expectorate mucus.
## Adult Dosing
### Acetaminophen Overdose
* **Oral:** Initial dose of 140 mg/kg, followed by 70 mg/kg every 4 hours for 17 doses.
* **Intravenous:**
* Loading dose: 150 mg/kg over 1 hour.
* Second infusion: 50 mg/kg over 4 hours.
* Third infusion: 100 mg/kg over 16 hours.
* *Note: IV formulations and protocols may vary; consult institutional guidelines.*
### COPD/Cystic Fibrosis (Inhaled)
* **Nebulization:** 3 mL to 5 mL of 10% solution or 6 mL to 10 mL of 20% solution, nebulized every 2 to 6 hours. Some protocols may use up to 600 mg per dose.
## Pediatric Dosing
### Acetaminophen Overdose
* **Oral:** Same as adult: 140 mg/kg loading dose, followed by 70 mg/kg every 4 hours for 17 doses.
* **Intravenous:** Same as adult: 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours. Dosing for neonates and infants may vary; consult institutional guidelines.
### COPD/Cystic Fibrosis (Inhaled)
* Dosing is typically based on adult recommendations and clinical response. The 10% solution is generally preferred in younger children.
## Dose Adjustments
No specific dose adjustments are typically required for renal or hepatic impairment, but caution is advised in severe impairment.
## Contraindications
Hypersensitivity to acetylcysteine or any component of the formulation.
## Adverse Effects
* **Inhaled:** Bronchospasm, bronchoconstriction, stomatitis, nausea, vomiting, rhinorrhea.
* **Oral (Acetaminophen Overdose):** Nausea, vomiting, rash, anaphylactoid reactions.
* **Intravenous (Acetaminophen Overdose):** Anaphylactoid reactions, urticaria, pruritus, flushing, bronchospasm, angioedema.
## Key Drug Interactions
* **Activated charcoal:** May bind to oral acetylcysteine, reducing absorption.
* **Nitroglycerin:** Increased hypotensive effect.
## Monitoring
* **Acetaminophen Overdose:** Serum acetaminophen levels, liver function tests (ALT, AST, bilirubin, INR), glucose, electrolytes, renal function, and clinical status.
* **Inhaled:** Bronchial secretions, respiratory status, and for signs of bronchospasm.
## Clinical Pearls
* The odor of acetylcysteine is unpleasant (sulfur-like) and may cause nausea. Administering with a bronchodilator may help mitigate bronchospasm associated with nebulized acetylcysteine.
* For acetaminophen overdose, treatment should be initiated as soon as possible, even if the acetaminophen level is not yet available, especially if a significant ingestion is suspected.
* Intravenous administration of acetylcysteine for acetaminophen overdose requires careful monitoring for anaphylactoid reactions.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information, institutional protocols, and patient-specific factors before making any clinical decisions.
