Fewer adverse effects with a modified two-bag acetylcysteine protocol in paracetamol overdose

Abstract

Adverse reactions to NAC were less common with the two-bag regimen. These results add to the accumulating evidence that reducing the initial NAC infusion rate reduces the risk of adverse reactions.

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand

“…A two‐bag acetylcysteine regimen slows the initial loading dose and simplifies the protocol (ie, 200 mg/kg over 4 h followed by 100 mg/kg over 16 h). This is widely used in toxicology units around Australia and has been shown to significantly reduce the rates of adverse reactions . GRADE: Strong; Evidence: Low .…”

The NACSTOP Trial: A Multicenter, Cluster‐Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose

“…( ) To simplify acetylcysteine dosing and reduce adverse reactions during the rapid initial load, ( ) we recently instituted a two‐bag acetylcysteine regimen consisting of 200 mg/kg over 4 hours followed by a further 100 mg/kg over 16 hours. ( ) Although the total dose and duration is similar to the standard acetylcysteine regimen, ( ) the incidence of adverse reactions is substantially lower. ( ) However, the fixed duration of 20 hours, which typically necessitates hospital admission, likely represents overtreatment for patients at very low risk, and ignores an opportunity for further risk stratification based on retesting midway through treatment.…”

“…(4) To simplify acetylcysteine dosing and reduce adverse reactions during the rapid initial Abbreviations: ALT, alanine transaminase; APAP, acetaminophen concentration at presentation; AST, aspartate transaminase; CI, confidence interval; ED, emergency department; INR, international normalized ratio; IQR, interquartile range; NAAR, nonallergic anaphylactic reaction; NAC, N-acetylcysteine; OR, odds ratio; VAMPIRE, Victorian Austin Monash Poisons Information, Research and Education. load, (5)(6)(7) we recently instituted a two-bag acetylcysteine regimen consisting of 200 mg/kg over 4 hours followed by a further 100 mg/kg over 16 hours. (8,9) Although the total dose and duration is similar to the standard acetylcysteine regimen, (4) the incidence of adverse reactions is substantially lower. (8)(9)(10) However, the fixed duration of 20 hours, which typically necessitates hospital admission, likely represents overtreatment for patients at very low risk, and ignores an opportunity for further risk stratification based on retesting midway through treatment.…”

“…(8,9) Although the total dose and duration is similar to the standard acetylcysteine regimen, (4) the incidence of adverse reactions is substantially lower. (8)(9)(10) However, the fixed duration of 20 hours, which typically necessitates hospital admission, likely represents overtreatment for patients at very low risk, and ignores an opportunity for further risk stratification based on retesting midway through treatment. (11) The administration of acetylcysteine within 8 hours of an acute single acetaminophen overdose prevents hepatotoxicity in nearly all patients.…”

Silkworm pupa oil attenuates acetaminophen‐induced acute liver injury by inhibiting oxidative stress‐mediated NF‐κB signaling

“…Currently, the only FDA-approved drug for APAP overdose is a potent antioxidant named N-acetylcysteine (NAC; Khayyat, Tobwala, Hart, & Ercal, 2016). Although oral or intravenous administration of NAC protects against APAPinduced hepatotoxicity, NAC treatment has a high incidence of anaphylactic reactions (McNulty, Lim, Chandru, & Gunja, 2018;Sandilands & Bateman, 2009). Although oral or intravenous administration of NAC protects against APAPinduced hepatotoxicity, NAC treatment has a high incidence of anaphylactic reactions (McNulty, Lim, Chandru, & Gunja, 2018;Sandilands & Bateman, 2009).…”