MASSACHUSETTS GENERAL HOSPITAL 

Department of Pharmacy

Department of Nursing

Adult General Care

GENERIC NAME

Acetylcysteine

TRADE NAME

Acetadote® (IV formulation)

Mucomyst® (po/inhalation form)

ACTION

Believed to act as glutathione substitute and directly combine with the toxic acetaminophen metabolite. May increase oxygen delivery, may enhance hepatosplanchnic perfusion

DESIGNATED CLINICAL AREA

Adult General Care

Adult Critical Care

INDICATIONS

Acetaminophen (Tylenol®)-overdose: IV use of acetylcysteine is restricted to patients meeting one, or more, of the following criteria:

•  Severe emesis; patient refractory to antiemetics and nasogastric tube

•  Gastrointestinal obstruction or bleeding

•  Medical and/or surgical conditions precluding use of oral acetylcysteine

•  Coingestion of iron, lithium, sustained release or enteric coated meds, and/or illicit drug packets, necessitating ongoing gastrointestinal decontamination

Acute Liver Failure (non-acetaminophen induced) patients meeting the following criteria:

•  Acute Liver Failure (non-acetaminophen induced)

•  Grade I & II Hepatic Encephalopathy

•  High Risk Situations (non-encephalopathic)

MUST BE APPROVED BY LIVER SERVICE ATTENDING MD (OR COVERING ATTENDING ON WEEKENDS)

Approval will be for 72 hours (longer use at discretion of Liver Service Attending MD.)

ADMINISTRATION GUIDELINES

USUAL DOSAGE RANGE AND ROUTE

Dosage for acetaminophen overdose:

DOSE (IV):

•  Loading: 150 mg/kg in 200 mL D5W x 1 dose over 15 minutes. Then 50 mg/kg in 500 mL D5W x 1 dose over 4 hrs. Then 100 mg/kg in 1000 mL D5W x 1 dose over 16 hrs.

•  DOSE (PO): 140 mg/kg x 1 dose, then 70 mg/kg every 4 hours x 17 doses

Dosage for non-acetaminophen induced acute liver failure:

Dosage (IV):

Hours 0-24:

•  Bag 1: 150mg/kg (in 200 mL D5W) over 1 hour (LOAD) -

•  Bag 2: 50mg/kg (in 500ml D5W) over 4 hours

•  Bag 3: 125mg/kg (in 1000ml D5W) over 19 hours

Hours 24-48:

•  Bag 1: 150mg/kg (in 1000ml D5W) over 24 hours

Hours 48-72:

•  Bag 1: 150mg/kg (in 1000ml D5W) over 24 hours

Treatment will be for 72 hours (or longer at discretion of Liver Service Attending MD)

CRITICAL ELEMENTS/SPECIAL CONSIDERATIONS

•  IV FORM NOT TO BE USED FOR: prevention of contrast-induced nephropathy (acetylcysteine only administered orally; dose: 600 mg po bid)

•  Acetylcysteine IV is contraindicated in patients with hypersensitivity or previous anaphylactoid reactions to acetylcysteine or any components in the preparation

•  Patient to remain on IV acetylcysteine until completion of therapy; pt cannot be switched to oral therapy

•  Requires dedicated IV line; pharmacy mixes all doses

•  Manufacturer recommends treatment within 10 hours of overdose, but favorable results have been seen in some patients up to 24 hours after overdose

•  MD must calculate dose for pt, order must contain dose and pt weight

PRECAUTIONS AND SIDE EFFECTS

•  Respiratory: bronchospasm, bronchoconstriction, respiratory distress

•  Nausea/vomiting

•  Anaphylactoid reaction: treat with diphenhydramine; some patients may require epinephrine - Tachycardia, Hypotension/Hypertension- Women who are breastfeeding

Non-acetaminophen induced acute liver failure

•  Cardiac monitoring for initial infusion [load] (monitor for arrhythmias, bradycardia)

Exclusions criteria:

•  Confirmed acetaminophen toxicity

•  Pregnancy

•  Severe septic shock

•  Cerebral herniation

•  Grade IV Hepatic Encephalopathy (unresponsive coma)

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