A recent open-label “NACSTOP trial” (A Wong et al. Hepatology 2019; 69: 774-84) examined a 12-hour regimen of acetylcysteine in patients at lower risk for severe hepatotoxicity from acetaminophen overdose.

Background/Methods: Intravenous acetylcysteine is generally delivered as 300 mg/kg over 20 hours in “nearly every patient deemed at any risk for hepatotoxicity following acetaminophen overdose.” Administration within 8 hours of an acute single acetaminophen overdose prevents hepatotoxicity in nearly all patients.

In this study, patients with normal serum alanine transaminase (ALT) and normal creatinine at presentation and at 12 hours along with acetaminophen level of <20 mg/L at 12 hours were assigned to either a 12 hour (250 mg/kg) or 20 hour (300 mg/kg) acetylcysteine (IV) infusion.

1411 Acetaminophen overdoses were identified; of these, 449 met criteria for study participation. 100 patients out of these 449 eligible were enrolled.

Key findings:

• There was no difference in ALT or INR at 20 hours between the two groups.
• No hepatotoxicity was evident in either group. 96 of 96 were well at 14-day telephone followup.

Discussion: “A normal ALT on  presentation has a high negative predictive values (100%) of individuals developing any serious liver injury (ALT >1000 IU/L) in those receiving acetylcysteine.” [Al-Hourani et al. QJM 2013; 1065: 541-6)

My take: This study shows that a shortened acetylcysteine infusion is likely safe in selected patients at low risk for hepatotoxicity.

Related blog posts:

• Therapeutic Misadventures with Acetamiophen
• Predicting outcome in Pediatric Acute Liver Failure | gutsandgrowth
• N-acetylcysteine for Acute Liver Failure
• Advice on drug-induced liver injury (DILI) | gutsandgrowth
• When death is on the line | gutsandgrowth
• Pediatric pharmaceutical poisoning | gutsandgrowth

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

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