Acetylcysteine
ACETADOTE
Pronunciation: a-seet-il-SIS-teen
What it isGlutathione-repleting antidote and disulfide-breaking mucolytic; acetaminophen toxicity and thick airway secretions.
Why this oneIt works best early after overdose but can still benefit established hepatic injury, so delayed presentation is not a reason to withhold it.
What limits itIV use can trigger anaphylactoid reactions; inhalation can provoke bronchospasm. Nausea and sulfur odor impair completion.
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Acetaminophen overdose, acute ingestion — three-bag regimen | Adults ≥41 kg | Loading 150 mg/kg IV over 1 hour | Then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours (300 mg/kg total over 21 hours) | 300 mg/kg total; ≥100 kg: 15,000 / 5,000 / 10,000 mg |
| Acetaminophen overdose, acute ingestion — two-bag regimen (alternative) | Adults ≥41 kg | Loading 200 mg/kg IV over 4 hours | Then 100 mg/kg over 16 hours (300 mg/kg total over 20 hours) | 300 mg/kg total; ≥100 kg: 20,000 / 10,000 mg |
| Acetaminophen overdose, acute ingestion — three-bag regimen only | Pediatric / ≤40 kg (≥5 kg) | Loading 150 mg/kg IV over 1 hour | Then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours (300 mg/kg total over 21 hours) | 300 mg/kg total; <5 kg not studied |
| Repeated supratherapeutic acetaminophen ingestion (RSI) | Adults & pediatric ≥5 kg | No fixed labeled regimen — guide by APAP level, AST/ALT, INR; nomogram does not apply | Per regional poison center | Undefined |
Renal Undefined
Hepatic Undefined
Acute ingestion: draw APAP level ≥4 h post-ingestion and apply revised Rumack-Matthew nomogram; give loading dose immediately if time unknown or presenting >8 h. Continue beyond 300 mg/kg if APAP still detectable, ALT/AST rising, or INR elevated after last dose.
Instructions
- IV only; hyperosmolar (2,600 mOsmol/L) — must dilute in 0.45% NaCl (preferred), D5W, or sterile water
- Diluent volume (3-bag): 5–20 kg 3 / 7 / 14 mL/kg; 21–40 kg 100 / 250 / 500 mL; 41–99 kg 200 / 500 / 1,000 mL
- Diluent volume (2-bag): 1,000 mL then 500 mL
- Reduce total volume if <40 kg or fluid-restricted (fluid overload → hyponatremia, seizure)
- Diluted solution: use within 24 hours at room temperature; do not use a previously opened vial IV
Available strengths
- inj 200 mg/mL
- sol 10, 20 %
- inhaler 100, 200 mg/mL
Cautions
- Hypersensitivity reactions, incl. fatal anaphylaxis (monitor asthmatics)
- Fluid overload (hyponatremia, seizure, death)
Adverse reactions
- Rash
- Urticaria/facial flushing
- Pruritus
- Nausea/vomiting
- Respiratory symptoms (cough, wheeze, bronchospasm)
- Tachycardia
Pregnancy Limited human data insufficient to inform risk; no fetal harm in rat/rabbit studies; delaying treatment of acetaminophen overdose increases maternal/fetal risk.
Lactation No human milk data; nearly cleared by 30 hours — may pump and discard for 30 hours after administration.
Cost
| Strength | #/mo | generic $/unit | CostPlus | |
|---|---|---|---|---|
| 200 mg/mL | inj | per unit | not offered |
Other forms: N-acetylcysteine (NAC)
NO BOXED WARNINGS
Principal riskHypersensitivity reactions; fluid overload