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Acetadote

Last reviewed on RxList: 4/24/2020
Drug Description

ACETADOTE
(acetylcysteine) Intravenous Injection

DESCRIPTION

Acetylcysteine injection is an intravenous antidote for the treatment of acetaminophen overdose. Acetylcysteine is the nonproprietary name for the N-acetyl derivative of the naturally occurring amino acid, L-cysteine (N-acetyl-L-cysteine). The compound is a white crystalline powder, which melts in the range of 104° to 110°C and has a very slight odor. The molecular formula of the compound is C5H9NO3S, and its molecular weight is 163.2. Acetylcysteine has the following structural formula:

ACETADOTE (acetylcysteine) Structural Formula Illustration

Acetadote is supplied as a sterile solution in vials containing 20% w/v (200 mg/mL) acetylcysteine. The pH of the solution ranges from 6.0 to 7.5. Acetadote contains the following inactive ingredients: sodium hydroxide (used for pH adjustment), and Sterile Water for Injection, USP.

Indications & Dosage

INDICATIONS

ACETADOTE is indicated to prevent or lessen hepatic injury after ingestion of a potentially hepatotoxic quantity of acetaminophen in patients with acute ingestion or from repeated supratherapeutic ingestion (RSI).

DOSAGE AND ADMINISTRATION

Pre-Treatment Assessment And Testing Following Acute Acetaminophen Ingestion

The following recommendations are related to acute acetaminophen ingestion. For recommendations related to repeated supratherapeutic exposure see Recommendations for Repeated Supratherapeutic Acetaminophen Ingestion.

  1. Assess the history and timing of acetaminophen ingestion as an overdose.
    • The reported history of the quantity of acetaminophen ingested as an overdose is often inaccurate and is not a reliable guide to therapy.
  2. Obtain the following laboratory tests to monitor hepatic and renal function and electrolyte and fluid balance: aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, international normalized ratio (INR), creatinine, blood urea nitrogen (BUN), blood glucose, and electrolytes.
  3. Obtain a plasma or serum sample to assay for acetaminophen concentration at least 4 hours after ingestion. Acetaminophen concentrations obtained earlier than 4 hours post-ingestion may be misleading as they may not represent maximum acetaminophen concentrations.
  4. If the time of acute acetaminophen ingestion is unknown:
    • Administer a loading dose of ACETADOTE immediately [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].
    • Obtain an acetaminophen concentration to determine need for continued treatment [see Nomogram for Estimating Potential for Hepatoxicity from Acute Acetaminophen Ingestion and Need for ACETADOTE Treatment].
  5. If the acetaminophen concentration cannot be obtained (or is unavailable or uninterpretable) within the 8hour time interval after acetaminophen ingestion or there is clinical evidence of acetaminophen toxicity:
    • Administer a loading dose of ACETADOTE immediately and continue treatment for a total of three doses over 21 hours [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].
  6. If the patient presents more than 8 hours after ingestion and the time of acute acetaminophen ingestion is known:
    • Administer a loading dose of ACETADOTE immediately [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion]
    • Obtain an acetaminophen concentration to determine need for continued treatment [see Nomogram for Estimating Potential for Hepatoxicity from Acute Acetaminophen Ingestion and Need for ACETADOTE Treatment].
  7. If the patient presents less than 8 hours after ingestion and the time of acute acetaminophen ingestion is known and the acetaminophen concentration is known:
    • Use the Rumack-Matthew nomogram (Figure 1) to determine whether or not to initiate treatment with ACETADOTE [see Nomogram for Estimating Potential for Hepatoxicity from Acute Acetaminophen Ingestion and Need for ACETADOTE Treatment].

Nomogram For Estimating Potential For Hepatoxicity From Acute Acetaminophen Ingestion And Need For ACETADOTE Treatment

ACETADOTE is an antidote for acetaminophen overdose. The critical ingestion-treatment interval for maximal protection against severe hepatic injury is between 0 – 8 hours. Efficacy diminishes progressively after 8 hours and treatment initiation between 15 and 24 hours post-ingestion of acetaminophen yields limited efficacy. However, it does not appear to worsen the condition of patients and it should not be withheld, since the reported time of ingestion may not be correct.

If the timing of the acute acetaminophen ingestion is known and the results of the acetaminophen assay are available within 8 hours:

  • Refer to the Rumack-Matthew nomogram (see Figure 1) to determine whether or not to initiate treatment with ACETADOTE.
  • Initiation of ACETADOTE depends on the plasma or serum acetaminophen concentration and also the clinical presentation of the patient.

The nomogram may underestimate the hepatotoxicity risk in patients with chronic alcoholism, malnutrition, or CYP2E1 enzyme inducing drugs (e.g., isoniazid), and consideration should be given to treating these patients even if the acetaminophen concentrations are in the nontoxic range.

Loading Dose

For patients whose acetaminophen concentrations are at or above the “possible” toxicity line (dotted line in nomogram):

  • Administer a loading dose of ACETADOTE [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].

For patients with an acute overdose from an extended-release acetaminophen, if the acetaminophen concentration at 4 hours post ingestion is below the possible toxicity line then obtain a second sample for acetaminophen concentration 8 to 10 hours after the acute ingestion. If the second value is at or above the “possible” toxicity line (dotted line in nomogram):

  • Administer a loading dose of ACETADOTE [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].

For patients whose values are below the “possible” toxicity line, but time of ingestion was unknown or sample was obtained less than 4 hours after ingestion:

  • Administer a loading dose of ACETADOTE [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].

For patients whose values are below the “possible” toxicity line and time of ingestion is known and the sample was obtained more than 4 hours after ingestion, do not administer ACETADOTE because there is minimal risk of hepatotoxicity.

Figure 1: Rumack-Matthew Nomogram for Estimating Potential for Hepatoxicity for Acetaminophen Posioning – Plasma or Serum Acetaminophen Concentration versus Time (hours) Post-acetaminophen Ingestion

Rumack-Matthew Nomogram for Estimating
Potential for Hepatoxicity for Acetaminophen Posioning – Plasma or Serum
Acetaminophen Concentration versus Time (hours) Post-acetaminophen Ingestion - Illustration

(Adapted from Rumack and Matthew, Pediatrics 1975; 55: 871-876)

Maintenance Dose

Determine need for continued treatment with ACETADOTE after the loading dose. Choose ONE of the following based on the acetaminophen concentration:

The acetaminophen concentration is above the possible toxicity line according to the nomogram (see Figure 1):

  • Continue ACETADOTE treatment with the maintenance dose for a total of three separate doses over an infusion period of 21 hours [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].
  • Monitor hepatic and renal function and electrolytes throughout treatment.

The acetaminophen concentration could not be obtained:

  • Continue ACETADOTE treatment with the maintenance dose for a total of three separate doses over an infusion period of 21 hours [see Recommended Dosage in Adults and Pediatrics for Acute Acetaminophen Ingestion].
  • Monitor hepatic and renal function and electrolytes throughout treatment.

For patients whose acetaminophen concentration is below the “possible” toxicity line (see Figure 1) and time of ingestion is known and the sample was obtained more than 4 hours after ingestion:

  • Discontinue ACETADOTE.

The acetaminophen concentration was in the non-toxic range, but time of ingestion was unknown or less than 4 hours:

  • Obtain a second sample for acetaminophen concentration and consider the patient’s clinical status to decide whether or not to continue ACETADOTE treatment.
  • If there is any uncertainty as to patient’s risk of developing hepatotoxicity, it is recommended to administer a complete treatment course.
Continued Therapy After Completion Of Loading And Maintenance Doses

In cases of suspected massive overdose, or with concomitant ingestion of other substances, or in patients with preexisting liver disease; the absorption and/or the half-life of acetaminophen may be prolonged. In such cases, consideration should be given to the need for continued treatment with ACETADOTE beyond a total of three separate doses over a 21-hour infusion period.

Acetaminophen levels and ALT/AST and INR should be checked after the last maintenance dose. If acetaminophen levels are still detectable, or if the ALT/AST are still increasing or the INR remains elevated; dosing should be continued and the treating physician should contact a US regional poison center at 1-800-222-1222, alternatively, a “special health professional assistance line for acetaminophen overdose” at 1-800-525-6115 for assistance with dosing recommendations, or 1-877-484-2700 for additional information.

Preparation And Storage Of ACETADOTE Diluted Solution Prior To Administration

Because ACETADOTE is hyperosmolar (2600 mOsmol/L), ACETADOTE must be diluted in sterile water for injection, 0.45% sodium chloride injection (½ normal saline), or 5% dextrose in water prior to intravenous administration [see WARNINGS AND PRECAUTIONS]. Dilution in these three solutions results in different osmolarity of the solution for intravenous administration (see Table 1 for examples of different osmolarity of the solution depending on the type of solution and the ACETADOTE concentration).

Visually inspect for particular matter and discoloration prior to administration. The color of the diluted solution ranges from colorless to a slight pink or purple once the stopper is punctured (the color change does not affect the quality of the product). The diluted solution can be stored for 24 hours at room temperature. Discard unused portion. If a vial was previously opened, do not use for intravenous administration.

Table 1: Examples of ACETADOTE Concentration and Osmolarity in Three Solutions

ACETADOTE ConcentrationOsmolarity
Sterile Water for Injection½ Normal SalineD5W
7 mg/mL91 mOsmol/L*245 mOsmol/L343 mOsmol/L
24 mg/mL312 mOsmol/L466 mOsmol/L564 mOsmol/L
* Adjust osmolarity to a physiologically safe level (generally not less than 150 mOsmol/L in pediatric patients).

Recommended Dosage In Adults And Pediatrics For Acute Acetaminophen Ingestion

ACETADOTE is for intravenous administration only.

Dosage Regimen

The total recommended dosage of ACETADOTE is 300 mg/kg given intravenously as 3 separate, sequential doses (i.e., 3-bag method to administer the loading, second, and third doses). The total recommended infusion time for 3 doses is 21 hours. For the recommended weight-based dosage and weight-based dilution in patients who weigh:

  • 5 to 20 kg (see Table 2)
  • 21 to 40 kg (see Table 3)
  • 41 kg or greater (see Table 4)

Table 2: Recommended ACETADOTE Dosage and Dilution for Patients 5 kg to 20 kg

Body WeightBag 1 (Loading Dose) 150 mg/kg in 3 mL/kg of diluent* infused over 1 hourBag 2 (Second Dose) 50 mg/kg in 7 mL/kg of diluent* infused over 4 hoursBag 3 (Third Dose) 100 mg/kg diluted in 14 mL/kg of diluent* infused over 16 hours
Loading DoseDiluent VolumeSecond DoseDiluent VolumeThird DoseDiluent Volume
5 kg**750 mg15 mL250 mg35 mL500 mg70 mL
10 kg1,500 mg30 mL500 mg70 mL1,000 mg140mL
15 kg2,250 mg45 mL750 mg105 mL1,500 mg210 mL
20 kg3,000 mg60 mL1,000mg140 mL2,000 mg280 mL
* Dilute ACETADOTE in one of the following three solutions: sterile water for injection, 0.45% sodium chloride injection, or 5% dextrose in water.
** Recommended dosing for those less than 5 kg has not been studied.

Table 3: Recommended ACETADOTE Dosage and Dilution for Patients 21 kg to 40 kg

Body WeightBag 1 (Loading Dose) 150 mg/kg in 100 mL of diluent* infused over 1 hourBag 2 (Second Dose) 50 mg/kg in 250 mL of diluent* infused over 4 hoursBag 3 (Third Dose) 100 mg/kg in 500 mL of diluent* infused over 16 hours
21 kg3,150 mg1,050 mg2,100 mg
30 kg4,500 mg1,500 mg3,000 mg
40 kg6,000 mg2,000 mg4,000 mg
*Dilute ACETADOTE in one of the following three solutions: sterile water for injection, 0.45% sodium chloride injection, or 5% dextrose in water.

Table 4: Recommended ACETADOTE Dosage and Dilution for Patients 41 kg or Greater

Body WeightBag 1 (Loading Dose) 150 mg/kg in 200 mL of diluent1 infused over 1 hourBag 2 (Second Dose) 50 mg/kg in 500 mL of diluent1 infused over 4 hoursBag 3 (Third Dose) 100 mg/kg in 1000 mL of diluent1 infused over 16 hours
41 kg6,150 mg2,050 mg4,100 mg
50 kg7,500 mg2,500 mg5,000 mg
60 kg9,000 mg3,000 mg6,000 mg
70 kg10,500 mg3,500 mg7,000 mg
80 kg12,000 mg4,000 mg8,000 mg
90 kg13,500 mg4,500 mg9,000 mg
≥ 100 kg**15,000 mg5,000 mg10,000 mg
* Dilute ACETADOTE in one of the following three solutions: sterile water for injection, 0.45% sodium chloride injection, or 5% dextrose in water.
** No specific studies have been conducted to evaluate the necessity of dose adjustments in patients weighing over 100 kg. Limited information is available regarding the dosing requirements of patients that weigh more than 100 kg.

Recommendations For Repeated Supratherapeutic Acetaminophen Ingestion

Repeated supratherapeutic acetaminophen ingestion (RSI) is an ingestion of acetaminophen at dosages higher than those recommended for extended periods of time. The risk of hepatotoxicity and the recommendations for treatment of acute acetaminophen ingestion (i.e., the Rumack-Matthew nomogram) do not apply to patients with RSI. Therefore, obtain the following information to guide ACETADOTE treatment for RSI:

  • Acetaminophen serum or plasma concentrations. A reported history of the quantity of acetaminophen ingested is often inaccurate and is not a reliable guide to therapy.
  • Laboratory tests to monitor hepatic and renal function and electrolyte and fluid balance: AST, ALT, bilirubin, INR, creatinine, BUN, blood glucose, and electrolytes.

For specific ACETADOTE dosage and administration information in patients with RSI, consider contacting your regional poison center at 1-800-222-1222, or alternatively, a special health professional assistance line for acetaminophen overdose at 1-800-525-6115.

HOW SUPPLIED

Dosage Forms And Strengths

Injection: 200 mg/mL (6 grams of acetylcysteine in 30 mL) in a single-dose vial.

Storage And Handling

ACETADOTE (acetylcysteine) injection is available as a 20% solution (200 mg/mL) in 30 mL single-dose glass vials. Each single dose vial contains 6 g/30mL (200 mg/mL) of ACETADOTE injection. ACETADOTE is sterile and can be used for intravenous administration. It is available as follows:

30 mL vials, carton of 4 (NDC 66220-207-30)

Do not use previously opened vials for intravenous administration.

Note: The color of ACETADOTE may turn from essentially colorless to a slight pink or purple once the stopper is punctured. The color change does not affect the quality of the product.

The stopper in the ACETADOTE vial is formulated with a synthetic base-polymer and does not contain Natural Rubber Latex, Dry Natural Rubber, or blends of Natural Rubber.

Store unopened vials at controlled room temperature, 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature]

Manufactured for: Cumberland Pharmaceuticals Inc. Nashville, TN 37203. Revised: Oct 2019

QUESTION

About how much does an adult human brain weigh? See Answer
Side Effects & Drug Interactions

SIDE EFFECTS

Clinical Studies Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

In the literature the most frequently reported adverse reactions attributed to intravenous acetylcysteine administration were rash, urticaria and pruritus. The frequency of adverse reactions has been reported to be between 0.2% and 21%, and they most commonly occur during the initial loading dose of acetylcysteine.

Loading Dose/Infusion Rate Study

In a randomized, open-label, multi-center clinical study conducted in Australia in patients with acetaminophen poisoning, the rates of hypersensitivity reactions between a 15-minute and 60-minute intravenous infusion for the 150 mg/kg loading dose of acetylcysteine were compared.

The incidence of drug-related adverse reactions occurring within the first 2 hours following acetylcysteine administration is presented in Table 5. Overall, 17% of patients developed an acute hypersensitivity reaction (18% in the 15-minute infusion group; 14% in the 60-minute infusion group) [see WARNINGS AND PRECAUTIONS, Clinical Studies].

Table 5: Incidence of Drug-Related Adverse Reactions Occurring Within the First 2 Hours Following Study Drug Administration by Preferred Term: Loading Dose/Infusion Rate Study

Treatment Group15-minutes60-minutes
Number of Patientsn=109n=71
Cardiac disorders5 (5%)2 (3%)
Severity: Tachycardia NOSUnknMildModerateSevereUnknMildModerateSevere
4 (4%)1 (1%)2 (3%)
Gastrointestinal disorders16 (15%)7 (10%)
Severity: Nausea Vomiting NOSUnknMildModerateSevereUnknMildModerateSevere
1 (1%)6 (6%)1 (1%)1 (1%)
2 (2%)11 (10%)2 (3%)4 (6%)
Immune System Disorders20 (18%)10 (14%)
Severity: Hypersensitivity reactionUnknMildModerateSevereUnknMildModerateSevere
2 (2%)6 (6%)11 (10%)1 (1%)4 (6%)5 (7%)1 (1%)
Respiratory, thoracic and mediastinal disorders2 (2%)2 (3%)
Severity:UnknMildModerateSevereUnknMildModerateSevere
Pharyngitis Rhinorrhea Rhonchi Throat tightness1 (1%)
1 (1%)
1 (1%)
1 (1%)
Skin & subcutaneous tissue disorders6 (6%)5 (7%)
Severity: Pruritus Rash NOSUnknMildModerateSevereUnknMildModerateSevere
1 (1%)2 (3%)
3 (3%)2 (2%)3 (4%)
Vascular disorders2 (2%)3 (4%)
Severity: FlushingUnknMildModerateSevereUnknMildModerateSevere
1 (1%)1 (1%)2 (3%)1 (1%)
Unkn= Unknown; NOS= not otherwise specified

Safety Study

A large multi-center study was performed in Canada where data were collected from patients who were treated with intravenous acetylcysteine for acetaminophen overdose between 1980 and 2005. This study evaluated 4709 adult cases and 1905 pediatric cases. The incidence of hypersensitivity reactions in adult (overall incidence 8%) and pediatric (overall incidence 10%) patients is presented in Tables 6 and 7.

Table 6: Distribution of reported hypersensitivity reactions in adult patients receiving intravenous acetylcysteine

ReactionIncidence (%)
n=4709
Urticaria/Facial Flushing6.1%
Pruritus4.3%
Respiratory Symptoms*1.9%
Edema1.6%
Hypotension0.1%
Anaphylaxis0.1%

Table 7: Distribution of reported hypersensitivity reactions in pediatric patients receiving intravenous acetylcysteine

ReactionIncidence (%)
n=1905
Urticaria/Facial Flushing7.6%
Pruritus4.1%
Respiratory Symptoms*2.2%
Edema1.2%
Anaphylaxis0.2%
Hypotension0.1%
*Respiratory symptoms are defined as presence of any of the following: cough, wheezing, stridor, shortness of breath, chest tightness, respiratory distress, or bronchospasm.

DRUG INTERACTIONS

No Information provided

Warnings & Precautions

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Anaphylactoid Reactions

Serious anaphylactoid reactions, including death in a patient with asthma, have been reported in patients administered acetylcysteine intravenously.

Acute flushing and erythema of the skin may occur in patients receiving acetylcysteine intravenously. These reactions usually occur 30 to 60 minutes after initiating the infusion and often resolve spontaneously despite continued infusion of acetylcysteine. Anaphylactoid reactions (defined as the occurrence of an acute hypersensitivity reaction during acetylcysteine administration including rash, hypotension, wheezing, and/or shortness of breath), have been observed in patients receiving intravenous acetylcysteine for acetaminophen overdose and occurred soon after initiation of the infusion [see ADVERSE REACTIONS]. If a reaction to acetylcysteine involves more than simply flushing and erythema of the skin, it should be treated as an anaphylactoid reaction. This usually entails administering antihistaminic drugs and in severe cases may require administration of epinephrine. In addition, the acetylcysteine infusion may be interrupted until treatment of the anaphylactoid symptoms has been initiated and then carefully restarted. If the anaphylactoid reaction returns upon reinitiation of treatment or increases in severity, intravenous acetylcysteine should be discontinued and alternative patient management should be considered.

Monitoring Patients With Asthma

Acetadote should be used with caution in patients with asthma, or where there is a history of bronchospasm.

Volume Adjustment: Patients Less Than 40 kg And Requiring Fluid Restriction

The total volume administered should be adjusted for patients less than 40 kg and for those requiring fluid restriction. To avoid fluid overload, the volume of diluent should be reduced as needed [see DOSAGE AND ADMINISTRATION]. If volume is not adjusted fluid overload can occur, potentially resulting in hyponatremia, seizure and death.

For specific treatment information regarding the clinical management of acetaminophen overdose, please contact your regional poison center at 1-800-222-1222, or alternatively, a special health professional assistance line for acetaminophen overdose at 1-800-525-6115.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Long-term studies in animals have not been performed to evaluate the carcinogenic potential of acetylcysteine.

Acetylcysteine was not genotoxic in the Ames test or the in vivo mouse micronucleus test. It was, however, positive in the in vitro mouse lymphoma cell (L5178Y/TK+/-) forward mutation test.

Treatment of male rats with acetylcysteine at an oral dose of 250 mg/kg/day for 15 weeks (0.1 times the recommended total human intravenous dose of 300 mg/kg based on body surface comparison) did not affect the fertility or general reproductive performance.

Use In Specific Populations

Pregnancy

Pregnancy Category B

There are no adequate and well-controlled studies of Acetadote in pregnant women. However, limited case reports of pregnant women exposed to acetylcysteine during various trimesters did not report any adverse maternal, fetal or neonatal outcomes.

There are published reports on four pregnant women with acetaminophen toxicity, who were treated with oral or intravenous acetylcysteine at the time of delivery. Acetylcysteine crossed the placenta and was measurable following delivery in serum and cord blood of three viable infants and in cardiac blood of a fourth infant at autopsy (22 weeks gestational age who died 3 hours after birth). No adverse sequelae developed in the three viable infants. All mothers recovered and none of the infants had evidence of acetaminophen poisoning.

Reproduction studies were performed in rats at oral doses up to 2000 mg/kg/day (1.1 times the recommended total human intravenous dose of 300 mg/kg based on body surface area comparison) and in rabbits at oral doses up to 1000 mg/kg/day (1.1 times the recommended total human intravenous dose of 300 mg/kg based on body surface area comparison). No effects on fertility or harm to the fetus due to acetylcysteine were observed.

Nursing Mothers

It is not known whether Acetadote is present in human milk. Because many drugs are excreted in human milk, caution should be exercised when acetylcysteine is administered to a nursing woman. Based on the pharmacokinetics of acetylcysteine, it should be nearly completely cleared 30 hours after administration. Nursing women may consider resuming nursing 30 hours after administration.

Pediatric Use

No adverse effects were noted during intravenous infusion with acetylcysteine at a mean rate of 4.2 mg/kg/h for 24 hours to 10 preterm newborns ranging in gestational age from 25 to 31 weeks and in weight from 500 to 1380 grams in one study or in 6 newborns ranging in gestational age from 26 to 30 weeks and in weight from 520 to 1335 grams infused with acetylcysteine at 0.1 to 1.3 mg/kg/h for 6 days. Elimination of acetylcysteine was slower in these infants than in adults; mean elimination half-life was 11 hours. There are no adequate and well-controlled studies in pediatric patients.

Geriatric Use

The clinical studies do not provide a sufficient number of geriatric subjects to determine whether the elderly respond differently.

Overdosage & Contraindications

OVERDOSE

An initial 150 mg/kg dose of acetylcysteine for a patient weighting 106 kg was mistakenly calculated as 160 g (a decimal point error resulting in a 10-fold higher than prescribed dose). An hour after the infusion started, the patient complained of generalized heat sensation and body pain and developed widespread urticaria and hypotension. The second acetylcysteine infusion was withheld and the patient was treated for anaphylaxis. Despite treatment the patient subcomed to the acute inflammatory reaction and died.

Single intravenous doses of acetylcysteine at 1000 mg/kg in mice, 2445 mg/kg in rats, 1500 mg/kg in guinea pigs, 1200 mg/kg in rabbits and 500 mg/kg in dogs were lethal. Symptoms of acute toxicity in the animals were ataxia, hypoactivity, labored respiration, cyanosis, loss of righting reflex and convulsions.

CONTRAINDICATIONS

ACETADOTE is contraindicated in patients with a previous hypersensitivity reaction to acetylcysteine [see WARNINGS AND PRECAUTIONS].

Clinical Pharmacology

CLINICAL PHARMACOLOGY

Mechanism Of Action

Acetylcysteine has been shown to reduce the extent of liver injury following acetaminophen overdose. Acetaminophen doses of 150 mg/kg or greater have been associated with hepatotoxicity. Acetylcysteine probably protects the liver by maintaining or restoring the glutathione levels, or by acting as an alternate substrate for conjugation with, and thus detoxification of, the reactive metabolite of acetaminophen.

Pharmacokinetics

After a single intravenous dose of acetylcysteine, the plasma concentration of total acetylcysteine declined in a polyexponential decay manner with a mean terminal half-life (T½) of 5.6 hours. The mean clearance (CL) for acetylcysteine was 0.11 liter/hr/kg and renal CL constituted about 30% of the total CL.

Distribution

The steady-state volume of distribution (Vdss) following administration of an intravenous dose of acetylcysteine was 0.47 liter/kg. The protein binding of acetylcysteine ranges from 66 to 87%.

Elimination

Metabolism

Acetylcysteine (i.e., N-acetylcysteine) is postulated to form cysteine and disulfides (N,N-diacetylcysteine and Nacetylcysteine). Cysteine is further metabolized to form glutathione and other metabolites.

Excretion

After a single oral dose of [35S]-acetylcysteine 100 mg, between 13 to 38% of the total radioactivity administered was recovered in urine within 24 hours. In a separate study, renal clearance was estimated to be approximately 30% of total body clearance.

Specific Populations

Hepatic Impairment

Following a 600 mg intravenous dose of acetylcysteine to subjects with mild (Child Pugh Class A, n=1), moderate (Child-Pugh Class B, n=4) or severe (Child-Pugh Class C; n=4) hepatic impairment and 6 healthy matched controls, mean T½ increased by 80%. Also, the mean CL decreased by 30% and the systemic acetylcysteine exposure (mean AUC) increased 1.6-fold in subjects with hepatic impairment compared to subjects with normal hepatic function. These changes are not considered to be clinically meaningful.

Renal Impairment

Hemodialysis may remove some of total acetylcysteine.

Clinical Studies

Loading Dose/Infusion Rate Study

A randomized, open-label, multi-center clinical study was conducted in Australia in patients with acetaminophen poisoning to compare the rates of hypersensitivity reactions between two rates of infusion for the intravenous acetylcysteine loading dose. One hundred nine subjects were randomized to a 15-minute infusion rate and seventy-one subjects were randomized to a 60 minute infusion rate. The loading dose was 150 mg/kg followed by a maintenance dose of 50 mg/kg over 4 hours and then 100 mg/kg over 16 hours. Of the 180 patients, 27% were male and 73% were female. Ages ranged from 15 to 83 years, with the mean age being 30 years (+13.0).

A subgroup of 58 subjects (33 in the 15-minute infusion group; 25 in the 60-minute infusion group) was treated within 8 hours of acetaminophen ingestion. No hepatotoxicity occurred within this subgroup; however, with 95% confidence, the true hepatotoxicity rates could range from 0% to 9% for the 15-minute infusion group and from 0% to 12% for the 60-minute infusion group.

Observational Study

An open-label, observational database contained information on 1749 patients who sought treatment for acetaminophen overdose over a 16-year period. Of the 1749 patients, 65% were female, 34% were male and less than 1% was transgender. Ages ranged from 2 months to 96 years, with 72% of the patients falling in the 16-to 40-year-old age bracket. A total of 399 patients received acetylcysteine treatment. A post-hoc analysis identified 56 patients who (1) were at high or probable risk for hepatotoxicity (APAP greater than 150 mg/L at the four hours line according to the Australian nomogram) and (2) had a liver function test. Of the 53 patients who were treated with intravenous acetylcysteine (300 mg/kg intravenous acetylcysteine administered over 20-21 hours) within 8 hours, two (4%) developed hepatotoxicity (AST or ALT greater than 1000 U/L). Twenty-one of 48 (44%) patients treated with acetylcysteine after 15 hours developed hepatotoxicity. The actual number of hepatotoxicity outcomes may be higher than what is reported here. For patients with multiple admissions for acetaminophen overdose, only the first overdose treated with intravenous acetylcysteine was examined. Hepatotoxicity may have occurred in subsequent admissions.

Evaluable data were available from a total of 148 pediatric patients (less than 16 years of age) who were admitted for poisoning following ingestion of acetaminophen, of whom 23 were treated with intravenous acetylcysteine. There were no deaths of pediatric patients. None of the pediatric patients receiving intravenous acetylcysteine developed hepatotoxicity while two patients not receiving intravenous acetylcysteine developed hepatotoxicity. The number of pediatric patients is too small to provide a statistically significant finding of efficacy; however the results appear to be consistent to those observed for adults.

Medication Guide

PATIENT INFORMATION

Hypersensitivity Reactions

Advise patients and caregivers that hypersensitivity reactions related to administration and infusion may occur during and after ACETADOTE treatment, including hypotension, wheezing, shortness of breath and bronchospasm [see WARNINGS AND PRECAUTIONS].

For specific treatment information regarding the clinical management of acetaminophen overdose, please contact your regional poison center at 1-800-222-1222, or alternatively, a special health professional assistance line for acetaminophen overdose at 1-800-525-6115.

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